The importance of being honest
Why owning up to mistakes is good practice
- By: Marika Davies, Medical Protection
Bethany Bowen was born with hereditary spherocytosis, a form of anaemia requiring regular blood transfusions. When she was 5 years old doctors recommended a splenectomy, which her parents agreed to in the hope it would help Beth to “keep up” with other children. The laparoscopic procedure should have been straightforward, but went drastically wrong when the operating team used an adult morcellator (like an apple corer) to remove the spleen. The device, which should never have been used on a child, caused fatal internal injuries. In the months after Beth’s death, her family struggled to get a full explanation of the causes of the tragedy from the hospital.
Daniel Sokol, a medical ethicist and barrister, says that the distress of losing a loved one can be compounded by an institutional refusal to be open about what happened. Doctors have had a professional duty to be open and honest with patients if things go wrong for many years. The General Medical Council advises doctors that if a patient under their care has experienced harm or distress they should put matters right, offer an apology, and provide a full explanation. But despite this professional duty, many patients and their relatives have experienced a culture of denial in the NHS, in which defensiveness, secrecy, concerns about reputation, and a fear of being sued have all contributed to a “wall of silence” when things go wrong. This prevents lessons being learnt and deprives patients of information they are entitled to know, a problem highlighted by several reports on patient safety over the past decade.
In February 2013 the Mid Staffordshire NHS Foundation Trust Public Inquiry (the Francis Report) was published. The inquiry uncovered serious failings in the quality and safety of care at the trust, and reported that openness and transparency, which are essential to providing high quality healthcare, were often ignored. The report proposed the establishment of a statutory duty of candour, which is a legal requirement to be open with patients when things go wrong, which was subsequently brought in by the government in November 2014.
What does the statutory duty of candour mean in practice?
The statutory duty of candour means that health service organisations such as hospital trusts, GP practices, and care homes are now legally required to tell a patient (or their representative) of any unintended or unexpected incident that causes moderate harm or worse (see box). The Care Quality Commission, the regulator of health services in England, enforces the duty and organisations that fail to comply risk criminal prosecution and a fine. The duty is an institutional one, but doctors have a professional obligation to cooperate and ensure the organisation can meet the requirements.
Is the duty of candour the same as whistleblowing?
No. The duty of candour is about being open with patients when things go wrong. Whistleblowing describes making a disclosure in the public interest. It means that if you believe there is systematic wrongdoing in your workplace, you can report this by following the correct processes and your employment rights will be protected by law. All NHS organisations should have a whistleblowing policy that sets out the process for raising concerns about patient safety.
The duty of candour
The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the statutory duty of candour.
Key points include:
- Healthcare providers must promote a culture that encourages candour, openness, and honesty at all levels.
- When a notifiable safety incident has occurred, the patient or their representative must be informed as soon as reasonably practicable after the incident has been identified.
- A notifiable patient safety incident is any unintended or unexpected incident that causes moderate harm, severe harm, death, or prolonged psychological harm.
- The patient (or their representative) must be given a full explanation of what is known at the time, and an apology. This should be given in person and then followed up in writing. Reasonable support must also be provided.
- The statutory duty is on the organisation, not the individual, but all those involved in the care of the patient should cooperate to ensure the obligation is met.
What will the duty of candour change?
Sokol says that the statutory duty of candour is potentially a huge change in the medicolegal landscape, but he warns there are barriers that stand in the way. “We know that there is a delay between legal developments and when that is translated at the frontline,” he says. “Clinicians must be aware of the existence of the duty of candour . . . not only that, they need to know what to do in practice when it happens,” he says.
Sokol also points out that knowing about the statutory duty of candour does not mean that anything will change in practice. What is needed, he says, is moral courage, which means standing up for what is morally right, such as admitting to a mistake, “even though you believe that something of personal value may be lost; that may be your reputation, friendships, or career prospects.” There would be less need for moral courage, says Sokol, if there was a change in culture in the NHS, to one of openness, honesty, and compassion. “For the duty of candour to have any concrete impact . . . it must be implemented throughout the NHS in a rigorous, visible, and systematic manner, with proper sanctions if there are breaches,” he says.
What role will medical students play in bringing in a culture of openness?
Susan Bewley, professor of complex obstetrics, at King’s College London, says that the focus for medical students should not be on the things that go wrong, and that they should not be expected to spot errors. Instead, she says, “they need to witness good workplace role models, they need space to pause and reflect, and they must remain curious and enabled to ask questions, particularly difficult ones,” she says.
Alistair Campbell, professor in medical ethics at the National University of Singapore School of Medicine, warns that the biggest challenge to culture change is making sure medical students encounter the right type of role models. “Unless practice changes, whatever we teach medical students will soon disappear,” he says. Anthony Haycroft, a barrister at Serjeants Inn Chambers, is more positive. He cites historical changes, such as the use of seat belts and crash helmets, drink drive laws, and banning smoking in public as clear positive examples of how culture can be changed, usually through education led by the law. “It may take years while trainee doctors, dentists, nurses, and new health managers come through the system trained in the duty,’’ Haycroft says, “but it is a worthwhile exercise.”
What obligations do medical students have to be open and honest?
Guidance set out by the GMC, says that students must report any concerns they have about patient safety. “During clinical placements at medical school, if you believe patient safety is at risk, or that patients’ care or dignity is being compromised, then you should in the first instance follow the procedure for raising concerns set out by your medical school,” it says. The GMC recognises that medical students, just like doctors, may be worried about the implications of raising a patient safety concern, and acknowledges that it is not always easy to speak out.
It’s not only when things go wrong that it is important to be honest with patients. David Molyneux, a general practitioner, believes that avoiding deception should be thought of as an almost absolute rule, and any potential downsides to this can be avoided or remedied by good communication skills. “When you find yourself in situations where you are considering deceiving a patient think ‘are there any ways of communicating with this patient that avoid the need to lie?’” says Molyneux. He gives the example of a patient who asks if they will live long enough to attend their granddaughter's wedding which, he says, “could lead to a discussion of their fears about dying and of the things that they want to do before they die.” Honesty, says Molyneux “underpins everything that doctors do . . . without it you cannot develop any significant trust or any kind of relationship with patients.”Marika Davies, , , Medical Protection,
Competing interests: MD is a medicolegal adviser for Medical Protection.
Provenance and peer review: Commissioned; not externally peer reviewed.
- Protection M. The story of Beth Bowen. 2014. www.medicalprotection.org/uk/casebook/casebook-september-2014/the-story-of-beth-bowen
- General Medical Council. Good medical practice. 2013. www.gmc-uk.org/guidance/good_medical_practice/respect_patients.asp.
- UK government. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. www.gov.uk/government/publications/report-of-the-mid-staffordshire-nhs-foundation-trust-public-inquiry.
- General Medical Council. Good clinical care. www.gmc-uk.org/education/undergraduate/26613.asp.
- Published: 06 July 2016
- DOI: 10.1136/sbmj.i1933