Duty of Candour in Health and Social Care

August 20, 2021
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Anyone working in health and social care has a responsibility to support service users and promote their wellbeing, which also includes their family and loved ones. An important element of high-quality care is honesty. Therefore, when something goes wrong, health and social care workers must tell the service user, their advocate, carer or family and apologise. This is also known as duty of candour and is a regulation under the Health and Social Care Act 2008 as well as a crucial part of care.

This article explains duty of candour, how it relates to health and social care workers as well as the different approaches and who uses them. It will also provide insight into potential situations or dilemmas in which duty of candour should be enforced.

What is Duty of Candour in Health and Social Care?

Duty of candour means every healthcare worker must be open and honest with patients when something goes wrong with their treatment or care. It is a legal obligation that care providers must inform the people affected by the incident, offer reasonable support, provide truthful information and a timely apology.

Duty of candour is now embedded into the NHS contract and Care Quality Commission (CQC) regulations. The first step is notifying the appropriate person, explaining what is known about what happened and offering an apology. This should also be put in writing and the appropriate person should be informed about the investigation that will be carried out. Furthermore, the potential short- and long-term effects of what has happened should be fully explained. The findings of the investigation should then be fed back to the appropriate person.

Everyone that works in health and social care has a duty of care for those they work with, therefore they should fulfil the duty of candour. To do this, employees should apologise for the harm caused, regardless of fault, and be open and transparent about what has happened.

There are two duties involved in duty of candour: professional and statutory. Both aim to ensure that those providing care are open and transparent with the people using their services, whether or not something has gone wrong. Although both are relatively similar, it is helpful to understand the differences, in order to realise their importance.

The Professional Duty of Candour

The professional duty of candour states that all healthcare professionals have the duty to tell the service user, or their family, advocate or carer, when something has gone wrong. It is different from the statutory duty of candour as it is regulated by specific healthcare professions such as the General Medical Council (GMC), Nursing and Midwifery Council (NMC) and the General Dental Council (GDC).

The Statutory Duty of Candour

The statutory duty of candour was introduced after the professional duty of candour, but also aims to make sure care providers are open and transparent. Statutory duty of candour covers all care providers registered with, and regulated by, the CQC.

It is different to the professional duty of candour as it contains specific requirements for situations known as notifiable safety incidents. This refers to unintended, unexpected incidents that occurred during a regulated activity which has, or might, result in severe harm or death. If a notifiable safety incident occurs, carrying out the professional duty of candour alone will not be enough to meet the requirements of the statutory duty of candour. It is important to note that for nurses, both the professional duty of candour and the statutory duty of candour apply.

Why is the Duty of Candour Important?

Duty of candour is an incredibly important element of providing high quality care. Service users and their loved ones deserve to know details of the care they are receiving and the truth about any incidents that occur. Duty of candour is also a key part of providing person-centred care by respecting service users through being honest and involving them in their care.

Another consideration is that duty of candour forms consistent responses across health and social care providers. When there has been an unexpected event or incident that has resulted in death or harm, all care services should respond following the procedures laid out in the duty of candour regulations.

The concept of being open and honest when something goes wrong during treatment or care has been expected of professionals for a long time, however it wasn’t specifically enforced or regulated. Therefore, the CQC introduced duty of candour as a regulation which came into effect for NHS bodies in 2014, and all other bodies regulated by CQC in 2015. This ensures every care professional is carrying out the duty of candour to the same standards.

A survey conducted by the Behavioural Insights Team in 2018 revealed that only 31% of medical patients felt they received an apology after a mistake. 63% of patients were given no explanation and 71% believe the organisation did not conduct an investigation into their incident. This highlights the importance of the duty of candour to ensure patients do not feel left in the dark or misled when it comes to medical accidents or incidents.

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A crucial part of duty of candour is apologising. Apologising acknowledges that something could have gone better and is the first step to learning from the incident and preventing it from reoccurring. Nevertheless, it is important to note that while apologising is always the right thing to do, it is not an admission of liability.

Furthermore, duty of candour is important because:

  • It allows for steps to be taken to mend the relationship between the service user and the care provider after an incident.
  • It ensures the service user and their family or carers are not left in the dark over an incident.
  • The service user receives a genuine apology for what happened from the people involved.
  • Care providers are able to offer guidance and support, or remedy the mistake.
  • Internal actions can be taken to prevent the mistake from occurring in the future.

Understanding Duty of Candour Legislation

Duty of candour is part of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 20. It sets out specific requirements that providers must follow when things go wrong in treatment or care. This ensures that care providers are open and transparent with service users, their family, carers and advocates.

The regulation also outlines guidance for details of accountability when reporting, investigating and managing the incidents, when to apply duty of candour, how to disclose investigation results and how to communicate information.

If you work in health and social care, familiarising yourself with the guidance provided in the duty of candour legislation is incredibly important. This will help to prepare you for potential incidents where you will need to put this guidance into practice.

Recognising Duty of Candour Scenarios

The CQC and GMC state that duty of candour should be applied in circumstances where something goes wrong with a patient or service users care which results in harm.  Harm can be organised into different severities ranging from moderate to severe, and even resulting in death.

Below are some example scenarios in which duty of candour must be applied, they differ in severity of the harm caused to the service user:

Moderate – A service user suffers with hay fever and has been advised by a pharmacist to take antihistamines every eight hours. This information was not passed on to other staff or updated in their care plan so the service user went without antihistamines for 24 hours and suffered with their allergies. This qualifies as a notifiable safety incident, therefore all steps outlined in the duty of candour should be carried out.

Severe – An occupational therapist completed a mobility assessment and advised that grab rails were needed in the service user’s bathroom. The therapist advised that staff should support the service user with washing until the grab rail was installed. The next morning staff did not assist the service user as they had forgotten about the update, the service user fell when getting out of the bath and broke his arm. This qualifies as a notifiable safety incident, therefore all steps outlined in the duty of candour should be carried out.

Death – Staff were administering first aid to a service user for a small scratch on their arm. The staff member inspected the scratch wearing latex gloves as they were unaware of the service user’s latex allergy. The service user suffered anaphylactic shock and was hospitalised. The service user did not make a full recovery and passed away. This qualifies as a notifiable safety incident, therefore all steps outlined in the duty of candour should be carried out.

A ‘notifiable safety incident’ is a specific term used in the duty of candour regulation and should not be confused with other types of safety incidents or notifications.

To be considered a notifiable safety incident, the incident must meet the following criteria:

  • It must have been unintended or unexpected.
  • It must have occurred during the provision of an activity the care provider regulates.
  • In the opinion of the healthcare professional, it already has, or might, result in death, or severe or moderate harm to the person receiving care.

A notifiable safety incident can happen whenever and wherever, so the most important point is that you know how to recognise one and how to respond. If an incident meets the three criteria outlined above, it is a notifiable safety incident and the duty of candour procedures should be followed. If something does not qualify as a notifiable safety incident, there is always an overarching duty of candour to be open and transparent with people using the service.

Responsibilities of the Duty of Candour

The responsibilities related to duty of candour include:

  • Telling the relevant person, face to face, that an incident has occurred.
  • Apologising to the relevant person.
  • Providing a true account of what happened, explaining what is currently known.
  • Giving a full explanation of the long- and short-term effects, offering an appropriate remedy or support.
  • Following up by providing this information, and the apology, in writing.
  • Keeping a full, written record of all meetings and communications.
  • Informing regulators such as CQC and raising concerns where appropriate.

The ‘registered person’, often this will be the manager or leader of the organisation, is responsible for carrying out, or delegating the responsibility for carrying out, the duty and must liaise with the ‘relevant person’. The ‘relevant person’ is either the person who was harmed or someone acting lawfully on their behalf.

As a healthcare worker, if you were involved in a notifiable safety incident you are responsible for providing an apology. The purpose of duty of candour is to share all information openly and with compassion and support as the person who was harmed has a right to understand what happened to them. Duty of candour is not about trying to place blame; therefore, apologies should be simple, straightforward expressions of sorrow and regret.

As mentioned previously, CQC regulate the statutory duty of candour. CQC monitor, assess and inspect whether care providers are enforcing duty of candour through calls and assessing data they receive. There are consequences for breaching duty of candour which can involve the CQC using their powers of enforcement, under regulation 20, and moving directly to criminal enforcement action.

Free Duty of Candour Letter Template

A duty of candour letter is provided for service users, their family, or carers after something has gone wrong with their care. The letter is a follow up from the initial conversation that should happen after an incident and should put the discussion in writing, including:

  • A summary of what happened.
  • An apology for what happened.
  • An explanation of the investigation that will be carried out.
  • The potential short- and long-term effects of what happened.
  • How the findings of the investigation will be communicated.
  • How any future findings or updates will be communicated.

The duty of candour letter is important as it reiterates what has already been said and gives the service user, their family or carer a reference point to check over and reread if they are uncertain about anything.

It also includes contact details of the care service and people who the service user, family members or carers can contact if they have any concerns or questions.

Here, we have included a template for a duty of candour letter that you can use to ensure you have included all the necessary details to meet regulations.

Duty of candour should be practiced by everyone working in health and social care as being open and honest ensures transparency between patients and their healthcare provider. The result of this is a better relationship and enhanced care that is constantly improving by learning from mistakes. If you work in health and social care you have a responsibility to follow the duty of candour.

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