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: The Chair and Panel have recommended that institutions involved in the child migration programmes who have not apologised for their role should give such apologies as soon as possible. Apologies should not only be made through public statements but specifically …
Gov response: An apology by the Sisters of Nazareth was repeated during the Child migration programmes investigation (p126). Between January 2020 and July 2020, Action for Children, Barnardo's, Catholic Church in England and Wales, Church of England, …
Accepted
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 …
Response Pending
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 …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
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 …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
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 …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
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 …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
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 …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
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.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
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.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
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).
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
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 …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
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 …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
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 …
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 …
Accepted
IHRD-7 — Monitoring Candour Compliance
Recommendation: Trusts should monitor compliance and take disciplinary action against breach.
Gov response: Compliance monitoring mechanisms being developed as part of duty of candour framework.
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.
Gov response: Support mechanisms established for staff raising concerns. Being Open Framework includes protections.
Accepted
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.
Gov response: Trusts reviewing employment contracts and policies for consistency with duty of candour requirements.
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.
Gov response: Being Open Framework implemented across Trusts. Training provided to staff on duty of candour principles.
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 …
Gov response: The Department of Health is taking forward legislation for a statutory duty of candour. Public consultation was held in 2020-2021. Legislation is being prepared as part of broader healthcare reforms.
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.
Gov response: UK Goverment The actions of Civil Servants and Ministers uncovered within the report are extremely concerning and do not reflect the values we expect those who serve the public to uphold. The Government accepts that …
Accepted in Part
No update 2+ yrs
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 …
Gov response: UK Goverment The actions of Civil Servants and Ministers uncovered within the report are extremely concerning and do not reflect the values we expect those who serve the public to uphold. The Government accepts that …
Accepted in Part
No update 2+ yrs
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 …
Gov response: UK Goverment The actions of Civil Servants and Ministers uncovered within the report are extremely concerning and do not reflect the values we expect those who serve the public to uphold. The Government accepts that …
Accepted in Part
No update 2+ yrs
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
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
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.
Gov response: Accepted. Duty of Candour regulations require healthcare providers to be open when things go wrong. NHS Resolution promotes early apology and has clarified that sincere apologies do not constitute admission of liability. Professional Standards Authority …
Accepted
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.
Gov response: Procedures established for sharing new information with families after investigation completion.
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 …
Gov response: Family involvement protocols established. Guidance issued on meaningful engagement with families throughout investigation processes. Patient Advocacy Service being developed.
Accepted
No update 2+ yrs
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.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
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 …
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
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 …
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 …
Accepted
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.
Gov response: Being considered alongside duty of candour legislation development.
Accepted in Part
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.
Gov response: Under review as part of wider duty of candour and accountability framework development.
Accepted in Part
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 …
Gov response: Scotland established an Independent National Whistleblowing Office and introduced Non-Executive Whistleblowing Champions in all Health Boards. Wales enacted the 2020 Act. Northern Ireland is implementing a Being Open Framework.
Accepted in Part
No update 2+ yrs
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 …
Gov response: Government acknowledges the importance of this principle but notes implementation complexity and potential employment law implications. Exploring whether professional standards and manager regulation could achieve accountability without unintended consequences.
Accepted in Part
No update 2+ yrs
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 …
Gov response: UK Government consultation (November 2024 - February 2025) sought views on whether a professional duty of candour should apply to NHS leaders. Response being prepared considering broader manager regulation proposals.
Accepted in Part
No update 2+ yrs
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.
Gov response: A November 2024 call-for-evidence found inconsistent application of the duty. Government is preparing consultation response with final review report to follow manager regulation consultation conclusions.
Accepted
No update 2+ yrs
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 …
Gov response: Scotland published updated non-statutory guidance in April 2025 and began stakeholder engagement in June 2025. Wales committed to evaluate the 2020 Act's impact by end of 2026.
Accepted
No update 2+ yrs
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.
Gov response: The Northern Ireland Executive committed to proposing an organisational duty of candour, considering consultation findings and broader Hillsborough Law developments.
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.
Gov response: 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. The …
Accepted in Part
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
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
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
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.
Gov response: Section 4.2 of the Scottish Government's response emphasizes person-centred care, with a key aim to ensure people have sufficient knowledge and understanding of their health care. The "Must Do with Me" elements of person-centred care …
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 …
Response Pending
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.
Gov response: Trust disciplinary procedures updated to address professional code breaches independently.
Accepted