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Duty of Candour Duty of Candour GUIDANCE FOR SURGEONS AND EMPLOYERS Supports Good Surgical Practice Domain 3: Communication, Partnership and Teamwork Published: 2015 Professional Standards The Royal College of Surgeons of England 35–43 Lincoln’s Inn Fields London WC2A 3PE Email: [email protected] View Good Surgical Practice online: www.rcseng.ac.uk/surgeons/surgical-standards/professionalism-surgery/gsp Duty of Candour Duty of Candour GUIDANCE FOR SURGEONS AND EMPLOYERS This guidance was developed with the contributions of: Mr Leslie Hamilton, The Royal College of Surgeons of England Miss Susan Hill, The Royal College of Surgeons of England Mr Peter Lamont, The Royal College of Surgeons of England Miss Clare Marx, The Royal College of Surgeons of England Ms Katerina Sarafidou, The Royal College of Surgeons of England Dr Suzanne Shale, Clearer Thinking The College would like to thank Dr Suzanne Shale, Ethics Consultant at Clearer Thinking, for preparing the first draft. For further details, please refer to the Clearer Thinking website at www.clearer-thinking.co.uk 1 The Royal College of Surgeons of England CONTENTS A. OVERVIEW OF THE DUTY OF CANDOUR 4 B. PURPOSE OF THIS GUIDANCE 5 C. THE PROFESSIONAL DUTY OF CANDOUR FOR ALL DOCTORS 6 1. Current guidance 6 2. What do surgeons have to do? 6 3. Low harm and near misses 7 4. Parallels between consent and candour 8 5. Surgeons’ duty towards their employers and regulators 8 D. THE STATUTORY DUTY OF CANDOUR 9 1. Current legislation 9 2. Difference between the duty of individuals and the duty of organisations 10 3. The statutory duty of candour across the UK nations 11 E. OUTLINE OF A DISCLOSURE PROCESS 12 F. WHAT TO CONSIDER WHEN CARRYING OUT THE DUTY OF CANDOUR 14 1. Who should have the discussion with the patient? 14 2. Apology and liability 14 3. Timing, location and who should be notified 15 4. Supporting patients 16 5. Open communication 17 6. Documentation 19 7. Notifiable safety incident occurring elsewhere 20 2 Duty of Candour G. SUPPORTING SURGEONS AND SURGICAL TEAMS WHEN A SAFETY INCIDENT HAS OCCURRED – RECOMMENDATIONS FOR EMPLOYERS AND SURGEONS 21 H. BUILDING A CULTURE OF LEARNING, OPENNESS AND SAFETY – RECOMMENDATIONS FOR EMPLOYERS 23 1. Incident reporting and investigation 23 2. Learning and applying lessons to practice 24 3. Developing a culture of safety 24 I. EXPLANATION OF TERMS 26 REFERENCES AND FURTHER READING 30 3 The Royal College of Surgeons of England A. OVERVIEW OF THE DUTY OF CANDOUR In late 2014, new legislation (Health and Social Care Act 2008 (Regulated Activities), Regulations 2014, Regulation 20) introduced a statutory duty of candour for healthcare providers in England, to ensure that they are open and honest with patients when things go wrong with their care. This means that any patient harmed through the provision of a healthcare service should be informed of the fact and offered an appropriate remedy, regardless of whether a complaint has been made or a question asked about it. Although the statutory duty applies specifically to organisations, individual doctors are the representatives of those organisations in their interactions with patients and therefore need to understand and cooperate with relevant policies and procedures. Surgeons already have a professional duty to be open to their patients when harm occurs, set out in Good Medical Practice (GMC, 2013), and Good Surgical Practice (RCS, 2014). The introduction of the statutory duty provides an opportunity for surgeons to reaffirm the good practice of having a detailed postoperative discussion with each of their patients, explaining fully the course of their operation and all events that occurred between the first and last surgical contact. When an incident takes place that reaches the threshold of the statutory duty of candour, surgeons will be required to follow a defined process of disclosure, over and above their own professional duty, which is led and facilitated by their trust. It should be emphasised that the statutory duty of candour refers to safety incidents caused through the provision of care. It does not refer to recognised complications or undesirable outcomes that occur as part of the natural course of the patient’s illness or their underlying condition. 4 Duty of Candour B. PURPOSE OF THIS GUIDANCE This document provides guidance on both the professional and the statutory duty of candour for surgeons and their employers. It makes recommendations on how to communicate with patients who have suffered harm and how to support them. It also highlights the need to provide early support to surgeons and surgical teams who have been involved in harm, as a vital part of safety management and avoiding harmful incidents in the future. A full explanation of terms that underpin the duty of candour is provided in the last section of the document. Although this guidance has been developed mainly for surgeons and their employers, most of its recommendations are applicable to all medical specialties. 5 The Royal College of Surgeons of England C. THE PROFESSIONAL DUTY OF CANDOUR FOR ALL DOCTORS 1. Current guidance The professional duty of candour for all doctors is broadly set out in the GMC’s Good Medical Practice (GMC, 2013, page 18): “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.” In addition, the GMC, jointly with the Nursing and Midwifery Council, developed the document Openness and Honesty When Things Go Wrong (GMC, 2015) to elaborate on the professional duty of candour for all healthcare professionals. When it comes to surgeons, the main principles of the professional and ethical duty to be open and honest are also outlined in the College’s Good Surgical Practice (RCS, 2014, page 42): » Inform patients promptly and openly of any significant harm* that occurs during their care, whether or not the information has been requested and whether or not a complaint has been made. » Act immediately when patients have suffered harm, promptly apologise and, where appropriate, offer reassurance that similar incidents will not reoccur. » Report all incidents where significant harm has occurred through the relevant governance processes of your organisation. 2. What do surgeons have to do? All surgeons should have an open discussion with patients about a safety incident that resulted in harm. In practice, this means that surgeons should: • Notify patients (or, where appropriate, their supporters) of the incident as soon as possible once it is established that something has gone wrong with their care. 6 Duty of Candour • Provide a factual explanation of all the facts known about the incident at the date of notification. Share all relevant information known to be true, explaining if anything is still uncertain and respond honestly and fully to any questions. • Provide a verbal apology. The verbal apology may also need to be provided in writing if this is required by local policy or the patient requests it. • Explain fully to the patient the short- and long-term effects of the incident. • Offer an appropriate remedy or support to put matters right (if possible). • Explain the steps that will be taken to prevent recurrence of the incident (where relevant). • Record details of the discussion in the patient’s clinical record. 3. Low harm and near misses At the level of individual doctors, the duty of candour consists of an open and honest disclosure to patients about all safety incidents that have resulted in harm or have the potential to result in harm or distress regardless of their severity, including low harm. There is no expectation to disclose to patients near misses or incidents that have resulted in no harm. However, surgeons may decide to do so if they think that the patient may want to know this information and that the lack of disclosure may undermine the relationship of trust between surgeon and patient. Local trust policies may also require doctors to disclose no-harm incidents and near misses, depending on circumstances and the patient’s best interest. In every case, low-harm incidents as well as near misses and incidents that resulted in no harm must be reported through the trust’s local reporting systems to support learning and service improvement, and to avoid future harm. 7 The Royal College of Surgeons of England 4. Parallels between consent and candour Good Surgical Practice emphasises the importance of establishing and maintaining effective partnerships with patients. Evidence provided in the 2014 Dalton/Williams review Building a Culture of Candour (DH, 2014) suggested that having a candid conversation when something goes wrong is far easier when it forms part of an ongoing clinical relationship in which issues of risk and consent have been clearly discussed from the outset. Prior to a surgical procedure, and as part of the consent discussion, surgeons are required to provide information on the procedure and its implications, including the risks inherent in the procedure and any side effects and complications. Correspondingly, after the surgical procedure, the surgeon has a duty towards his or her patient to give an account of what happened during the operation. Surgeons should aim to have a detailed postoperative discussion with every patient as a matter of course, offering a full explanation of all events that happened between the first and last surgical contact. As with the consent process, the duty to be open and honest when things go wrong is not a one-off event, but a process that may require more than one meeting to ensure that all necessary information has been made available and that patients have had the opportunity to reflect on it, and to give patients the opportunity to ask questions.
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