Duty of Candour

Regulated Health and social care services in Scotland must comply with the duty of candour procedure. This is a legal requirement which means that when things go wrong and mistakes happen, the people affected understand what has happened, receive an apology, and we learn how to improve for the future.  

An important part of this duty is that we provide an annual report on duty of candour incidents in our services. This short report describes how our services have operated the duty of candour procedure between 1 April 2019 and 31 March 2020 

  1. How many incidents happened to which the duty of candour applies? 

In the period from 1 April 2019 – 31 March 2020, there was 1 incident to which the duty of candour applied.   

Incidents in which the duty of candour apply are unintended or unexpected incidents that result in death or harm as defined in the Act, and do not relate directly to the natural course of someone’s illness or underlying condition. 

Detail and number of Incidents  How Duty was carried out  Policy and procedure for reporting and identifying incidents 
1 incident –Someone experienced pain or psychological harm for 28 days or more.  Regional Manager met with family, providing apology and an account of what had happened. Family accepted apology.  The Duty of Candour policy and procedure was followed.  All other notifications to Care Inspectorate and Social Work were completed.  
  1. To what extent did TMF follow the duty of candour procedure?  

 Incidents that occur in our services are reported through the organisation Safeguarding reporting process. This ensures that our safeguarding team have opportunity to examine, discuss and determine if an incident should be classed as a duty of candour.   

Through the safeguarding team’s  assessment the above listed event was determined to be a duty of candouand steps were taken to ensure the duty of candour procedure was invoked, that the people affected were informed and apologies were made.  

  1. What have we learned? 

In the second year of implementing Duty of Candour: 

  • We have continued to support staff to understand the duty of candour process and the aims and values associated with the Act.  Evaluation of this awareness and development support demonstrates that it has been positively received with staff feedback showing that the guidance and training has been helpful.  
  • Alongside reporting our learning to the Care Inspectorate, we have shared our learning with social work and our commissioning colleagues to enable other colleagues to benefit from our learning  
  • Our annual reporting has become an item which will be assessed and refined for process improvements 
  • Our annual reporting has also become an item for our Trustees to discuss with safeguarding and candour incidents incorporated  in our risk register monitoring 
  • To continuously check that robust procedures are in place with all staff for locking cupboards in the affected service 
  • Clear guidelines and protocols should be updated regularly and signed by all staff supporting service users with specific health conditions which require specialised 1-1 support.  This will ensure that staff are clear on specific conditions and needs
  1. Information about our policies and procedures 

Where something has happened that triggers the duty of candour procedure, this is identified through our incident reporting process by staff.  The Project Manager works in conjunction with the Regional Manager who reports the incident to the Care Inspectorate.  When a duty of candour incident has happened, the manager and staff set up a learning review.  This allows everyone involved to review what happened and to identify changes for the future.     

All new staff learn about the duty of candour procedure during their Ready for Work Week induction training.  We know that serious mistakes can be distressing for staff as well as people who use our services and their families. We have support in place for our staff if they have been affected by a duty of candour incident.  

  1. Other information 

This is the second year of the duty of candour being in operation and it has been our first year to report a duty of candour incident.  It has been a year of learning and refining our existing processes to further enhance the organisational duty of candour requirements.  We also review all formal complaints for potential duty of candour and may initiate a significant adverse event review following receipt of a complaint.   

As required, we have advised Scottish Ministers of this report and we have also placed it on our website.   

If you would like more information about this report, please contact us using the contact details found on our website. 

Patricia Donnelly 

Chief Executive 


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