Duty of Candour implementation
Identified shortcomings in the practical operation and implementation of duties of candour within healthcare systems.
83 items
1 source
12 inquiries
Source spread
Where this theme appears
Duty of Candour implementation has been flagged across 1 independent accountability source:
83 inquiry recs
This theme has been identified in one data source. As more data is added, cross-references may emerge.
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Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry Recommendations (83) — showing 50 strongest matches
92 — Apologies to former child migrants
Recommendation: As we have set out in the institution-specific sections of the report, some institutions have still not apologised for their role in the child migration programmes. We recommend that they do so, as soon as possible. We recommend that they …
No response yet
R104 — Statutory duty of candour
Recommendation: 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 service users and the public. (ii) Where …
No response yet
In progress
BRIS-34 — Ensure patients receive acknowledgement, explanation, and apology when care goes wrong
Recommendation: When things go wrong, patients are entitled to receive an acknowledgement, an explanation and an apology.
Unknown
BRIS-33 — Establish a duty of candour for all NHS staff regarding adverse events
Recommendation: 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.
Unknown
F184 — Enforcement by the Care Quality Commission
Recommendation: 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 …
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted. This is accepted in respect of the statutory duty of candour. This new duty will be a requirement for registration with the Care Quality Commission. In line with other registration requirements, Care Quality Commission …
Accepted
In progress
F183 — Criminal liability
Recommendation: 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 …
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Not accepted, however we agree with the intention behind this recommendation. The duty of candour is a further drive towards openness and transparency. We have set out in the Care Bill that in future, as …
Not accepted
F182 — Statutory duty of openness and transparency
Recommendation: 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 …
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted. Subject to the passage of the Care Bill, a new criminal offence will be introduced applicable to care providers that supply or publish certain types of information which is false or misleading, where that …
Accepted
F181 — Enforcement of the duty Statutory duties of candour in relation to harm to patients
Recommendation: 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 …
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted in principle. As set out in recommendation 174, the Government will introduce an explicit duty of candour as a Care Quality Commission registration requirement. The duty would apply to health and adult social care …
Accepted in part
F178 — Implementation of the duty Ensuring consistency of obligations under the duty of openness transparency and …
Recommendation: 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 …
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted in principle. We agree that staff should be honest and open with patients, and The NHS Constitution already emphasises the importance of honesty and openness in its values and sections outlining staff responsibilities, rights …
Accepted in part
In progress
F177 — Openness in public statements
Recommendation: Any public statement made by a healthcare organisation about its performance must be truthful and not misleading by omission.
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted. Accountability is a key leadership role and effectively means organisations operate effectively and with openness, transparency and candour at all times. The NHS Leadership Academy’s guide, The Healthy NHS Board 2013 – Principles for …
Accepted
In progress
F176 — Openness with regulators
Recommendation: Any statement made to a regulator or a commissioner in the course of its statutory duties must be completely truthful and not misleading by omission.
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted. The Government’s response to the Inquiry, Patients First and Foremost reaffirmed a commitment to the values of openness, honesty and acceptance of challenge and when things go wrong to learn from and not conceal …
Accepted
In progress
F175 — Candour about harm
Recommendation: 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).
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted. All regulated professionals through the principles that underpin their standards and codes of conduct are required to be open and transparent with patients in respect of discussions about treatment and care. As set out …
Accepted
In progress
F174 — Candour about harm
Recommendation: 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 …
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted. The Secretary of State for Health legally required NHS England to insert a contractual duty of candour into the NHS Standard Contract in 2013–14. This means that NHS Trusts and Foundation Trusts are contractually …
Accepted
In progress
F173 — Principles of openness transparency and candour
Recommendation: 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 …
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted. Promoting honesty, openness and transparency, and instilling a culture that values compassion, dignity and the highest quality of care is one the key responsibilities of the Department of Health as part of its role …
Accepted
In progress
11 — Raise awareness of incident reporting and duty of candour
Recommendation: 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 …
Words of: Department of Health, Learning not blaming (Cm 9113), government response to the Morecambe Bay Investigation and two other reports, July 2015
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Unknown
IHRD-7 — Monitoring Candour Compliance
Recommendation: Trusts should monitor compliance and take disciplinary action against breach.
Words of: Mr Swann, Minister of Health, written ministerial statement to the Northern Ireland Assembly, 25 March 2021
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
No update 2+ yrs
IHRD-6 — Support for Candour Compliance
Recommendation: Support and protection should be given to those who properly fulfil their duty of candour.
Words of: Mr Swann, Minister of Health, written ministerial statement to the Northern Ireland Assembly, 25 March 2021
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
No update 2+ yrs
IHRD-5 — Employment Contracts and Duty of Candour
Recommendation: 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.
Words of: Mr Swann, Minister of Health, written ministerial statement to the Northern Ireland Assembly, 25 March 2021
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
No update 2+ yrs
IHRD-4 — Trust Awareness of Duty of Candour
Recommendation: 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.
Words of: Mr Swann, Minister of Health, written ministerial statement to the Northern Ireland Assembly, 25 March 2021
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
No update 2+ yrs
IHRD-1 — Statutory Duty of Candour
Recommendation: 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 …
Words of: Mr Swann, Minister of Health, written ministerial statement to the Northern Ireland Assembly, 25 March 2021
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
No update 2+ yrs
IBI-5c — Ministerial Duty of Candour
Recommendation: 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.
Words of: UK Government, Full Government Response to the Infected Blood Inquiry's May 2024 Report (CP 1318), presented to Parliament by the Minister for the Cabinet Office, 14 May 2025
Gov response: These recommendations are accepted in principle and the Prime Minister has committed to bringing forward legislation on a duty of candour for public servants. The actions of Civil Servants and Ministers uncovered within the report …
Accepted in part
IBI-5b — Monitoring Non-Statutory Duties
Recommendation: 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 …
Words of: UK Government, Full Government Response to the Infected Blood Inquiry's May 2024 Report (CP 1318), presented to Parliament by the Minister for the Cabinet Office, 14 May 2025
Gov response: These recommendations are accepted in principle and the Prime Minister has committed to bringing forward legislation on a duty of candour for public servants. The actions of Civil Servants and Ministers uncovered within the report …
Accepted in part
IBI-5a — Civil Service Statutory Duty of Candour
Recommendation: 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 …
Words of: UK Government, Full Government Response to the Infected Blood Inquiry's May 2024 Report (CP 1318), presented to Parliament by the Minister for the Cabinet Office, 14 May 2025
Gov response: These recommendations are accepted in principle and the Prime Minister has committed to bringing forward legislation on a duty of candour for public servants. The actions of Civil Servants and Ministers uncovered within the report …
Accepted in part
BRIS-117 — Require contractual stipulation for confidential, non-disciplinary reporting of sentinel events.
Recommendation: There should be a stipulation in every healthcare professional’s contract that sentinel events must be reported, that reporting can be confidential, and that reporting within a specified time period will not attract disciplinary action.
Unknown
BRIS-26 — Provide comprehensive information on risks, alternatives, and outcomes for informed patient consent
Recommendation: As part of the process of obtaining consent, except when they have indicated otherwise, patients should be given sufficient information about what is to take place, the risks, uncertainties, and possible negative consequences of the proposed treatment, about any alternatives …
Unknown
In progress
BRIS-24 — Treat patient consent as an ongoing process, not a single signature event
Recommendation: The process of informing the patient, and obtaining consent to a course of treatment, should be regarded as a process and not a one-off event consisting of obtaining a patient’s signature on a form.
Unknown
In progress
14 — Board apologies
Recommendation: We recommend that when things go wrong, boards should apologise at the earliest stage of investigation and not hold back from doing so for fear of the consequences in relation to their liability.
Words of: Department of Health and Social Care, Government response to the independent inquiry report into the issues raised by former surgeon Ian Paterson, 16 December 2021
Gov response: Accept Healthcare organisations have a statutory duty of candour, which sets out specific requirements providers must follow when things go wrong with care and treatment, including providing truthful information and an apology. This duty is …
Accepted
In progress
IHRD-42 — Sharing New Investigation Information
Recommendation: In the event of new information emerging after finalisation of an investigation report or there being a change in conclusion, then the same should be shared promptly with families.
Words of: Mr Swann, Minister of Health, written ministerial statement to the Northern Ireland Assembly, 25 March 2021
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
IHRD-37 — Family Involvement in SAI Investigations
Recommendation: Trusts should seek to maximise the involvement of families in SAI investigations and in particular: (i) Trusts should publish a statement of patient and family rights in relation to all SAI processes including complaints. (ii) Families should be given the …
Words of: Mr Swann, Minister of Health, written ministerial statement to the Northern Ireland Assembly, 25 March 2021
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
F180 — Candour about incidents
Recommendation: 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.
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted. As stated in recommendation 174, the intention is introduce an explicit duty of candour on providers as a Care Quality Commission registration requirement. The Department of Health will publish shortly draft regulations on a …
Accepted
24 — Involve patients and relatives in incident investigation
Recommendation: 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 …
Words of: Department of Health, Learning not blaming (Cm 9113), government response to the Morecambe Bay Investigation and two other reports, July 2015
Gov response: 37. We accept this recommendation. A duty of candour has been introduced. 38. A lack of openness and honesty at Morecambe Bay was a fundamental cause of both the distress of the families, and of …
Accepted
In progress
1 — Admit problems and apologise to affected families
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should formally admit the extent and nature of the problems that have previously occurred, and should apologise to those patients and relatives affected, not only for the avoidable damage caused but …
Words of: Department of Health, Learning not blaming (Cm 9113), government response to the Morecambe Bay Investigation and two other reports, July 2015
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Unknown
IHRD-3 — Guidance on Statutory Duty of Candour
Recommendation: 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.
Words of: Mr Swann, Minister of Health, written ministerial statement to the Northern Ireland Assembly, 25 March 2021
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
No update 2+ yrs
IHRD-2 — Criminal Liability for Candour Breach
Recommendation: Criminal liability should attach to breach of this duty and criminal liability should attach to obstruction of another in the performance of this duty.
Words of: Mr Swann, Minister of Health, written ministerial statement to the Northern Ireland Assembly, 25 March 2021
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
No update 2+ yrs
IBI-4b — Organisational Culture Change
Recommendation: Cultural Change: That a culture of defensiveness, lack of openness, failure to be forthcoming, and being dismissive of concerns about patient safety be addressed both by taking the steps set out in (a) above, and also by making leaders accountable …
Words of: UK Government, Full Government Response to the Infected Blood Inquiry's May 2024 Report (CP 1318), presented to Parliament by the Minister for the Cabinet Office, 14 May 2025
Gov response: This recommendation is accepted in principle by the UK Government, the Welsh Government, the Scottish Government and the Northern Ireland Executive.
Accepted in part
IBI-4a(v) — Leadership Accountability for Safety
Recommendation: 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 …
Words of: UK Government, Full Government Response to the Infected Blood Inquiry's May 2024 Report (CP 1318), presented to Parliament by the Minister for the Cabinet Office, 14 May 2025
Gov response: 4a) v. Advancing patient safety and reducing harm in the NHS is a priority for this Government. We acknowledge the importance of recording and responding to patient safety incidents and the underpinning principle of this …
Accepted in part
IBI-4a(iv) — Individual Duty of Candour for Leaders
Recommendation: 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 …
Words of: UK Government, Full Government Response to the Infected Blood Inquiry's May 2024 Report (CP 1318), presented to Parliament by the Minister for the Cabinet Office, 14 May 2025
Gov response: 4a) iv. The Government recognises the importance of strong and accountable leadership in fostering an open and compassionate culture in the NHS. That is why we have committed to implementing professional standards for and regulating …
Accepted in part
IBI-4a(iii) — Duty of Candour - England Review
Recommendation: Duty of candour: The review of the duty of candour currently under way in England should be completed as soon as practicable.
Words of: UK Government, Full Government Response to the Infected Blood Inquiry's May 2024 Report (CP 1318), presented to Parliament by the Minister for the Cabinet Office, 14 May 2025
Gov response: The Government is clear that the statutory (organisational) duty needs to act as a catalyst for health and social care providers to improve openness and commit to a learning culture. The Government is supportive of …
Accepted
IBI-4a(ii) — Duty of Candour - Scotland and Wales Review
Recommendation: 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 …
Words of: Scottish Government, in its own section of the Full Government Response to the Infected Blood Inquiry's May 2024 Report (CP 1318), presented to Parliament by the Minister for the Cabinet Office, 14 May 2025
Gov response: The organisational duty of candour provisions of the Health (Tobacco, Nicotine etc. and Care) (Scotland) Act 2016 and the Duty of Candour Procedure (Scotland) Regulations 2018 set out the procedure that organisations providing health services, …
Accepted
In progress
IBI-4a(i) — Duty of Candour - Northern Ireland
Recommendation: Duty of candour: A statutory duty of candour in healthcare should be introduced in Northern Ireland.
Words of: Northern Ireland Executive, in its own section of the Full Government Response to the Infected Blood Inquiry's May 2024 Report (CP 1318), presented to Parliament by the Minister for the Cabinet Office, 14 May 2025
Gov response: As part of the Health and Social Care Three Year plan, Minister Mike Nesbitt committed to advance proposals for an organisational duty of candour, in the first instance, as well as considering proposals for an …
Accepted
No update 2+ yrs
DM-17 — Statutory duty of candour for law enforcement
Recommendation: 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.
Words of: Home Office, Government response to the report of the Daniel Morgan Independent Panel (CP 857), presented to Parliament by the Home Secretary, 15 June 2023
Gov response: 2.3.2. The Panel agreed with other independent inquiries, such as Bishop James Jones’ report on the experiences of the Hillsborough families, about the need for a duty of candour for public services, including the police. …
Response Unclear
No update 2+ yrs
BRIS-115 — Discipline NHS staff who cover up or fail to report sentinel events
Recommendation: Members of staff in the NHS who cover up or do not report a sentinel event may be subject to disciplinary action by their employer or by their professional body.
Unknown
BRIS-114 — Grant immunity for NHS staff reporting sentinel events within 48 hours
Recommendation: Members of staff in the NHS should receive immunity from disciplinary action by the employer or by a professional body if they report a sentinel event to the trust or to the national database within 48 hours, except where they …
Unknown
BRIS-113 — Make reporting of sentinel events easy using all communication means
Recommendation: The reporting of sentinel events must be made as easy as possible, using all available means of communication (including a confidential telephone reporting line).
Unknown
BRIS-107 — Create open, non-punitive NHS environment for reporting sentinel events
Recommendation: Every effort should be made to create in the NHS an open and non-punitive environment in which it is safe to report and admit sentinel events.
Unknown
In progress
BRIS-25 — Extend consent process to all clinical procedures involving touching, focusing on communication
Recommendation: The process of consent should apply not only to surgical procedures but to all clinical procedures and examinations which involve any form of touching. This must not mean more forms: it means more communication.
Unknown
In progress
BRIS-23 — Endorse and implement DoH consent guide across all NHS healthcare professional practice
Recommendation: We note and endorse the recent statement on consent produced by the DoH: ‘Reference guide to consent for examination or treatment’, 2001. It should inform the practice of all healthcare professionals in the NHS and be introduced into practice in …
Unknown
In progress
R69 — Explanation to relatives on CDI death
Recommendation: Health Boards should ensure that if a patient dies with CDI either as a cause of death or as a condition contributing to the death, relatives are provided with a clear explanation of the role played by CDI in the …
Words of: Scottish Government, The Scottish Government's Response to the Vale of Leven Hospital Inquiry Report, section 1.3, 18 June 2015
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
CR17 — Protocol for duty to assist referrals
Recommendation: 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 …
Words of: Department for Transport, Cranston Inquiry Report: Interim Response (CP 1635), July 2026
Gov response: HMCG accepts the importance of a protocol for making referrals to the Regulatory Compliance and Investigations team (RCIT) and revised its SOPs in October 2023 to enshrine this practice. This update reminded all staff of …
Accepted
IHRD-75 — Independent Disciplinary Action
Recommendation: Notwithstanding referral to the GMC, or other professional body Trusts should treat breaches of professional codes and/or poor performance as disciplinary matters and deal with them independently of professional bodies.
Words of: Mr Swann, Minister of Health, written ministerial statement to the Northern Ireland Assembly, 25 March 2021
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
No update 2+ yrs