Duty of Candour — What to Do After a Patient Safety Incident

So far in this course, we have focused on preventing patient safety incidents and responding when they occur. But what happens after an incident? This lesson covers the duty of candour — the legal and ethical obligation to be open and honest with patients when things go wrong.

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What Is the Duty of Candour?

The duty of candour is a legal requirement in the NHS (introduced by the Health and Social Care Act 2008 and strengthened following the Francis Inquiry into Mid Staffordshire NHS Foundation Trust). It requires healthcare organisations and professionals to:

1. Tell the patient (or their family) when something has gone wrong
2. Apologise sincerely
3. Explain what happened and what is being done about it
4. Support the patient through any consequences
5. Learn from the incident to prevent recurrence

The GMC reinforces this in Good Medical Practice:

"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 put matters right (if that is possible), offer an apology, and explain fully and promptly what has happened and the likely short-term and long-term effects."

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Why the Duty of Candour Matters in the SJT

The SJT frequently tests whether candidates understand that:

1. Honesty is non-negotiable — even when it is uncomfortable or could lead to complaints
2. Apologising is not admitting liability — saying sorry is a professional and human response
3. Cover-ups are always wrong — concealing errors is more dangerous than the errors themselves
4. Reporting is a duty, not optional — incident reporting is how the NHS learns and improves
5. Patients have a right to know — withholding information about their care is a breach of trust

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The Post-Incident Response Framework

When a patient safety incident has occurred, the following steps should be taken (in order):

Step 1: Ensure Immediate Safety

Before anything else, make sure the patient is safe. If the incident has caused ongoing harm (e.g., wrong drug still infusing), resolve the immediate danger first.

Step 2: Inform the Clinical Team

The responsible clinician must be informed immediately. As a medical student, your role is to ensure the right people know — not to manage the clinical consequences yourself.

Step 3: Be Open with the Patient

The duty of candour requires that the patient (or their next of kin, if the patient lacks capacity) is told:

• What happened — in clear, non-technical language
• What the consequences may be — honestly, without minimising or catastrophising
• What is being done — to address the immediate harm and prevent recurrence
• An apology — sincere and empathetic

Step 4: Report the Incident

All patient safety incidents must be reported through the hospital's incident reporting system (typically Datix in the NHS). This applies to:

• Actual harm events
• Near-misses (incidents that could have caused harm but did not)
• "No harm" incidents (errors that occurred but did not affect the patient)

Step 5: Support the Patient and the Staff

Patients affected by incidents need ongoing support — clinical follow-up, emotional support, and regular updates on any investigation.

Staff involved in incidents also need support. Making an error is distressing, and a blame culture discourages reporting. The NHS promotes a "just culture" where honest reporting is encouraged and systemic issues are addressed.

Step 6: Investigate and Learn

Serious incidents trigger a formal investigation (previously known as a Root Cause Analysis, now part of the Patient Safety Incident Response Framework — PSIRF). The aim is not to blame individuals but to understand what went wrong and how to prevent it.

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Worked Example 1: The Drug Error You Witnessed

Scenario:

You are a medical student on a medical ward. You witnessed a nurse give the wrong antibiotic to a patient — ceftriaxone instead of cefuroxime. The nurse realised the error immediately after administration and is visibly distressed. She turns to you and says, "The patient seems fine. Maybe we don't need to tell anyone?"

Applying the SAFE Framework with Duty of Candour:

S — Spot the Risk: A drug error has occurred. Although the patient seems fine now, ceftriaxone and cefuroxime have different spectra, side effects, and interactions. The patient needs medical review.

A — Act Appropriately: The nurse is suggesting concealing the error. This violates the duty of candour and could put the patient at risk if delayed effects occur.

F — Follow the Right Path:

1. Be empathetic but clear: "I understand this is stressful, but we need to let the medical team know so they can check the patient is okay. Reporting this protects you as well as the patient."
2. The nurse should inform the nurse in charge and the responsible doctor.
3. If the nurse refuses, you must inform the nurse in charge or your clinical supervisor yourself. This is non-negotiable.
4. The patient must be told what happened (duty of candour).
5. The incident must be reported through the hospital's system.

E — Ensure Follow-Up:

• The patient should be monitored for adverse reactions
• The incident should be formally reported
• The nurse should be supported — this is likely a systemic issue (similar drug names), not negligence

SJT Ratings:

Action	Rating
Explain to the nurse that the error must be reported and the patient informed	Very Appropriate
Inform the nurse in charge and the responsible doctor	Very Appropriate
Agree to keep quiet because the patient seems fine	Very Inappropriate
Report the nurse to the NMC (Nursing and Midwifery Council) immediately	Inappropriate — disproportionate as a first response; the incident should be managed through local processes first

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Worked Example 2: The Patient Who Asks "What Went Wrong?"

Scenario:

A patient on the ward says to you: "The doctor told me there was a problem with my blood test results — they were mixed up with someone else's, so I've been getting the wrong treatment for two days. Nobody has really explained what happened. Can you tell me?"

Analysis: