In recent years there has been increasing emphasis on honesty and transparency in health care – particularly following a number of public inquiries into patient care failures. Any culture of secrecy or cover-up in health care is to be challenged, which has led to a focus on making ‘candour’ in health care mandatory.

Candour has been defined by the Professional Standards Authority as 'being open and transparent when something has gone wrong'. Currently, nurses are affected by both professional and statutory duties of candour.

Organisations registered with the Care Quality Commission (CQC) in England have a statutory duty of candour. Such organisations run the risk of criminal sanctions (fines and/or possible de-registration) if they fail to comply with the requirement to be open and honest when issues of concern are raised.

Part of the duty is to report back to the patient or relatives if there has been a ‘notifiable safety incident’, defined as:

 ‘any unintended or unexpected incident that … in the reasonable opinion of a healthcare professional could result in, or appears to have resulted in

 a) the death of the service user or

 b) severe harm, moderate harm or prolonged psychological harm to the service user’

The organisational duty does not include a requirement to tell the patient about ‘near-misses’, although this is recommended.

Similar provisions came into force in Scotland in 2018 and in Wales from 1 April 2023.

The provision remains under consideration in Northern Ireland.

The General Medical Council (GMC) and the Nursing and Midwifery Council (NMC) produced joint guidance on the professional duty of candour: Openness and honesty when things go wrong: The professional duty of candour. It sets out professional standards on what health and care professionals in the UK should do if something goes wrong during patient care.

Failure to comply with these principles could lead to Fitness to Practise processes against registered nurses, midwives and nursing associates.

The combination of the above duties means that when things go wrong, practitioners provide an account of the facts that are known at the time - face to face if possible - as soon as possible after the mistake has been discovered. The practitioner should also advise on what further enquiries might need to be made and should make an apology.

The NMC/GMC guidance offers specific advice on how to make an apology that is meaningful, and points out that an apology does not mean that the practitioner is accepting legal liability for what has happened, nor that the practitioner is accepting any personal responsibility for the mistakes of others or for systemic failings.

A verbal apology may need to be followed up by a written apology, depending on the patient’s wishes and on your workplace policy.

Helpfully, the guidance does reflect upon who should take responsibility for these actions, as follows:

We recognise that care is normally provided by multidisciplinary teams, and we don’t expect every team member to take responsibility for reporting adverse incidents and speaking to patients if things go wrong. However, we do expect you to make sure that someone in the team has taken on responsibility for each of these tasks, and we expect you to support them as needed.

If you are asked to prepare ‘the candour letter,’ the RCN advises you to seek further support from your employer as it is the provider of the service that must take more responsibility.

If you are worried about what to do or find your employer is not being supportive, read the guidance above and contact us for further advice as needed.

Martha’s Rule: the introduction of a process for raising concerns about a patient’s deteriorating condition

The first phase of the introduction of Martha’s Rule was implemented by the NHS (England) in April 2024. Once fully implemented, patients, families, carers and staff will have round-the-clock access to a rapid review from a separate care team if they are worried about a person’s condition.

The three components of Martha’s Rule are:

1. Patients will be asked, at least daily, about how they are feeling, and if they are getting better or worse, and this information will be acted on in a structured way.
2. All staff will be able, at any time, to ask for a review from a different team if they are concerned that a patient is deteriorating, and they are not being responded to.
3. This escalation route will also always be available to patients themselves, their families and carers and advertised across the hospital.

The implantation of Martha's Rule will take a phased approach, beginning with sites who already offer 24/7 critical care outreach cover. The initial focused approach on the provider sites during 2024/25 will inform the development of the wider national roll out which will take place over 2025/26. There are also plans to roll out an adapted Martha's Rule model across other settings such as community and mental health hospitals.

CQC

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