24 Accepted

Involve patients and relatives in incident investigation

Morecambe Bay Investigation · Report of the Morecambe Bay Investigation · Issued 3 March 2015 · Addressed to: CQC

Source — verbatim from the inquiry

Inquiry recommendation

We commend the introduction of the duty of candour for all NHS professionals. This should be extended to include the involvement of patients and relatives in the investigation of serious incidents, both to provide evidence that may otherwise be lacking and to receive personal feedback on the results. Action: the Care Quality Commission, NHS England.

Morecambe Bay Investigation, Report of the Morecambe Bay Investigation · 3 Mar 2015 Source PDF →

Published evidence summary

Publicly available evidence relating to this recommendation:

- In July 2015, the government stated: "We accept this recommendation" and confirmed that the organisational duty of candour was now in force as a condition of CQC registration (Learning Not Blaming, Cm 9113, Department of Health, July 2015).
- The duty of candour (CQC Regulation 20) has been in force since November 2014, requiring providers to inform patients of safety incidents and set out what enquiries will be undertaken (Health and Social Care Act 2008 (Regulated Activities) Regulations 2014).
- The GMC and NMC published joint professional duty of candour guidance on 29 June 2015, including advice on apologising to patients when things go wrong (Learning Not Blaming, Cm 9113, Department of Health, July 2015).
- The NHS England Serious Incident Framework (March 2015) requires providers to involve patients and families in investigations and share findings (Learning Not Blaming, Cm 9113, Department of Health, July 2015).

Response — verbatim from government

CQC

37. We accept this recommendation. A duty of candour has been introduced.
38. A lack of openness and honesty at Morecambe Bay was a fundamental cause
of both the distress of the families, and of the inability of the Trust to learn from
serious incidents. At a regulatory, provider and professional level action is being
taken to increase the involvement of patients/relatives in investigation of serious
incidents.
39. All providers must now comply with a new legal requirement for openness – the
duty of candour – as a condition of their registration with the Care Quality
Commission and hence a condition of their providing care. Providers must now
inform patients where there has been a significant failure in their care or treatment
and set out what further enquiries will be undertaken into the incident and to inform
patients of the outcome of such enquiries. Registered providers must also seek and
act on feedback from patients in order to improve services. We believe that these
requirements address the recommendation. However, we will keep the effectiveness
of the duty of candour under review and will consider whether further changes are
needed in due course.
40. The new NHS England Serious Incident Framework, published on 27 March
2015, also requires providers to: comply with national requirements and guidance in
relation to being open with patients or their representatives when things have gone
wrong; support and enable staff in disclosing incidents to patients and their
representatives; and involve patients and families/carers in investigations, sharing
findings and facilitating specialist support where appropriate.
41. In addition, all healthcare professionals including doctors, nurses and midwives
have an individual professional duty of candour, which is a responsibility to be open
and honest. This responsibility is set out in their respective professional codes of
conduct. In October 2014, the Department welcomed a joint statement by eight of
the statutory regulators of healthcare professionals, including the General Medical
Council and the Nursing and Midwifery Council, reaffirming that every healthcare
professional must be open and honest with patients when something goes wrong
with their treatment or care. Similarly, the Department is pleased to note that the
General Medical Council and the Nursing and Midwifery Council launched their new
joint guidance on the professional duty of candour on 29 June 2015, which includes
advice on apologising to patients when things go wrong.
42. The Government fully expect both individuals and organisations to comply with
these processes; and will also seek further advice from the expert group considering
the national investigations capability on:
• how any new investigation function can ensure a genuine commitment to
openness,
transparency
and
engagement
with
patients
and
their
families/carers throughout the investigation process; and,
• whether this can be made an integral objective of any investigative process.

CQC · 16 Jul 2015 Written response →

Evidence trail — what's actually happened since

  • 31 Dec 2015 Duty of candour requirements strengthened with guidance on involving patients and families in investigations. Source →

Each entry above links to a primary source — gov.uk written statement, consultation response document, or inspection report. The Index does not characterise government intent; it tracks what has been published.

How this page is built

Source and Response are verbatim from primary documents. The Evidence trail records published activity since — written statements, consultation outcomes, inspection findings, parliamentary references. The Index does not paraphrase or characterise intent; it tracks what has been published. Where the evidence is the absence of action (a missed deadline, a slipped timetable), that absence is documented from primary sources rather than inferred.

This recommendation's data is verified periodically against primary sources. The Index is monitored for staleness weekly.