Jeremy Hunt’s announcement that the government will consider extending the legal duty of health professionals to be open and honest with patients or their families when mistakes cause harm is one of the most significant developments in patients’ rights and patient safety in recent history.
If extended, the duty of candour, which was originally recommended in the Francis report after the Mid Stafford hospital scandal, will apply in all cases of significant harm, including moderate and severe, not just in cases of death or serious injury. While the health secretary’s move is to be welcomed, the focus will now need to turn to developing organisational cultures where staff are supported and trained to be open with patients when things go wrong.
Healthcare staff want to provide the best possible care to patients and work hard to achieve this, but working in healthcare remains an inherently risky enterprise, and unfortunately errors will continue to occur. We are human, and therefore fallible, and staff are often working in complex environments where the condition of patients is highly variable and frequently unpredictable. As professionals they often struggle to come to terms with their own mistakes, which in itself can be an impediment to disclosure.
A “just culture” would need to recognise that mistakes are usually made by failures in systems or genuine human error, and that a mistake can have devastating consequences for all concerned.
For a number of years it has been recognised that a culture of fear, blame denial and secrecy does persist in some parts of the NHS, which makes it hard for staff to admit when things have gone wrong and to learn from their mistakes (1). In the past this has, accompanied by an era of unprecedented levels of litigation, contributed to a defensive position in the health service that has also led to an erosion of confidence and trust – especially after well-publicised consequences for whistleblowers who have tried to raise concerns.
So, the combination of the new duty of candour, alongside changes in the law offering more comprehensive protection for whistleblowers, represents a significant opportunity for change. But without also making sure there is strong leadership on hospital boards, within management and training, and a spotlight on organisations that are leading by building a culture of candour as part of a wider culture of safety, learning and improvement, then the opportunity will be lost.
At Southampton University, we’ve been engendering a duty of candour in students. Pre-registration education, undertaken prior to embarking on their careers, is one way of teaching aspiring professionals about the realities of errors and the importance of candour. By giving them the opportunity, at an early stage, to get to grips with the realities of professional error we hope they will assimilate these principles and equip them with the skills needed to come to terms with their own mistakes. We all make mistakes but ethical training that also reinforces the moral courage that is necessary to combat some of the disincentives to candour will hopefully aid culture change.
Regulatory bodies such as the Nursing and Midwifery Council are currently in the process of revising their guidance to accommodate the new duty of candour. They might wish to consider the language used in future standards, and describe appropriate professional behaviour “when” rather than “if” mistakes happen.