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:
  • that incident appears to have resulted in or could result in any of the outcomes outlined in the table below; and
  • That the outcome relates directly to the incident rather than the natural course of the person’s illness or underlying condition.

2023-24 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	0

During the period 1st April 2023 – 31st March 2024 two incidents triggered the Duty of Candour. This totals four incidents since the introduction of Duty of Candour in 2018.

Both incidents were identified promptly as triggering Duty of Candour, and our procedure was followed with full investigations, involvement from our external Health and Safety consultant, and relevant external and internal reporting. The families/guardians 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, Registered Managers Forum and Wider Leadership Team meetings. This included circulation of the relevant HSE guidance and alert, and also reminders and input on our recording and reporting expectations.

Our Training, Policy and Procedure

As part of a wider review of our core training, and in alignment with our current operating structure, this year we decided to make Duty of Candour Elearning mandatory only for those in management roles, and optional for front line colleagues. We also introduced a two year refresher period for this course. All colleagues however gain an awareness of Duty of Candour through their organisational induction, and will read the policy as part of our Adult Support and Protection training every two years. The Duty of Candour Elearning remains available to all colleagues on our training platform Kallidus.

Our new policy is that all managers (and selected others in alignment with their role responsibilities) undertake this Duty of Candour Elearning module within their first six months of employment and two yearly thereafter. Training statistics are monitored monthly, shared across the organisation and reminders about this Elearning are given individually as appropriate. As of April 2024, 93% of current managers had current accreditation for this course with others due to complete it.

Our Duty of Candour policy and supporting resources have been updated this year and 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 identified Senior Lead will meet with relevant others and assess any report findings, identify required actions and ongoing learning. Lessons learned will be shared organisationally as appropriate.

Our external and confidential 24/7 support service (Legal and General Spectrum Life) 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?

Following a Duty of Candour incident in 2022-23 we have introduced a new mandatory eating and drinking checklist for people we support, and a lessons learned presentation was rolled out across the organisation. Following an incident this year we have increased our awareness and practice around the safe use of hot water practice and heat packs.

We improved our processes for dealing with incidents triggering Duty of Candour under the oversight of a Senior Colleague, which has worked well. This includes the use of a timeline to show key events and steps in the process which has proved helpful. We intend to further update our internal policies and guidelines following our experience of the incidents this year.

We have also identified the need for continuing promotion of Duty of Candour awareness 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.

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Click here for a downloadable copy of our Duty of Candour Report for 2023 - 2024

Duty of Candour Report 2022 - 2023

Duty of Candour Report 2021 - 2022

Duty of Candour Report 2020 - 2021

Duty of Candour Report 2019 - 2020