Duty of Candour

Pamela Parker Lead Sonographer Background

• 27th November 2014 marked an historic moment for NHS in England • Statutory duty of candour comes into force following two decades of campaign Background

• Regulation 20: Duty of Candour • March 2015 • Care Quality Commission Definition

• A legal duty to be open and honest with patients or their families when things go wrong that can cause harm

• Duty of Candour aims to help patients receive accurate, truthful information from health providers

Definition

• ‘Any patient harmed by the provision of a healthcare service is informed of the fact and an appropriate remedy offered, regardless of whether a complaint has been made or a question asked about it’ www.professionalstandards.org.uk Why?

• 24% The percentage of NHS trusts that regularly inform patients of safety incidents. • 1 Million : The estimated number of patient safety incidents in English hospitals every year • 50% The percentage of patient safety incidents that are avoidable Why?

• £9 -10 billion :The potential liability of the NHS; (based on reporting from NHS trusts about medical accidents, deemed to be negligence risks). Development

• “Robbie’s Law” Robbie’s Law

• In December 1989, Robbie Powell aged 10, of Ystradgynlais in Wales is hospitalised for four days. • He loses 25% of his body weight and is critically dehydrated. • The hospital suspects Addison’s disease • Doctors there order an ACTH test for the condition, but this isn’t followed through. Robbie’s Law

• The test recommendation isn’t communicated to the Powells, but is communicated to his GPs. Instead the Powells are told by the hospital that Robbie suffers from gastroenteritis caused by a throat infection Robbie’s Law

• Four months later, in April 1990, Robbie again suffers from vomiting, weight loss and acute stomach pains. • He is seen seven times by five doctors over 15 days. • None of them perform the basics: check symptoms, do a blood test or refer to the hospital. Robbie’s Law

• Only one doctor checks the medical records, containing the crucial warning from the hospital. • He dies from critical dehydration as a result of Addison’s disease. Robbie’s Law

• His death could have been avoided, but due to a combination of mismanagement, dishonesty and deliberate cover-up, none of the doctors are prosecuted

http://www.robbieslawtrust.co.uk/summary/ Outcome

• Robbie’s Law and the Duty of Candour is born from a seriously dire need for openness and honesty in healthcare. • Robbie’s Law means that healthcare staff must tell patients and their next of kin the truth, when a patient safety incident occurs Openness

• Letter sent to the patient with apologies given about what had happened. • The patient came to see the treating GP shortly after receiving the letter. • He had been giving thought to speaking to a solicitor about the delay in diagnosis • On reflection he had been struck by the openness, the apologies and the care and support of the GP Learning

• The patient felt that the most important thing to happen was for the doctors to learn from the incident

Being Open When Errors Are Made • Open discussions between the patient and the healthcare provider when things go wrong. • Acceptance by healthcare staff that open conversations will take place at an early stage. • Reduction in overly defensive approaches to information sharing about incidents in relation to the patient in question. Triggers

• The death of a patient when due to treatment received or not received (not just their underlying condition). • Severe harm - in essence permanent serious injury as a result of care provided. • Moderate harm - in essence non permanent serious injury or prolonged psychological harm. Moderate harm - US

• Misdiagnosis leading to unnecessary surgery • Misdiagnosis leading to delays in treatment • Therapeutic treatment delivered incorrectly How do we deal with this?

Duty of Candour Radiology Report Discrepancy Flowchart

Radiology Report Discrepancy Flowchart

Radiology review meeting held & discrepancy identified

Level of radiological discrepancy determined at review

Grade 2 and 3 with reasonable Grade 0 or Grade 2 and 3 Grade 1 (no clinical likelihood of clinical significance significance) Ultrasound to discuss Radiology Lead for the discrepancy meeting discusses with referring clinical team and informs discrepancy with referrer via letter of error and any remedial actions Radiologist before taken (such as arranged further scans) notifying referrer.

Not significant Significant

Radiology records incident on DATIX

Decision by referrer/clinician following discussions between Radiology and the clinical team. Should the patent be informed?

Yes

No Actions taken to provide patient with explanation and apology recorded on DATIX by service or specialty lead 10 days Moderate (2) Major (3)

Date apology provided recorded on DATIX by member of staff who gave the apology

Written apology offered to the patient/family

Error recorded in discrepancy meeting notes DATIX closed if Grade 2 or 3 Written apology is provided to the

patient/family

Letter sent to Summary of discrepancy [email protected] for meeting notes discussed at inclusion on DATIX RMT on a quarterly basis and included in Imaging DIG report

Moderate (2) Major (3)

Serious Incident / Never Event investigation Yes or No

Investigation concluded

Letter including Letter offering to outcomes and learning share final report and approved by Health an offer to meet with Group triumvirate prior the panel to discuss to sending to the the report sent to patient/family patient/family 10 days

Letter sent to [email protected] for inclusion on DATIX

The incident investigation must be shared with the patient/family. This includes action plans, details of investigations and means actual written reports and if necessary, plain English explanations of their contents.

Radiology Report Discrepancy Flowchart

Radiology review meeting held & discrepancy identified

Level of radiological discrepancy determined at review

Not significant Significant

Radiology records incident on DATIX

Decision by referrer/clinician following discussions between Radiology and the clinical team. Should the patent be informed?

Yes

No Actions taken to provide patient with explanation and apology recorded on DATIX by service or specialty lead 10 days Moderate (2) Major (3)

Date apology provided recorded on DATIX by member of staff who gave the apology

Written apology offered to the patient/family

Error recorded in discrepancy meeting notes DATIX closed if Grade 2 or 3 Written apology is provided to the

patient/family

Letter sent to Summary of discrepancy [email protected] for meeting notes discussed at inclusion on DATIX RMT on a quarterly basis and included in Imaging DIG report

Moderate (2) Major (3)

Serious Incident / Never Event investigation Yes or No

Investigation concluded

Letter sent to [email protected] for inclusion on DATIX

• Errors discussed and graded at discrepancy meeting • Where deemed to be a moderate disagreement in the report an apology is given via the referring clinician • Actions recorded

21/04/2015 US Urinary tract

This examination has been reviewed as part of the department's internal governance and audit procedure and a disagreement with the original report has been highlighted.

Images do not provide reasonable evidence of the presence of calculi in the left kidney and may be due to artefact from the arcuate arteries.

We are sorry for any inconvenience caused to you and Mr XXXX and would be grateful if you could apologise on our behalf to the patient, if deemed appropriate by yourself. What is an apology?

• Clinical staff may • In reality candour is worry that being open all about sharing with patients may accurate information compromise the with patients ability to deal with a • The facts are the claim if one is facts and staff should subsequently made be supported to help by the patient patients understand what has happened to them.

What is an apology?

• Where staff should be • It can be more more cautious is damaging to a where the facts are relationship with the not yet know or where patient to speculate they are being asked inaccurately than to to speculate beyond investigate and find what is known. the facts and then provide the extra information.

Apology or Admission of Liability

• Saying sorry is not an admission of liability; it is the right thing to do • NHS LA does not withhold cover if an apology or explanation has been given www.nhsla.com

Actions • Understand your organisation's incident reporting process • Understand your role within the organisation's statutory Duty of Candour requirements • Ensure there is support for you and your staff throughout this process • Engage with clinicians to develop a clear and open process