This is a legal requirement as set out in the Health, (Tobacco, Nicotine etc and Care) (Scotland) Act 2016 and The Duty of Candour Procedure (Scotland) Regulations 2018, to ensure that if something goes wrong in health or social care services that the people affected are offered an explanation, an apology, and an assurance that staff will learn from this error. Learning is shared with the people affected, within the organisation, and across the sector as required.

The purpose of the Duty of Candour is to ensure organisations are open, honest and supportive when there is an unexpected or unintended incident resulting in death or harm. We must activate the Duty of Candour procedure as soon as reasonably practicable after becoming aware that:

  • An unintended or unexpected incident occurred in the provision of the health, care or social work service provided by the organisation as the responsible person;

  • In the reasonable opinion of a registered health professional not involved in the incident:

    1. a)  that incident appears to have resulted in or could result in any of the outcomes outlined in the

      table below; and

    2. b)  That the outcome relates directly to the incident rather than the natural course of the person’s

      illness or underlying condition.

2022-23 Report

It is a requirement that we produce an annual Duty of Candour Report as below:

Type of unexpected or unintended incident  Number of times this happened
Someone has died 0
Someone has permanently less bodily, sensory, motor, physiological or intellectual functions 0
Someone’s treatment has increased because of harm 0
The structure of someone’s body changes because of harm 0
Someone’s life expectancy becomes shorter because of harm 0
Someone’s sensory, motor or intellectual functions is impaired for 28 days or more 1*
Someone experienced pain or psychological harm for 28 days or more 1*
A person needed health treatment in order to prevent them dying 0
A person needed health treatment in order to prevent other injuries 1

During the period 1st April 2022 – 31st March 2023 two incidents triggered the Duty of Candour. One incident with the * above covered two of the descriptions. These were our first incidents which triggered the Duty of Candour since its introduction in 2018.

Both incidents were identified promptly as triggering Duty of Candour and our procedure was followed with full investigations from our external H+S Consultancy firm and relevant external and internal reporting. Both families received an apology and explanation. Appropriate steps were taken in both cases to prevent a recurrence, and learning was shared across the organisation through our Health and Safety meetings, Branch Lead network and Wider Leadership Team meetings. We have also reviewed our internal recording processes and organisational Duty of Candour response process to strengthen these areas.

Our Training, Policy and Procedure

Cornerstone’s policy is that all colleagues undertake the Duty of Candour e-learning module, which has been available on Kallidus, our training system, since May 2018. Training statistics are monitored monthly, shared across the organisation and reminders about this e-learning are given regularly via our weekly internal communication bulletin or individually as appropriate. As of 10th April 2023, 97% of current colleagues had completed this training. The 3% who have still to complete the training includes new colleagues who are required to complete this course over their first six months, people who are on long term absence or not working currently, and a few who are only just over the six months. Completion rates show an improvement from the 95% a year ago, demonstrating continued commitment to Duty of Candour within the organisation.

Our Duty of Candour policy and supporting resources are currently being updated following learning from the above incidents. These are available to colleagues via our Microsoft Teams platform. Should an incident occur which triggers implementation of Duty of Candour, the Registered Manager will notify the Care Inspectorate, Health and Safety Executive and any other appropriate body. A Senior Leadership Team member will lead the organisational response including the apology to the person/ family and will delegate responsibilities as appropriate. Each incident will be fully investigated, documented and reported, and current Scottish Government advice will always be followed. Where appropriate, our external Health and Safety Consultant will also be involved.

The SLT Lead will meet with relevant others and assess any report findings, identify required action and ongoing learning. The full lessons learned will be shared organisationally as appropriate.

Our external and confidential 24/7 support service (AXA BeSupported) is available to all colleagues and will be promoted if Duty of Candour is triggered. Our Quality and Service Delivery Committee of the Board of Directors will be kept updated on any Duty of Candour incidents.

What have we learned?

In order to implement the statutory Duty of Candour we have made e-learning on this subject mandatory for all colleagues and reviewed our internal policies and guidelines. These are currently being updated following the two incidents this year triggering the duty, and further resources are being developed to support the process in the event of an incident. We identified the need for a named SLT lead in the event of an incident, a clearer time frame for actions needed, and improved information resources for those managing the incident.

We identified the need to continue to monitor training statistics regularly to ensure adherence to our policy, and issue regular targeted email reminders to relevant colleagues. This has improved the figures of those who have been with us over six months but have not completed this essential eLearning. We have learned from exploring why this situation has occurred and ensuring colleagues fully understand their responsibilities.

We have also identified the need for continuing promotion of Duty of Candour awareness after the initial eLearning completion and encourage colleagues to refresh their knowledge regularly. We continue to encourage open discussions over potential Duty of Candour situations as a learning for all.

If you would like more information about this report, please contact the Quality Improvement Team on [email protected] or 0300 131 333 option 1 then option 7.

Click here for the downloadable version of our Duty of Candour Report 2022 - 2023

Duty of Candour Report 2021 - 2022

Duty of Candour Report 2020 - 2021

Duty of Candour Report 2019 - 2020