Transcript Duty of Candour - Southern Health NHS Foundation Trust

Duty of Candour - Southern
Health NHS Foundation Trust
Carlton Sadler, Senior Associate
6 February 2015
Duty of Candour - Southern Health NHS Foundation
Trust
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Contractual Duty and Sanctions
Statutory Duty and Sanctions
Statutory Duty – thresholds
Delivering candour
Professional Duties
CQC Inspection
Candour case studies
The size of the problem
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Estimated that one in ten patients admitted to hospitals in developed
countries will be unintentionally the victim of an error.
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Around 50% of these events could have been avoided, if lessons
from previous incidents had been learned.
Carruthers & Philip (2006) Safety First – a report for patients, clinicians and healthcare
managers.
Candour
“To err is human, to cover up is unforgivable, to fail to learn is
inexcusable”
– Sir Liam Donaldson
Candour
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“I’d far rather be treated by a doctor who at some stage in their
career has made a mistake, owned up to it, learnt from the mistake
and become a better doctor as a result of that” – Peter Walsh
AvMA
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“if I was going to be choosing -- if the only information I had was
reporting systems for my choice of hospital, I would choose the one
with the highest possible reporting rate” – Prof Charles Vincent
“What is required now is a real change in
culture, a refocusing and recommitment of all
who work in the NHS – from top to bottom of
the system - on putting the patient first”
- Robert Francis QC
Candour (and more)
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Openness: enabling concerns to be raised and disclosed freely
without fear, and for questions to be answered;
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Transparency: allowing true information about performance and
outcomes to be shared with staff, patients and the public;
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Candour: ensuring that patients harmed by a healthcare service
are informed of the fact and that an appropriate remedy is offered,
whether or not a complaint has been made or a question asked
about it.
Candour (and more)
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Openness
• Complaints - Facilitating / quarterly publishing
• Raising concerns and Whistle blowing
• ‘Gagging’ clauses
Duties of candour
• professional
• contractual
• statutory
Transparency
• ‘duty of co-operation’
• Inquest disclosure
• Offence – false or misleading information
Candour – the duties
Candour – the contractual duty
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SC 35 – since 1 April 2013
(and change to NHS Constitution)
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“Reportable Patient Safety Incident” – moderate or
severe harm or death
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“occurs or is suspected”
Candour – the contractual duty
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“Reportable Patient Safety Incident” – a Patient Safety Incident which
involves moderate harm or severe harm
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“Patient Safety Incident” - any unintended or unexpected incident that
occurs in respect of a Service User, during and as a result of the provision
of the Services, that could have led, or did lead to, harm to that Service
User
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Moderate: Any patient safety incident that resulted in a moderate increase
in treatment and which caused significant but not permanent harm, to one
or more persons receiving NHS-funded care.
Severe: Any patient safety incident that appears to have resulted in
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permanent harm to one or more persons receiving NHS-funded care.
Candour – the contractual duty
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Notify “as soon as practicable, but in any event within 10
Operational Days”
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Verbal/ in person “including, where possible the clinician
responsible for the episode of care”
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Provide all facts the provider knows about
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Appropriate Apology
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Offer of written notification
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“a step by step explanation of events and circumstances which
resulted in the incident and any other pertinent information …
updated as the investigation proceeds”
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Copy of the investigation report (35.1.6)
Candour – the contractual duty
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Provider failure to comply – Co-ordinating Commissioner:
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Notifies CQC
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Requires formal written apology and explanation to the
Relevant person
Provider to “publish details of that failure prominently” on its
website
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Can implement contractual consequences – deductions
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“Recovery of the cost of the episode of care, or £10,000 if the cost
of the episode of care is unknown or indeterminate”
- SC 35.3 and 4
Candour – the statutory duty
A statutory obligation should be imposed to observe a duty of candour:
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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 provide such information and
explanation as the patient reasonably may request;
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On registered medical practitioners and registered nurses …
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The provision of information in compliance with this requirement should not
of itself be evidence or an admission of any civil or criminal liability, but
non-compliance with the statutory duty should entitle the patient to a
remedy.
- MSI r 181
Candour – the statutory duty
Candour – the statutory duty
Candour – the statutory duty
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Regulatory requirement – s 81 Care Act 2014
Health and Social Care Act 2008 (Regulated Activities)
Regulations 2014 – regulation 20
Threshold – ??
• ‘health service bodies’
• other providers
Direct prosecution – Level 4 fine
Providers
Directors etc “consent/ connivance/ neglect”
Candour – the statutory duty
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Threshold – ‘significant harm’
(Dalton/ Williams – March 2014)
death
Severe harm
Moderate harm
‘notifiable to CQC’
Health and Social Care Act 2008
(Regulated Activities) Regulations 2014
Threshold – health service bodies
“notifiable safety incident” means any unintended or unexpected
incident that occurred in respect of a service user during the provision
of a regulated activity that, in the reasonable opinion of a health care
professional, could result in, or appears to have resulted in—
(a) the death of the service user, where the death relates directly to the
incident rather than to the natural course of the service user’s illness or
underlying condition, or
(b) severe harm, moderate harm or prolonged psychological harm to
the service user;
Notifiable Safety Incident - thresholds
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“severe harm” means a permanent lessening of bodily, sensory, motor,
physiologic or intellectual functions, including removal of the wrong limb or
organ or brain damage, that is related directly to the incident and not
related to the natural course of the service user’s illness or underlying
condition.
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“moderate harm” means—
(a) harm that requires a moderate increase in treatment, and
(b) significant, but not permanent, harm;
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“moderate increase in treatment” means an unplanned return to surgery,
an unplanned re-admission, a prolonged episode of care, extra time in
hospital or as an outpatient, cancelling of treatment, or transfer to another
treatment area (such as intensive care);
Cf – draft Regulations (July 2014)
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“In relation to the provision of health care services,
“notifiable safety incident” means a safety incident that
appears to have resulted in—
(a) the death of the service user, where the death
relates to the incident rather than to the natural
course of the service user’s illness or underlying
condition, or
(b) severe harm or moderate harm to the service
user”.
Delivering candour
Candour – a history lesson?
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“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” – MSI r 180
Candour – a history lesson?
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Being Open – NPSA (2005 – reissued in 2009)
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It is Step 5: Involve and communicate with patients and the public (in
Seven steps to patient safety)
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Benefits for the organisation include:
- reinforces a culture of openness;
- potentially reduces the costs of litigation;
- improves the patient experience and satisfaction with the
organisation;
- greater opportunity to learn when things go wrong
Candour – practicalities
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Mechanisms of Being open
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Apology – meaningful, not delayed for investigation
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Professional support - to ensure a robust and consistent approach to
incident investigation, healthcare organisations are advised to use the
NRLS’s Incident Decision Tree
Candour - practicalities
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Mechanisms of Being open (cont’d)
Risk management
- Root Cause Analysis, Significant Event Audit (SEA) or similar should be
used to uncover the underlying causes of the incident.
- every organisation’s Being open policy should be integrated into local
incident reporting and risk management policies and processes
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Clinical (Quality) governance
- Being open involves a system of accountability through the chief
executive to the board to ensure implementation and review of
effectiveness.
- Continuous learning programmes and audits should be developed that
allow healthcare organisations to learn from the patient’s experience of
Being open
Candour – practicalities
Being open actions
Boards
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Identifying executive and non-executive leads responsible for ensuring that
the Being open principles and policy are embedded in the organisation.
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Ensuring that a Being open policy is in place and fully implemented
throughout the organisation – the policy must be fully integrated with other
policies, especially clinical governance, risk management and concerns
and complaints policies
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Gaining assurance that a training programme is in place to raise
awareness amongst all staff of the Being open framework
The statutory duty
20.—(1) A health service body must act in an open and
transparent way with relevant persons in relation to care
and treatment provided to service users in carrying on a
regulated activity.
The statutory duty
20 (2) As soon as reasonably practicable after becoming aware that a notifiable safety
incident has occurred a health service body must—
(a) notify the relevant person that the incident has occurred in accordance with paragraph
(3), and
(b) provide reasonable support to the relevant person in relation to the incident, including
when giving such notification.
(3) The notification to be given under paragraph (2)(a) must—
(a) be given in person by one or more representatives of the health service body,
(b) provide an account, which to the best of the health service body’s knowledge is true,
of all the facts the health service body knows about the incident as at the date of the
notification,
(c) advise the relevant person what further enquiries into the incident the health service
body believes are appropriate,
(d) include an apology, and
(e) be recorded in a written record which is kept securely by the health service body.
The statutory duty
20 (4) The notification … must be followed by a written notification given or sent
to the relevant person containing—
(a) the information provided under paragraph (3)(b),
(b) details of any enquiries to be undertaken in accordance with paragraph
(3)(c),
(c) the results of any further enquiries into the incident, and
(d) an apology.
Duty of candour – extracts from
CQC guidance
20(1) A health service body
must act in an open and
transparent way with relevant
persons in relation to care and
treatment provided to service
users in carrying on a
regulated activity.
The Being Open Framework referenced below provides guidance on
the action that organisations can take to create a culture that supports
staff to act in an open and transparent way. In meeting this component
of the regulation, providers must consider the following:
• There should be a board level commitment to being open and
transparent in relation to care and treatment.
• The culture of the organisation should encourage candour, openness
and honesty at all levels, as an integral part of a culture of safety that
supports organisational and personal learning.
• The provider should have policies and procedures in place to support
a culture of openness and transparency, and ensure these are followed
by all staff.
• The provider should take action to tackle bullying, harassment and
undermining in relation to duty of candour, and must investigate any
instances where a member of staff may have obstructed another in
exercising their duty of candour.
• The provider should have a system in place to identify and deal with
possible breaches of the professional duty of candour by staff who are
professionally registered, including the obstruction of another in their
professional duty of candour. This is likely to include an investigation
and escalation process that may lead to referral to their professional
regulator or other relevant body.
Duty of candour – extracts from CQC guidance
20(2) As soon as reasonably
practicable after becoming
aware that a notifiable safety
incident has occurred a health
service body must–
20(2)(a) notify the relevant
person that the incident has
occurred in accordance with
paragraph (3),
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… the relevant person must be informed as soon as reasonably
practicable after the incident has been identified. The NHS Standard
Contract requires that the notification must be within at most 10 working
days of the incident being reported to local systems, and sooner where
possible.
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The Being Open Framework referenced below provides guidance on
how to ensure good communication with the patient, their families and
carers.
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Where the degree of harm is not yet clear but may fall into the above
categories, the relevant person must be informed of the notifiable safety
incident in line with the requirements of the regulation.
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The NHS body is not required by the regulation to inform a person using
the service when a ‘near miss’ has occurred …
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Appropriate arrangements to notify [person acting lawfully on patient’s
behalf] when person affected by incident:
- 16 years and over and lack capacity
- under 16 and not competent
- dies
Other than the situations outlined above, information should only be
disclosed to family members or carers where the person using the
service has given their express or implied consent.
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Duty of candour – extracts from CQC guidance
20(2)(b) provide
reasonable support to the
relevant person in relation
to the incident, including
when giving such
notification
The provider must give the relevant person all reasonable support
necessary to help overcome the physical, psychological and emotional
impact of the incident. This could include all or some of the following:
- Offering emotional support during the notifications, for example
from a family member/ friend/ care professional/ trained advocate.
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Offering access to … e.g. via interpretative services, non-verbal
communication aids, written information, Braille etc.
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Providing access to any necessary treatment and care to recover
from or minimise the harm caused where appropriate.
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Providing the relevant person with information about available
impartial advocacy and support services, their local Healthwatch
and other relevant support groups, eg Cruse Bereavement Care
and AvMA, to help them deal with the outcome of the incident.
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Arranging for care and treatment to be delivered by another
professional, team or provider if this is possible, should the relevant
person wish.
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Providing support to access its complaints procedure.
Duty of candour – extracts from CQC guidance
20(3) – Initial
Notification
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A step-by-step account of all relevant facts known about the incident at the
time … include as much or as little relevant information as the relevant
person(s) want to hear, … and should be jargon free and explain any
complicated terms.
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The provider must also explain to the relevant person what further enquires
they will make.
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The provider must ensure that a meaningful apology is given, in person, by
one or more appropriate representatives of the provider to relevant persons.
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In making a decision about who is most appropriate to provide the notification
and/or apology, the provider should consider seniority/ relationship to the
person using the service/ experience and expertise.
Note:
• On occasion, a provider may discover a notifiable safety incident that
happened some time ago, or one that relates to care that was delivered by
another provider. The provider that discovers the incident should work with
others who are responsible for notifying the relevant person of the incident.
Duty of candour – extracts from CQC guidance
20(4) The notification given
under paragraph (2)(a) must
be followed by a written
notification given or sent to
the relevant person
containing—
(a)the information provided
under paragraph (3)(b),
(b)details of any enquiries to
be undertaken in
accordance with paragraph
(3)(c),
(c)the results of any further
enquiries into the incident,
and
(d)an apology.
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...
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The outcomes or results of any inquiries and investigations must
also be provided in writing to the relevant persons, should they
wish to receive them.
Duty of candour – extracts from CQC guidance
20(5) But if the relevant
person cannot be contacted
in person or declines to
speak to the representative
of the health service body–
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The provider must make every reasonable attempt to contact the
relevant person through all available communication means. All
attempts to contact the relevant person must be documented.
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If the relevant person does not wish to communicate with the
provider, their wishes must be respected and a record of this
must be kept.
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If the relevant person has died and there is nobody who can
lawfully act on their behalf, a record of this should be kept.
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…
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Any correspondence from relevant person(s) relating to the
incident should be responded to in an appropriate and timely
manner and a record of communications kept.
(a) paragraphs (2) to (4) are
not to apply, and
(b) a written record is to be
kept of attempts to contact
or to speak to the relevant
person.
(6) The health service body
must keep a copy of all
correspondence with the
relevant person under
paragraph (4).
Duty of candour - Dalton/ Williams
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“for all its technological advances, healthcare is a deeply human business.
Systems and processes are necessary supports to good, compassionate
care, but they can never serve as its substitute. It follows from this that
making a reality of candour is a matter of hearts and minds more than it is
a matter of systems and processes, important as they can be. A
compliance-focused approach will fail. If organisations do not start from the
simple recognition that candour is the right thing to do, systems and
processes can only serve to structure a regulatory conversation about
compliance. The commitment to candour has to be about values and it has
to be rooted in genuine engagement of staff, building on their own
professional duties and their personal commitment to their patients” – para
32
“hearts and minds more than …
systems and processes”
“It is the intention of the Trust to ensure that all adverse incidents and near
misses are reported in order to ensure that all known hazards to the health, safety
and well being of staff, patients and others are eliminated wherever possible, and as
a minimum reduced to the lowest level reasonably practicable.
It needs to be emphasised that the Trust adopts an ‘open and fair’ policy in the
investigation of adverse incidents. The overriding principle of such a policy is that
when things have gone wrong, the Trust places more emphasis on taking
corrective action to improve practice rather than to apportion blame and take
punitive action. This is based on the assumption that Trust staff act in good faith.
This does not however mean that disciplinary action will not be taken where
appropriate and necessary following on from an investigation…
Accurate and timely reporting of all adverse incidents is an essential part of
the risk reduction process.”
MSNHSFT Adverse Incident policy (May 2007)
Duty of candour - Dalton/ Williams
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The importance of consent
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“where practitioners are isolated, they are likely to need
support to ensure that they are candid”
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CQC – “looking for patterns in organisational behaviour
rather than one-off breaches (though stark cases will of
course merit particular scrutiny).”
- para 10
Dalton/ Williams – Australian Open Disclosure
Framework
Professional Duties
Candour – professional duties
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“The professional regulators will develop new guidance to make it clear
professionals’ responsibility to report ‘near misses’ for errors that could
have led to death or serious injury, as well as actual harm, … and will
review their professional codes of conduct to bring them into line with this
guidance.” – Hard Truths vol 2 p157
Candour – professional duties
Be open and candid with all service users about all aspects of care and treatment,
including when any mistakes or harm have taken place
To achieve this, you must:
14.1 act immediately to put right the situation if someone has suffered actual harm for any
reason or an incident has happened which had the potential for harm
14.2 explain fully and promptly what has happened, including the likely effects, and apologise
to the person affected and, where appropriate, their advocate, family or carers, and
14.3 document all these events formally and take further action (escalate) if appropriate so they
can be dealt with quickly.
- para 14 NMC Code (Jan 2015)
“You must be open and honest with patients if things go wrong. If a patient under your care has
suffered harm or distress, you should:
a. put matters right (if that is possible)
b. offer an apology
c. explain fully and promptly what has happened and the likely short-term and long-term effects”
– para 55 Good Medical Practice
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Openness and honesty when things go wrong: the
professional duty of candour
A draft for consultation – NMC/GMC – 4 November
2014
http://www.gmc-uk.org/Openness_and_honesty___Draft_guidance.pdf_58423740.pdf
NMC/ GMC draft guidance (November 2014)
NMC/ GMC draft guidance (November 2014)
NMC/ GMC draft guidance (November 2014)
Doctors and nurses told to say
sorry for mistakes – Daily telegraph 4 November
2014
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But the British Medical Association (BMA) said staff must not be
forced to apologise and take the blame for failings before it was
established where the fault lay.
Mahlersghost "the British Medical Association (BMA) said staff must not
be forced to apologise and take the blame for failings before it was
established where the fault lay."
Bloody right. As with a car accident, say NOTHING like "I'm sorry"
since that's tantamount to admission off guilt in the eyes of the law.
By all means. once blame has been established, but not till then,
EVER. Even if you know it IS your fault!
“The way you change the culture of the organisation is by
having conversations that don’t result in action plans. We
talk about it! … What I want the organisation to know is
we’ve talked about it. Changing culture – it is about signs,
symbols and iconography and it’s about lots of things. You
change the culture by talking”.
(Chief executive, case study respondent) –
Nuffield Trust
Thresholds for Health service bodies
Contract
Death
Severe
harm
Moderate
harm
‘Could’
cause the
above
Low Harm
Near Miss
Francis
Draft Regs Regs
Prof Duty
CQC Inspection
Duty of candour – CQC guidance
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We expect to mainly use the new regulations on candour to confirm or
encourage good practice through the ratings we give, rather than to
enforce them directly.
Criminal sanctions have a role to play – but by themselves they are
unlikely to be the strongest driver for promoting a culture of openness in
providers.
We will … develop the processes that our inspectors will use to inspect
and enforce the duty of candour … and ensure that our approach is
proportionate, for example taking account of the degree of harm and the
extent to which a breach was an act of omission as opposed to
commission.
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We will not shy away from using the full weight of our powers, but we
anticipate that this will be in cases where we have evidence of deliberate
withholding or manipulation of information.
Scrutiny of candour
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CQC intelligent monitoring system reviews:
- staff surveys and whistleblowing to CQC
- “Moderate” and “Serious” incidents reported to
NRLS
- incidents not reported as “Moderate” or “Serious”
Scrutiny of candour (CQC November 2014)
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During our inspections we will sample the records of a number of
notifiable safety incidents and determine whether:
- The notification was given by a representative of the provider.
- The relevant person received (to the best of the provider’s
knowledge) a true account of the incident to date.
- The provider explained what further enquiries were being
made.
- The provider included an apology (defined as an expression
of sorrow or regret in respect of the incident).
- The action taken was recorded in writing and kept securely.
Kent and Canterbury Hospital inspection
(August 2014) – what rating?
Kent and Canterbury Hospital inspection
(August 2014) – what rating?
The Legal Implications of Apologies
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An apology is not a legal admission of liability
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Negligence - a determination for the court
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Admissions of fact may influence the question
of liability at common law
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NHSLA’s position
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“The NHS LA is not an insurer and we will never withhold cover for
a claim because an apology or explanation has been given”
- Saying Sorry leaflet
http://www.nhsla.com/Claims/Documents/Saying%20Sorry%20%20Leaflet.pdf
Concluding thoughts
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Classification of incidents
? ‘candour’ field in Datix
Policies – integrate
Training/ candour champions?
EVIDENCE candour
Culture of organisation should encourage candour
Tackle bullying or harassment undermining the duty of
candour
System in place to deal with breaches of a professional
duty of candour by staff
Sign up to Safety
•
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3 year plan
Reduce avoidable harm by 50%
Save 6,000 lives
If eligible, members will have the potential to
access a one off payment to support
implementation of their SIP plans.ie up to 10%
of current contribution, paid in 2015/16.
Candour case studies
Is the duty of candour triggered?
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where there has been a failure to implement a discharge care plan in
time for discharge (due to an error)?
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where a patient in hospital subject to delayed discharge contracts C.
diff?
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By a resuscitation events?
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In relation to harm done to deceased patients (eg grazes to a
deceased patient's body in the mortuary)?
Is the duty of candour triggered?
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where a detention is unlawful based on a technicality (ie where there
has been an administrative error on a form) but the individual would
have been detained in any event?
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where there has been inadvertent disclosure of information to the
nearest relative, where the patient has expressly refused permission
for information to be shared?
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Cancellation of a patient’s hip-replacement surgery for two weeks due
to decontamination issues in theatre?
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Patient assaults healthcare assistant with a knife resulting in staff
member suffering severe injury and patient prosecuted for GBH. A
SIRI report is produced by the Trust.
Duty of candour – case study 1
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Julie is a 65 year old who suffers from dementia. She is currently detained under s.2 MHA on
Wood Ward. Other than this, Julie is fit and well. Julie has been assessed as a high risk of falls
and she is meant to be receiving 1:1 care. However, due to a bout of influenza, Wood Ward is
short staffed and instead, Julie is receiving 15 minute observations.
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Julie is found on the floor next to her bed by an HCA undertaking observations. Nursing staff
attend and request a medical review. The junior doctor assesses Julie and determines that she
has no obvious injuries and requests neurological observations for the next 2 hours.
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Unfortunately, no neurological observations are undertaken. 3 days later Julie presents with
increased confusion and dizzy spells. She has lost the use of her right arm. Investigations are
undertaken and a CT scan shows that Julie has suffered a bleed on the brain consistent with a
stroke. Sadly, it is too late for Julie to receive surgical treatment to reverse the symptoms of the
stroke.
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Due to her dementia, Julie lacks capacity to make decisions about her care and treatment. She
has 2 daughters who visit her most days.
Duty of candour – case study 2
Bob suffers from treatment resistant schizophrenia. He lives in the community with his
mother and is under a CTO. Bob is prescribed clozapine, an antipsychotic, which is
delivered to Bob on a weekly basis by his CPN. Bob takes clozapine in a liquid format
and the pharmacy dispense it in individual daily doses.
When Jess, Bob's CPN visits, Bob appears to have deteriorated. His mother informs Jess
that Bob stopped taking his clozapine 4 days ago.
Jess speaks with the pharmacist over the telephone who explains that Bob's clozapine
will need to be re-titrated from a much lower dose. Instead of returning the medication
and re-issuing it in individual bottles, Jess and the pharmacist agree that the pharmacist
will provide a re-titration chart, setting out the dosage that Bob needs to receive each day
for the next 7 days. Jess arranges for a registered nurse to visit Bob each day to draw up
the right dosage of his clozapine from his pre-existing supply.
Duty of candour – case study 2
(cont’d)
Jess is not able to visit Bob for 3 days, but she goes to see him on day 4 of his retitration. She reviews his medication chart and considers the re-titration chart. Jess
realises that the nurses that have visited Bob over the past couple of days have
miscalculated the dosage and that Bob has actually received a minor overdose. Jess
undertakes a thorough physical examination and determines that Bob does not appear to
be suffering from any side effects.
As part of receiving clozapine, Bob is required to have routine blood tests, so Jess draws
some blood to determine the levels of clozapine in his system. Given that Bob is not
displaying any adverse side effects, Jess is reluctant to inform him of the overdose
unless and until the blood test results show that he has a dangerous level in his system.
One of Bob's presenting complaints of his schizophrenia is paranoia and Jess is very
worried that if she advises him of the mistake, he will refuse to accept treatment at all.
Duty of candour – case study 3
Darren is referred to mental health services and offered an
outpatient appointment for 1 September. Darren does not
attend the appointment but subsequently contacts the Trust
requesting a further appointment, which is arranged for 11
September.
However, Darren commits suicide on 9
September.
Duty of candour – case study 4
Warren is referred to mental health services and offered an
outpatient appointment for 1 September.
Warren's
appointment on 1 September is subsequently cancelled by
the Trust, due to a shortage of staff, and rearranged for 11
September. However, Warren commits suicide on 9
September.
Duty of candour – case study 5
A Community Intervention Crisis Team operates flexible
appointments when they plan to see patients at home
during a particular 'window' within the day. However, the
Crisis Team member gets held up dealing with Tina so that,
when they arrive at Stephanie's house just outside of the
allotted time, Stephanie is no longer there and cannot be
contacted.
Is the duty of candour triggered?
Any Questions?
Contact:
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t: 0870 194 1633
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