Patient Safety Management Network: Strengthening understanding of Duty of Candour through collaboration

Summary

The Patient Safety Management Network (PSMN) recently held two insightful and collaborative sessions focused on the Duty of Candour—the legal requirement for healthcare organisations to be open and transparent with those receiving care and treatment. The session brought together a diverse group of experts from the Care Quality Commission (CQC), NHS Resolution and the PSMN members to explore common challenges and seek clarity on key aspects of this essential duty.

Through the joint effort between members of the PSMN and the invited experts a Frequently Asked Questions (FAQs) resource was produced that addresses the most pressing concerns about Duty of Candour. This collaborative approach ensured that the FAQ tool reflects the insights and expertise of those actively engaged in the regulation, implementation and oversight of candour practices. By pooling their knowledge, the team was able to provide clarity on a subject that often presents nuanced challenges to healthcare providers.

Content

Understanding the Duty of Candour

The PSMN sessions delved into both the statutory and professional Duty of Candour, highlighting their distinct but complementary roles:

• Statutory Duty of Candour Regulated by the CQC, this duty comprises two key elements:

1. Being open and transparent with patients at all times, regardless of whether an incident occurs.
2. Responding to notifiable safety incidents (NSIs) by following a defined process.

• Professional Duty of Candour This duty, overseen by professional regulatory bodies, encourages individual healthcare professionals to act with honesty and openness when something goes wrong.

Defining Notifiable Safety Incidents

A NSI is defined by three criteria:

1. The incident must be unintended or unexpected.
2. It should occur during the provision of a regulated activity (14 regulated activities are listed by the CQC).
3. In the reasonable opinion of a healthcare professional, the incident has resulted in, or might result in, death or severe or moderate harm.

Defining and identifying NSIs remains a challenge, particularly because harm thresholds differ between healthcare bodies and other providers. Discussions also highlighted how understanding ’unintended or unexpected‘ is tied to the incident not the outcome, which adds another layer of complexity.

CQC’s role in assessing Duty of Candour

While the CQC does not investigate every NSI, it assesses compliance with the Duty of Candour by focusing on organisational culture. Ensuring that openness and transparency are embedded in day-to-day practices is key to meeting regulatory expectations.

Guidance on saying sorry

NHS Resolution provided valuable guidance on “saying sorry”, reinforcing that an apology is not an admission of liability but an essential step in acknowledging that something could have been done better. This simple but powerful act can build trust and contribute to a culture of transparency.

A commitment to clarity and improvement

These PSMN sessions underscored the importance of continuous learning and collaboration in addressing complex safety issues. By bringing together regulators, safety experts and healthcare professionals, the PSMN has taken a significant step toward ensuring that the Duty of Candour is consistently understood and applied across all healthcare settings.

The creation of the FAQs page is not just a resource, it’s a testament to the power of collaboration in driving positive change and enhancing patient safety.

“Openness and transparency are not just regulatory requirements—they are the foundations of a culture that puts patients first.”

The Duty of Candour FAQs can be read here or downloaded from the attached pdf below.

PSMN_Duty of Candour FAQs_24032025.pdf

How to join the Patient Safety Management Network

You can join by signing up to the hub today. When putting in your details, please tick Patient Safety Management Network in the ‘Join a private group’ section. If you are already a member of the hub, please email [email protected].