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Duty-Of-Candour-Policy-V1.0-09.01 Duty of Candour Policy FINAL 09.01.17 Document Control Title Duty of Candour Policy Author Author’s job title Head of Corporate Governance Directorate Department Strategy & Transformation Corporate Governance Date Version Status Comment / Changes / Approval Issued 0.1 06.10.16 Draft Initial version for consultation 0.2 26.10.16 Draft Draft amended to reflect comments from consultation and to include template letters 0.3 09.01.17 Draft Revised to incorporate recommendations from CQC review into the way NHS Trusts review and investigate patient deaths, ‘Learning, candour and accountability’, published December 2016 1.0 09.01.17 Final Approved by Safer Care Delivery Committee Main Contact Head of Quality & Safety Tel: Direct Dial – 01271 314168 Level 5 North Devon District Hospital Raleigh Park Barnstaple, EX31 4JB Lead Director Director of Nursing Superseded Documents Being Open & Duty of Candour Policy v5.0 24Mar15 Issue Date Review Date Review Cycle April 2017 April 2020 Three years Consulted with the following stakeholders: Head of Quality & Safety Director of Nursing Assistant Director of Nursing Divisional Nurses Medical Director Deputy Medical Directors Associate Medical Directors Approval and Review Process Quality Assurance Committee Local Archive Reference G:\Corporate Governance\Head of Corporate Governance Local Path Miscellaneous\Policies\Duty of Candour Filename Duty of Candour Policy v0.3 09.01.17 Policy categories for Trust’s internal Tags for Trust’s internal website (Bob) website (Bob) Openness, transparency, patient harm, being Corporate Governance, Clinical open Governance Corporate Governance G:\Corporate Governance\Compliance Team\Policies Procedural Documents\Published Policy Database\Patient Safety\being open\Duty of Candour Policy v1.0 09.01.17.docx Page 1 of 21 Duty of Candour Policy FINAL 09.01.17 CONTENTS Document Control……………………………………………………………………………………………..1 1. Purpose .................................................................................................................................... 4 2. Background .............................................................................................................................. 5 3. Definitions ................................................................................................................................ 5 Candour .................................................................................................................................... 5 Apology ..................................................................................................................................... 5 Notifiable safety incident ............................................................................................................ 6 Moderate harm .......................................................................................................................... 6 Severe harm .............................................................................................................................. 6 Prolonged psychological harm ................................................................................................... 6 Prolonged pain .......................................................................................................................... 6 Relevant person ........................................................................................................................ 6 4. Responsibilities ....................................................................................................................... 7 Role of the Medical Director and Director of Nursing .................................................................. 7 Role of the Quality Assurance Committee .................................................................................. 7 Role of professionally registered staff......................................................................................... 7 Role of all staff ........................................................................................................................... 7 5. Being open and honest when things go wrong ...................................................................... 8 Informing people about an incident ............................................................................................ 8 Providing reasonable support .................................................................................................... 9 Giving an apology .................................................................................................................... 10 Providing information ............................................................................................................... 10 6. Continuity of care .................................................................................................................. 10 7. The duty of candour meeting ................................................................................................ 11 Who should attend? ................................................................................................................. 11 Where should it be held? ......................................................................................................... 11 How should information be communicated? ............................................................................. 11 What should be documented? ................................................................................................. 12 Following-up ............................................................................................................................ 12 Sharing an investigation report................................................................................................. 12 8. Demonstrating compliance with duty of candour ................................................................ 13 Documenting compliance ......................................................................................................... 14 9. Support for staff ..................................................................................................................... 14 10. Training for staff .................................................................................................................... 15 11. Notifying the regulatory bodies............................................................................................. 15 12. Monitoring Compliance with and the Effectiveness of the Policy ....................................... 15 Standards/ Key Performance Indicators ................................................................................... 15 Process for Implementation and Monitoring Compliance and Effectiveness .............................. 16 13. Equality Impact Assessment ................................................................................................. 16 14. References ............................................................................................................................. 17 15. Associated Documentation ................................................................................................... 17 Corporate Governance G:\Corporate Governance\Compliance Team\Policies Procedural Documents\Published Policy Database\Patient Safety\being open\Duty of Candour Policy v1.0 09.01.17.docx Page 2 of 21 Duty of Candour Policy FINAL 09.01.17 Quick reference guide Moderate harm Prolonged Notifiable safety psychological Severe harm incident occurs harm Death Prolonged pain Provide To the patient To staff affected immediate and their family support Line-manager Complete Inform others incident report Duty manager on DATIX Speak to the Respond Explain what patient / their honestly to Notify patient happened family in person questions Ensure Provide Explain what appropriate Identify single can be done to reasonable support point of contact remedy support available Meaningful Sincere Give an apology expression of Face-to-face sorrow or regret Advise of any Give additional Provide Send DOC investigations or information as it follow-up letter information enquiries arises Update Advise of information and investigation Repeat apology Follow-up progress of findings investigations Share report Record all Document Add copy of Document conversations in compliance with follow-up letter patient notes duty of candour to patient notes Corporate Governance G:\Corporate Governance\Compliance Team\Policies Procedural Documents\Published Policy Database\Patient Safety\being open\Duty of Candour Policy v1.0 09.01.17.docx Page 3 of 21 Duty of Candour Policy FINAL 09.01.17 1. Purpose 1.1. The purpose of this document is to promote clear, honest and effective communication with patients, their families and carers throughout their care and treatment, in line with the requirements under the Duty of Candour. 1.2. It sets out some specific requirements that healthcare professionals and NHS organisations must follow when things go wrong with care and treatment, including informing people about the incident, providing reasonable support, providing clear and factual information, and giving an apology. 1.3. It also incorporates recommendations from the Care Quality Commission’s publication in December 2016 of a review into the way NHS Trusts review and investigate the deaths of patients, ‘Learning, candour and accountability’ and the need to ensure that deceased patients’ families are given an opportunity to engage in the mortality
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