Duty of Candour implementation
Identified shortcomings in the practical operation and implementation of duties of candour within healthcare systems.
507 items
12 sources
10 inquiries
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
Inquiry recommendation
95match
F178 - Implementation of the duty Ensuring consistency of obligations under the duty of openness transparency and candour
The NHS Constitution should be revised to reflect the changes recommended with regard to a duty of openness, transparency and candour, and all organisations should review their contracts of employment, policies and guidance to ensure that, where relevant, they expressly include and are consistent with above principles and these recommendations.
Matched on
terms: candour, duty, implementation
Inquiry recommendation
91match
F181 - Enforcement of the duty Statutory duties of candour in relation to harm to patients
A statutory obligation should be imposed to observe a duty of candour: On healthcare providers who believe or suspect that treatment or care provided by it to a patient has caused death or serious injury to a patient to inform that patient or other duly authorised person as soon as is practicable of that fact and thereafter to...
Matched on
terms: candour, duty
Inquiry recommendation
90match
IBI-4a(ii) - Duty of Candour - Scotland and Wales Review
Duty of candour: The operation of the duties of candour in healthcare in Scotland and in Wales should be reviewed, as it is being in England, to assess how effective its operation has been in practice. Since the duty was introduced in 2023 in Wales, the review there need not be immediate, but should be no later than...
Matched on
terms: candour, duty
Inquiry recommendation
87match
IHRD-4 - Trust Awareness of Duty of Candour
Trusts should ensure that all healthcare professionals are made fully aware of the importance, meaning and implications of the duty of candour and its critical role in the provision of healthcare.
Matched on
terms: candour, duty
Inquiry recommendation
87match
IHRD-1 - Statutory Duty of Candour
A statutory duty of candour should now be enacted in Northern Ireland so that: (i) Every healthcare organisation and everyone working for them must be open and honest in all their dealings with patients and the public. (ii) Where death or serious harm has been or may have been caused to a patient by an act or omission...
Matched on
terms: candour, duty
Inquiry recommendation
83match
BRIS-33 - Establish a duty of candour for all NHS staff regarding adverse events
A duty of candour, meaning a duty to tell a patient if adverse events2 have occurred, must be recognised as owed by all those working in the NHS to patients.
Matched on
terms: candour, duty
Inquiry recommendation
83match
11 - Raise awareness of incident reporting and duty of candour
The University Hospitals of Morecambe Bay NHS Foundation Trust should identify and implement a programme to raise awareness of incident reporting, including requirements, benefits and processes. The Trust should also review its policy of openness and honesty in line with the duty of candour of professional staff, and incorporate into the programme compliance with the refreshed policy. This...
Matched on
terms: candour, duty
Inquiry recommendation
83match
IHRD-5 - Employment Contracts and Duty of Candour
Trusts should review their contracts of employment, policies and guidance to ensure that, where relevant, they include and are consistent with the duty of candour.
Matched on
terms: candour, duty
Inquiry recommendation
82match
IBI-5a - Civil Service Statutory Duty of Candour
The Government should reconsider whether, in the light of the facts revealed by this Inquiry, it is sufficient to continue to rely on the current non-statutory duties in the Civil Service and Ministerial Codes, coupled with those legal duties which occur on the occasions when civil servants and ministers interact with courts, inquests and inquiries, as securing candour.
Matched on
terms: candour, duty
Inquiry recommendation
82match
IBI-4a(iv) - Individual Duty of Candour for Leaders
Statutory duty of candour: The statutory duties of candour in England, Scotland, Wales (and Northern Ireland, when introduced) should be extended to cover those individuals in leadership positions in the National Health Service, in particular in executive positions and board members.
Matched on
terms: candour, duty
Inquiry recommendation
82match
IBI-4a(i) - Duty of Candour - Northern Ireland
Duty of candour: A statutory duty of candour in healthcare should be introduced in Northern Ireland.
Matched on
terms: candour, duty
Inquiry recommendation
78match
IBI-5c - Ministerial Duty of Candour
The Government should consider the extent to which Ministers should be subject to a duty beyond their current duty to Parliament under the Ministerial Code.
Matched on
terms: candour, duty
Inquiry recommendation
78match
IHRD-3 - Guidance on Statutory Duty of Candour
Unequivocal guidance should be issued by the Department to all Trusts and their legal advisors detailing what is expected of Trusts in order to meet the statutory duty.
Matched on
terms: candour, duty
Inquiry recommendation
78match
IBI-4a(iii) - Duty of Candour - England Review
Duty of candour: The review of the duty of candour currently under way in England should be completed as soon as practicable.
Matched on
terms: candour, duty
Inquiry recommendation
78match
DM-17 - Statutory duty of candour for law enforcement
The Panel recommends the creation of a statutory duty of candour, to be owed by all law enforcement agencies to those whom they serve, subject to protection of national security and relevant data protection legislation.
Matched on
terms: candour, duty
Inquiry recommendation
78match
F173 - Principles of openness transparency and candour
Every healthcare organisation and everyone working for them must be honest, open and truthful in all their dealings with patients and the public, and organisational and personal interests must never be allowed to outweigh the duty to be honest, open and truthful.
Matched on
terms: candour, duty
Inquiry recommendation
74match
IHRD-6 - Support for Candour Compliance
Support and protection should be given to those who properly fulfil their duty of candour.
Matched on
terms: candour, duty
Committee recommendation
74match
#37 - Formally consider introducing a professional duty of candour to increase police transparency.
We recommend that the NPCC, College of Policing, Home Office and Association of Police and Crime Commissioners formally consider whether a professional “duty of candour” might drive greater transparency in policing. We consider that, while this would not be enough on its own to drive the culture change needed, it would help set the direction of travel towards...
Matched on
terms: candour, duty
PFD report
69match
Sally Froggatt
There was a failure to comply with the Duty of Candour, inadequate staff training, contradictory corporate guidelines, and nursing staff did not communicate known patient risk factors to consultants.
Matched on
terms: candour, duty
PFD report
69match
Lee Eustace
An insufficient feeding protocol likely contributed to death, compounded by failures to raise a Datix, send a Duty of Candour letter, and disclose critical information to the Coroner.
Matched on
terms: candour, duty
Inquiry recommendation
69match
IHRD-2 - Criminal Liability for Candour Breach
Criminal liability should attach to breach of this duty and criminal liability should attach to obstruction of another in the performance of this duty.
Matched on
terms: candour, duty
PHSO recommendation
69match
Broken trust: making patient safety more than just a promise
The Department of Health and Social Care and NHS England should further scrutinise the lack of compliance with duty of candour. They should review the operation of duty of candour to assess its effectiveness and make recommendations for improvement.
Matched on
terms: candour, duty
Inquiry recommendation
66match
F182 - Statutory duty of openness and transparency
There should be a statutory duty on all directors of healthcare organisations to be truthful in any information given to a healthcare regulator or commissioner, either personally or on behalf of the organisation, where given in compliance with a statutory obligation on the organisation to provide it.
Matched on
terms: duty
CQC action
65match
Verve Health
The service must ensure staff are applying the duty of candour when things go wrong.
Matched on
terms: candour, duty
CQC action
65match
Edwina Place
The provider should seek advice and guidance from a reputable source about Regulation 20: Duty of Candour to ensure requirements are met at all times, including clear record keeping.
Matched on
terms: candour, duty
Inquiry recommendation
64match
IBI-5b - Monitoring Non-Statutory Duties
If, on review, the Government considers that it is sufficient to rely on the current non-statutory duties in the Civil Service Code, it should nonetheless introduce a statutory duty of accountability on senior civil servants for the candour and completeness of advice given to Permanent Secretaries and Ministers, and the candour and completeness of their response to concerns...
Matched on
terms: candour, duty
Inquiry recommendation
64match
IBI-4a(v) - Leadership Accountability for Safety
Statutory duty of candour: Individuals in leadership positions should be required by the terms of their appointment and by secondary legislation to record, consider and respond to any concern about the healthcare being provided, or the way it is being provided, where there reasonably appears to be a risk that a patient might suffer harm, or has done...
Matched on
terms: candour, duty
CQC action
64match
Kingfishers Nursing Home
The service implements a system to meet the requirements of the duty of candour process.
Matched on
terms: candour, duty
Inquiry recommendation
62match
F175 - Candour about harm
Full and truthful answers must be given to any question reasonably asked about his or her past or intended treatment by a patient (or, if deceased, to any lawfully entitled personal representative).
Matched on
terms: candour
Inquiry recommendation
62match
F174 - Candour about harm
Where death or serious harm has been or may have been caused to a patient by an act or omission of the organisation or its staff, the patient (or any lawfully entitled personal representative or other authorised person) should be informed of the incident, given full disclosure of the surrounding circumstances and be offered an appropriate level of...
Matched on
terms: candour
Inquiry recommendation
62match
IHRD-7 - Monitoring Candour Compliance
Trusts should monitor compliance and take disciplinary action against breach.
Matched on
terms: candour
Inquiry recommendation
60match
24 - Involve patients and relatives in incident investigation
We commend the introduction of the duty of candour for all NHS professionals. This should be extended to include the involvement of patients and relatives in the investigation of serious incidents, both to provide evidence that may otherwise be lacking and to receive personal feedback on the results. Action: the Care Quality Commission, NHS England.
Matched on
terms: candour, duty
Committee recommendation
60match
#10 - 1st Report - The Coroner Service
The failure of health and social care bodies to fulfil their duty of candour to bereaved people during coroners’ investigations and inquests is disappointing. The Ministry of Justice should amend the Coroners’ rules to make it patently clear that the duty of candour extends to the Coroner Service. The Government should consider whether a similar duty to be...
Matched on
terms: candour, duty
CQC action
60match
Universal Care - Beaconsfield
We recommend the provider seek guidance from a reputable source to ensure the duty of candour requirements are fully understood by all staff.
Matched on
terms: candour, duty
CQC action
60match
Gallaudet Home
We recommend that the manager ensures they update their knowledge on the duty of candour from a reliable source and take action to update their practice accordingly
Matched on
terms: candour, duty
PFD report
57match
Hilda Haughton
Patient falls resulted from unraised cot sides and were compounded by a lack of hospital staff candour. Concerns were also raised regarding the safety of increased fire-door closing times in hospitals.
Matched on
terms: candour
PFD report
57match
Benjamin Leonard
The Scouts Association lacks a culture of candour and independent regulatory oversight for safety and safeguarding. A critical internal Fatal Accident Inquiry Panel Report was not completed in a timely manner, hindering learning.
Matched on
terms: candour
Inquiry recommendation
57match
F180 - Candour about incidents
Guidance and policies should be reviewed to ensure that they will lead to compliance with Being Open, the guidance published by the National Patient Safety Agency.
Matched on
terms: candour
CQC action
56match
Church Road
The provider ensures all staff and managers are familiar with the requirements of the regulations regarding duty of candour so they act in accordance with these.
Matched on
terms: candour, duty
PHSO casework decision
56match
P-002354 - Liverpool University Hospitals NHS Foundation Trust
Ms A complains the Trust failed to uphold its duty of candour and lied about events that led to her having a cardiac arrest and being placed in a coma. She also says it gave misleading information about the cause for her condition, gave her an overdose of adrenaline and its record-keeping was poor.
Matched on
terms: candour, duty
PHSO casework decision
56match
P-004205 - A practice in the Darlington area
Ms O complains about the care her father received from a GP practice in North-East England between May and October 2022. She complains the Practice failed to diagnose a serious ear infection promptly, breached its Duty of Candour, and handled her complaint poorly.
Matched on
terms: candour, duty
Inquiry recommendation
53match
F184 - Enforcement by the Care Quality Commission
Observance of the duty should be policed by the Care Quality Commission, which should have powers in the last resort to prosecute in cases of serial non-compliance or serious and wilful deception. The Care Quality Commission should be supported by monitoring undertaken by commissioners and others.
Matched on
terms: duty
Inquiry recommendation
53match
CR17 - Protocol for duty to assist referrals
HM Coastguard and the Maritime and Coastguard Agency should establish a protocol for referrals by HM Coastguard to the Maritime and Coastguard Agency's regulatory compliance investigations team, identifying the threshold for making a referral on a potential breach by a vessel of the duty to render assistance, the information to be communicated and how the numbers of referrals...
Matched on
terms: duty
Inquiry recommendation
53match
IHRD-72 - Candour in Trust Communications
All Trust publications, media statements and press releases should comply with the requirement for candour and be monitored for accuracy by a nominated non-executive Director.
Matched on
terms: candour
CQC action
51match
Cygnet Bury Hudson
The provider should ensure that all staff know what the specific roles are in relation to independent mental health advocates and independent mental capacity advocates and have a good understanding of the duty of candour.
Matched on
terms: candour, duty
PFD report
49match
Elisa Fuller
Insufficient support and systems hinder junior staff from escalating concerns to seniors, and there is a lack of understanding regarding the essential retention of placentas post-delivery.
Matched on
classifier match
PFD report
49match
Emma Langley
The current system for recording patients' refusal of hospital admission, involving a generic summary and electronic signature on a tablet, fails to adequately ensure distressed patients/families understand they are rejecting medical advice.
Matched on
classifier match
PFD report
49match
Agnes Sansom
Patient record systems failed to communicate urgent information in a timely manner, and vulnerable patients were forced to share walking aids on hospital wards, creating safety risks.
Matched on
classifier match
PFD report
49match
Peter Cole
Inadequate monitoring of repeat medication allows vulnerable patients to accumulate dangerous quantities, a widespread problem leading to significant waste of healthcare resources.
Matched on
classifier match
Inquiry recommendation
49match
F183 - Criminal liability
It should be made a criminal offence for any registered medical practitioner, or nurse, or allied health professional or director of an authorised or registered healthcare organisation: Knowingly to obstruct another in the performance of these statutory duties; To provide information to a patient or nearest relative intending to mislead them about such an incident; Dishonestly to make...
Matched on
classifier match