Duty of Candour
Duty of Candour Awareness for Administration Staff
Organisation: WMI Psychiatry
Audience: Administration and non-clinical staff
Version: 2.0
Review date: 01 January 2027
Module owner: Registered Manager
Clinical approval: Nominated Individual
Pass mark: 12 out of 15
Recommended completion time: 60–75 minutes
Refresher frequency: Annually or sooner following a relevant incident or regulatory change
1. Purpose of this module
Duty of candour means being open and honest with people when something has gone wrong during their care or treatment.
This module explains:
what duty of candour means
the difference between general openness and the statutory duty of candour
what may constitute a notifiable safety incident
how administration staff may become aware of a concern
what administration staff must do when a possible incident is reported
what staff may and may not say
how apologies should be handled
how incidents should be recorded and escalated
how duty of candour interacts with complaints, safeguarding and data protection
how WMI Psychiatry should learn from incidents
The statutory duty of candour is established by Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
The regulation requires registered providers to act openly and transparently with people receiving care. It also sets formal notification requirements when a notifiable safety incident has occurred. CQC Regulation 20
This module is designed for administration staff. It does not authorise administration staff to:
decide whether the statutory legal threshold has been met
conduct a clinical investigation
assess the extent of clinical harm
provide a clinical explanation
speak on behalf of a clinician without authority
admit negligence or legal liability
contact a patient or family about an incident without authorisation
decide whether an incident must be reported to CQC
alter, conceal or remove information from a record
delay escalation while trying to establish every detail
Administration staff must recognise concerns, preserve information, report them promptly and support the authorised response.
2. Learning outcomes
By the end of this module staff should be able to:
Explain duty of candour in clear language.
distinguish between the general duty to be open and the statutory notification process.
Explain the difference between organisational and professional duties of candour.
Recognise information which may indicate that something has gone wrong.
Understand that not every incident is a notifiable safety incident.
Understand that administration staff do not decide whether the statutory threshold has been met.
Escalate a possible safety incident without unnecessary delay.
Respond appropriately when a patient or family member first raises a concern.
Avoid speculation, blame and unauthorised clinical explanations.
Understand the purpose of an apology.
Explain why an apology is not automatically an admission of legal liability.
Protect confidentiality during the candour process.
Make an accurate and contemporaneous record.
Understand how candour may operate alongside complaints, safeguarding and data protection procedures.
Contribute to organisational learning and safer care.
3. WMI Psychiatry local contacts and procedures
These details must be confirmed before the module is issued.
Internal escalation
Registered Manager: Caroline Lawrence
Contact method: [INSERT WORK CONTACT METHOD]
Nominated Individual: Dr James Glass
Contact method: [INSERT WORK CONTACT METHOD]
Duty of Candour Lead: [CONFIRM NAME AND CONTACT METHOD]
Responsible clinician: [INSERT ESCALATION METHOD]
Complaints Lead: [INSERT NAME AND CONTACT METHOD]
Safeguarding Lead: [INSERT NAME AND CONTACT METHOD]
Data Protection Lead: Dr James Glass
Contact method: [INSERT WORK CONTACT METHOD]
Out-of-hours escalation: Registered Manager or Nominated Individual
Contact method: [INSERT APPROVED METHOD]
Incident reporting system: WMI Psychiatry Incident Reporting System
Location of incident log: [INSERT LOCATION]
Location of duty of candour records: [INSERT LOCATION]
Location of complaints records: [INSERT LOCATION]
Location of current policies: WMI Google Drive
Location of business continuity information: WMI Business Continuity Policy
Staff must know
Before completing this module staff must know:
how to contact the Registered Manager
how to contact the responsible clinician
how to submit an incident report
how to identify an urgent incident
where relevant policies are stored
how to preserve emails, messages and records
what to do outside normal working hours
who is authorised to communicate with the patient or relevant person
4. What duty of candour means
Duty of candour is the requirement to be open and honest when something goes wrong during care or treatment.
Candour includes:
acknowledging that something has happened
informing the appropriate person
explaining the known facts
saying what will happen next
giving a sincere apology
offering reasonable support
carrying out further enquiries
providing a written follow-up where required
sharing the results of relevant enquiries
taking action to reduce the risk of recurrence
Candour is not limited to serious mistakes. WMI Psychiatry should promote openness whenever something goes wrong even if the formal statutory notification threshold is not met.
A culture of candour should make it easier for:
patients to ask questions
families to raise concerns
staff to report mistakes
clinicians to discuss uncertainty
managers to investigate incidents
the organisation to learn from events
Candour is not about assigning blame before the facts are known. It is about honesty, accountability and respectful communication.
5. General openness and statutory duty of candour
There are two related concepts.
General duty to be open and transparent
WMI Psychiatry must act openly and transparently with people receiving care.
This means staff should:
communicate honestly
avoid hiding relevant information
acknowledge concerns
correct inaccurate information
report mistakes
explain delays where appropriate
tell the relevant person when something has gone wrong
respond properly to reasonable questions
This responsibility applies broadly across the service.
Statutory notification process
The formal statutory process applies when a notifiable safety incident has occurred.
When the threshold is met the registered person must:
notify the relevant person as soon as reasonably practicable
provide an account of the facts known at that time
explain what further enquiries are considered appropriate
include an apology
provide reasonable support
keep a secure written record of the notification
provide written follow-up information
provide further information from enquiries where appropriate
record attempts to contact the relevant person if contact cannot be made
Administration staff must not assume that an incident either does or does not meet the statutory threshold.
The possible incident must be reported to the Registered Manager and responsible clinician. The authorised clinical and management leads will decide what process applies.
6. Organisational and professional duties
Organisational duty
The statutory organisational duty applies to the registered provider and registered manager.
WMI Psychiatry must have systems which support:
prompt identification of incidents
appropriate clinical review
communication with the relevant person
timely apologies
written follow-up
accurate record keeping
investigation and learning
staff training
management oversight
Professional duty
Doctors, nurses and other regulated healthcare professionals also have professional duties of candour.
The General Medical Council states that healthcare professionals must be open and honest when care or treatment goes wrong and causes or has the potential to cause harm or distress. GMC professional duty of candour
The organisational duty and the clinician’s professional duty may apply to the same incident.
Administration staff support these duties by ensuring that information is:
recognised
recorded
preserved
escalated
communicated to the right people
Administration staff do not take over the clinician’s professional responsibilities.
7. What is a notifiable safety incident?
A notifiable safety incident is a specific legal category. It is not simply any complaint, mistake or poor experience.
For an independent provider such as WMI Psychiatry the relevant threshold should be confirmed against the organisation’s legal registration status.
Subject to that confirmation the incident will generally need to be:
unintended or unexpected
connected with the provision of a regulated activity
considered by a healthcare professional to have caused or potentially caused one of the outcomes specified in Regulation 20
These outcomes include:
death which relates directly to the incident rather than the natural course of the person’s condition
impairment of sensory, motor or intellectual functions lasting or likely to last continuously for at least 28 days
changes to the structure of the person’s body
prolonged pain
prolonged psychological harm
shortening of life expectancy
a need for treatment by a healthcare professional to prevent death or one of the other specified outcomes
For this purpose prolonged pain or prolonged psychological harm generally means that the effect has lasted or is likely to last continuously for at least 28 days.
The full legal wording is available in Regulation 20.
Administration staff must not assess the threshold
Administration staff must not decide:
whether harm will last for 28 days
whether an incident caused a person’s condition
whether treatment prevented serious harm
whether a clinical outcome was expected
whether the incident was connected with regulated care
whether the legal definition has been met
Those decisions require authorised management input and an appropriate healthcare professional’s opinion.
If you receive information suggesting that care may have caused harm you must escalate it promptly.
8. Incidents which may require escalation
Possible concerns may come to the administration team through:
a telephone call
an email
a complaint
a patient portal message
a prescription query
a clinician’s instruction
a pharmacy message
a letter from another healthcare provider
a hospital discharge notification
a report from a family member
an incident report
an unexpected appointment cancellation
information received after treatment has ended
Examples which require prompt escalation include:
a patient reports becoming seriously unwell after a medication change
a prescription was issued with incorrect instructions
important risk information was not passed to a clinician
a test result or clinical letter was sent to the wrong person
a referral was not made when intended
a patient attended hospital following advice or treatment provided by WMI Psychiatry
a patient reports significant psychological harm following an incident
a clinician discovers that important information was missing during a decision
a medication request was allocated to the wrong patient record
a safeguarding disclosure was not escalated
a patient states that an error has caused lasting harm
a family reports that a patient has died unexpectedly
a patient received confidential information about somebody else
an urgent clinical message was not reviewed
an appointment or monitoring requirement was incorrectly recorded
a technological or administrative failure may have affected safe care
The fact that an incident involved an administrative process does not mean it was clinically insignificant.
A missed message, incorrect document, delayed escalation or inaccurate patient identifier may have consequences for care.
9. Near misses and lower-level incidents
A near miss is an event which could have caused harm but did not do so.
For example:
an administrator notices that a letter is addressed to the wrong patient before sending it
a prescription request is placed on the wrong record but the mistake is corrected before prescribing
an urgent message is nearly overlooked but is identified before the deadline
a document containing confidential information is attached to an email but the email is stopped before transmission
A near miss will not normally meet the statutory duty of candour threshold because the specified harm did not occur.
It should still be reported.
Near-miss reporting helps WMI Psychiatry identify:
unsafe processes
recurring mistakes
training needs
system weaknesses
workload problems
unclear responsibilities
risks which could cause harm in future
Do not conceal a near miss because the patient was not harmed.
10. Immediate response to a possible incident
When administration staff become aware of a possible safety incident they should:
identify whether there is an immediate clinical or safety concern
alert the responsible clinician without delay where urgent action may be required
notify the Registered Manager
preserve the original information
make a factual contemporaneous record
submit an incident report
follow safeguarding or data protection procedures where relevant
confirm who will lead communication with the patient
avoid speculation
continue to pass on new information
If a patient may require urgent medical attention follow WMI Psychiatry’s clinical emergency procedure.
Call 999 where there is an immediate threat to life or another emergency requiring an urgent response.
Do not delay urgent action while deciding whether the event meets the statutory duty of candour threshold.
11. Receiving the first report from a patient or family member
An administration staff member may be the first person to hear that something has gone wrong.
The initial response can affect the person’s confidence in the service.
You should:
listen without interrupting unnecessarily
remain calm
acknowledge the concern
check whether the person is currently safe
identify whether urgent clinical help may be needed
take accurate contact details
record the person’s own description
explain that the concern will be escalated
give a realistic timescale for the next contact
notify the correct people immediately
Helpful wording includes:
“I am sorry to hear that this has happened. I am going to make sure that the Registered Manager and the responsible clinician are informed immediately.”
“I cannot provide a clinical explanation myself. I can record what you have told me and arrange for the appropriate person to contact you.”
“Before we continue can I check whether you need urgent medical help now?”
“I will record your concerns accurately. May I confirm the best number for the appropriate person to contact you?”
Do not say:
“That definitely should not have happened.”
“The clinician has made a serious mistake.”
“Nobody here is responsible.”
“That cannot have been caused by the medication.”
“This is definitely a duty of candour incident.”
“You will receive compensation.”
“Please do not make a complaint.”
“If you do not complain we can deal with this informally.”
“I am sure everything will be fine.”
“There is no point reporting it.”
12. What administration staff may say
Administration staff may:
express concern
offer a human apology for the person’s experience
explain that the matter will be escalated
confirm who has been informed
provide an agreed timescale
explain the complaints process
check for immediate safety concerns
give contact details for authorised support
confirm administrative facts which have been verified
arrange communication with an authorised lead
For example:
“I am sorry that you have had this experience.”
“I am sorry that this has caused you distress.”
“I have informed the Registered Manager.”
“The responsible clinician has been asked to review this urgently.”
“You will receive an update by 4 pm tomorrow.”
“We will not wait for the complaint process before considering any immediate safety action.”
Administration staff should not provide:
an unauthorised clinical opinion
a legal opinion
an unverified explanation
an assessment of causation
criticism of an individual staff member
an assurance that no harm occurred
a promise about the investigation’s outcome
a promise of compensation
confidential information about another person
13. The formal notification
When the statutory threshold is met the relevant person must be notified as soon as reasonably practicable.
The notification should be led by a person who:
understands the incident
is authorised to speak for WMI Psychiatry
can explain the known clinical facts
can answer questions appropriately
can arrange further support
understands the person’s communication needs
This will normally involve the Registered Manager and an appropriate clinician.
The initial notification must:
state that an incident has occurred
provide an account of the facts known at that time
be truthful to the best of the organisation’s knowledge
explain what further enquiries are considered appropriate
include an apology
offer reasonable support
be recorded securely
The person should then receive written notification containing:
the information provided during the initial notification
the apology
details of further enquiries
relevant results from those enquiries
information about what will happen next
WMI Psychiatry must not wait for a complete investigation before making the initial notification.
It is acceptable to say that some information is not yet known.
14. Saying sorry
An apology is an essential part of candour.
An apology is an expression of sorrow or regret that an incident occurred.
A suitable apology should be:
sincere
clear
personal
timely
relevant to what happened
free from defensive language
Examples include:
“I am very sorry that this happened.”
“We are sorry for the harm and distress this incident has caused.”
“I am sorry that we did not pass your urgent message to the clinician when we should have done.”
Avoid conditional or defensive wording such as:
“I am sorry if you were upset.”
“I am sorry that you feel that way.”
“Mistakes happen.”
“We are sorry but we were extremely busy.”
“We apologise although nobody could have prevented this.”
“We are sorry if there was any misunderstanding.”
An apology should not be withheld because of concern that it will automatically create legal liability.
Section 2 of the Compensation Act 2006 states that an apology, an offer of treatment or another form of redress does not by itself amount to an admission of negligence or breach of statutory duty. Compensation Act 2006
Administration staff may offer an appropriate human apology. The formal organisational apology should be given by an authorised person.
15. Known facts and uncertainty
Candour requires honesty about what is known and what remains uncertain.
The authorised person may say:
“At this stage we know that your message was received on Monday but was not passed to the clinician until Wednesday. We are reviewing why that happened and whether it affected your care.”
They should not say:
“The delay definitely caused the deterioration.”
They should also not say:
“The delay had no effect.”
Either conclusion may be premature before clinical review.
Records should distinguish between:
confirmed facts
information reported by the patient
information reported by another person
clinical opinion
matters still being investigated
actions already completed
actions planned
Staff must not alter an earlier record to make events appear clearer or more favourable.
If a correction is needed it must be made through the proper record amendment process so the original entry and reason for the correction remain identifiable.
16. The relevant person
The relevant person will usually be the patient.
A different person may need to receive the notification when:
the patient has died
the patient lacks capacity for the relevant decision
another person is lawfully acting on the patient’s behalf
the patient is a child
the patient has authorised a representative
a person holds an appropriate legal authority
Administration staff must not assume that a relative is automatically entitled to receive confidential information.
Before disclosing information staff should confirm:
the patient’s identity
the representative’s identity
the patient’s consent where applicable
whether the person has lawful authority
what information may be shared
whether safeguarding considerations apply
If authority is unclear seek advice from the Registered Manager or responsible clinician.
Do not refuse to record information from a family member simply because information cannot be disclosed to them. Staff can listen and pass the concern to the appropriate person without confirming confidential details.
17. Children and young people
Where the patient is a child or young person the authorised lead should consider:
the young person’s age
their understanding
their capacity or competence
parental responsibility
the young person’s wishes
confidentiality
safeguarding
the most appropriate way to explain what happened
whether information should be provided to both the young person and their parent or carer
A young person should not be excluded automatically from a discussion about their own care.
Information should be communicated in a way they can understand.
Administration staff must obtain advice before deciding who should receive detailed information.
18. Reasonable support
Regulation 20 requires reasonable support to be provided to the relevant person.
Support may include:
providing a named contact
offering a further meeting
explaining the investigation process
providing information in an accessible format
arranging an interpreter
allowing a trusted person to attend
providing information in writing
allowing additional time to ask questions
explaining the complaints procedure
signposting to independent advocacy
arranging appropriate clinical follow-up
providing updates at agreed intervals
making communication adjustments
Administration staff may help arrange this support.
Do not promise a form of support which has not been authorised or cannot be provided.
19. Reasonable adjustments and accessible communication
Candour communication should meet the person’s communication needs.
Adjustments may include:
plain English
Easy Read information
larger text
written information following a telephone discussion
an interpreter
communication by email rather than telephone
additional processing time
shorter meetings
breaks during a meeting
a quiet environment
support from an advocate
avoiding figurative or ambiguous language
checking understanding
allowing questions to be submitted in advance
Do not assume that a diagnosis determines the adjustment required.
Ask the person what would help them understand and participate.
An adjustment should be recorded so that it is applied consistently during future communication.
20. Confidentiality and candour
Duty of candour does not remove the duty of confidentiality.
Staff must not:
disclose another patient’s information
provide information to an unauthorised family member
send incident records through a personal account
discuss the incident in a public area
share screenshots through an unapproved platform
identify staff members unnecessarily
provide personal contact details
include unrelated confidential information in a letter
send a candour letter without checking the recipient
assume that every person copied into a complaint may receive clinical information
Before sending written information check:
the patient’s identity
the recipient’s authority
the postal or email address
the attachments
the document title
whether another patient is named
whether secure transmission is required
whether the communication has been approved
A confidentiality breach during the candour process may create a separate reportable incident.
21. Duty of candour and complaints
A complaint and a duty of candour response are not the same process.
A person does not need to make a complaint before WMI Psychiatry acts candidly.
Duty of candour should not be delayed until:
a complaint is submitted
a complaint is acknowledged
the complaints investigation is complete
the patient asks for an apology
the patient obtains legal advice
the patient proves that harm occurred
A complaint may reveal a possible safety incident.
When this happens staff should:
record the complaint
escalate the possible incident
consider immediate safety action
begin the complaints process
assess whether the statutory candour process applies
coordinate communication
keep the records for each process clear
A patient may receive both a complaint response and a duty of candour communication.
The complaint should still be investigated fairly even if the incident has already been discussed with the patient.
22. Duty of candour and safeguarding
An incident may also reveal a safeguarding concern.
Examples include:
a child was left at risk
information about domestic abuse was not escalated
a vulnerable adult may have been neglected
a staff member behaved abusively
confidential information was disclosed to a person who may present a risk
a patient reports exploitation or coercion
an incident involves possible sexual misconduct
Duty of candour does not replace safeguarding action.
Staff should:
take immediate action where someone may be unsafe
inform the Safeguarding Lead
follow the safeguarding procedure
preserve relevant evidence
avoid conducting their own investigation
record who was informed
continue with the appropriate candour process
Do not delay a safeguarding referral while waiting for an incident investigation.
23. Duty of candour and data protection
A patient safety incident may also involve a personal data breach.
For example:
a clinical letter is sent to the wrong person
a patient receives another person’s prescription information
an email account is compromised
information affecting treatment is deleted or altered
unauthorised access affects the confidentiality or availability of records
Staff must follow both:
the incident reporting procedure
the data breach procedure
The Data Protection Lead will decide whether the breach must be reported to the Information Commissioner’s Office or communicated under data protection law.
A data breach notification and a duty of candour notification are separate legal considerations. One does not automatically replace the other.
24. Duty of candour and CQC notifications
The duty of candour process should not be confused with notifying CQC about certain events.
An incident may require:
communication with the patient under Regulation 20
a statutory notification to CQC
a safeguarding referral
a data breach report
a police report
notification to an insurer
a complaint investigation
internal governance review
The Registered Manager is responsible for ensuring that the correct external reporting requirements are considered.
Administration staff should not assume that submitting an internal incident form completes every required notification.
25. Record keeping
Candour records must be accurate, secure and sufficiently detailed.
The record should include:
the date and time the incident became known
how the incident was identified
the people involved
the patient’s account
the known facts
any immediate safety action
who was notified
the time of each escalation
the clinical opinion about the incident where applicable
the decision about whether the statutory threshold was met
the reasons for that decision
the identity of the relevant person
communication needs or reasonable adjustments
the date and method of the initial notification
who participated
the information provided
the apology given
questions asked
support offered
further enquiries agreed
the written follow-up
attempts to contact the relevant person
investigation findings
actions taken to reduce recurrence
any complaint, safeguarding or data protection action
Records should use factual and respectful language.
Appropriate:
“The patient stated that they attended the emergency department after taking the new dose. The responsible clinician and Registered Manager were informed at 10:15 am.”
Inappropriate:
“The patient was probably overreacting and wanted to blame the clinic.”
Records must not contain speculation presented as fact.
26. Contact attempts
If the relevant person cannot be contacted staff should:
use approved contact details
make proportionate attempts
follow any known communication preferences
consider whether an alternative authorised contact exists
record the date, time and method of every attempt
avoid including unnecessary sensitive information in voicemail
seek management advice before using a new address or third party
continue to protect confidentiality
A suitable voicemail may state:
“This is [NAME] calling from WMI Psychiatry. Please contact us on [APPROVED NUMBER] regarding an important matter.”
Do not leave detailed clinical or incident information unless it has been confirmed that doing so is appropriate and secure.
If the person declines to discuss the incident the refusal and any information offered should be recorded.
The organisation should not pressure the person to participate.
27. Investigation and follow-up
An investigation should establish:
what happened
when it happened
how it was identified
what the expected process was
whether the expected process was followed
what harm occurred
what immediate action was taken
whether other patients may be affected
what contributed to the incident
what changes are required
who is responsible for those changes
how improvement will be checked
The patient or relevant person should receive appropriate updates.
The final communication should explain:
the outcome of the enquiries
what is known
any continuing uncertainty
what action has been taken
what action is still planned
how recurrence will be reduced
how further questions can be raised
how to make a complaint if required
Information should be honest and understandable.
Technical or clinical language should be explained.
28. Staff honesty and reporting
All staff must report incidents honestly.
Staff must not:
conceal a mistake
ask another person not to report
remove an email or message
change a time or date
retrospectively create a misleading record
minimise possible harm
blame the patient without evidence
delay reporting to protect a colleague
provide an explanation they know is inaccurate
discourage a patient from asking questions
imply that care will be affected if the patient complains
A staff member who identifies their own mistake should report it promptly.
Reporting an error allows WMI Psychiatry to:
protect the patient
correct the problem
prevent further harm
communicate honestly
support staff
improve systems
Deliberate concealment is much more serious than an honestly reported mistake.
29. Supporting staff
Incidents can be distressing for the staff involved.
A staff member may experience:
anxiety
guilt
embarrassment
fear of disciplinary action
difficulty concentrating
loss of confidence
worry about the patient
concern about professional consequences
Staff should be treated fairly and supported to provide an honest account.
Support may include:
a private discussion
clear information about the review
supervision
temporary adjustments to duties
occupational health support
wellbeing support
additional training
the opportunity to correct factual inaccuracies
updates about the outcome
A fair review should consider individual actions and system factors.
A learning culture does not mean that serious misconduct is ignored. It means that conclusions are based on evidence rather than immediate blame.
30. Common barriers to candour
Candour may be undermined when staff:
fear being blamed
believe that saying sorry admits liability
wait for complete certainty
assume another person has reported the incident
treat the matter only as a complaint
use vague or defensive wording
provide conflicting explanations
fail to identify the relevant person
overlook communication needs
fail to document contact attempts
delay written follow-up
focus on reputation rather than patient safety
minimise psychological harm
assume administrative errors cannot cause serious harm
WMI Psychiatry should address these barriers through:
clear procedures
leadership
staff training
prompt management support
coordinated communication
accessible reporting systems
regular governance review
evidence that incidents result in improvement
31. Practical scenarios
Scenario 1: Urgent message not passed on
A patient telephones on Monday and reports concerning side effects. The message is not passed to the clinician until Wednesday. The patient later states that they attended hospital.
The administrator receiving this information should:
check whether there is a current urgent clinical concern
alert the responsible clinician immediately
notify the Registered Manager
preserve the original message and call records
record the patient’s account accurately
submit an incident report
avoid deciding whether the delay caused the hospital attendance
confirm who will contact the patient
The administrator should not wait for the patient to make a formal complaint.
Scenario 2: Incorrect medication instructions
A patient states that their prescription label contains different instructions from those given during the appointment.
The administrator should:
advise the patient not to rely on an administrative interpretation
arrange urgent clinical or pharmacy clarification
record the exact discrepancy
notify the responsible clinician
notify the Registered Manager
submit an incident report
preserve copies of the relevant information
The administrator must not tell the patient which dose to take unless authorised and professionally qualified to do so.
Scenario 3: Family member requesting information
A patient’s parent reports that the patient became seriously unwell after a medication change. The patient is an adult and there is no recorded consent to disclose information to the parent.
The administrator should:
listen to the information
record the concern
escalate it urgently
avoid confirming confidential information
explain that information can be received even where information cannot be disclosed
seek advice about contacting the patient
Confidentiality does not prevent staff from receiving relevant safety information.
Scenario 4: Complaint identifies possible harm
A complaint states that an urgent assessment was cancelled incorrectly and that the patient’s mental health deteriorated during the delay.
The complaint should be recorded.
The possible safety incident should also be escalated through the incident procedure. The complaints process should not delay clinical review or consideration of duty of candour.
Scenario 5: Administrator identifies their own error
An administrator realises that they attached a patient’s document to the wrong internal record. A clinician may have relied on the incorrect information.
The administrator should:
inform the clinician
notify the Registered Manager
preserve the audit trail
submit an incident report
follow the data breach procedure if another person’s information was involved
cooperate honestly with the investigation
They should not delete the attachment without preserving evidence or following the authorised correction process.
Scenario 6: No harm occurred
An administrator prepares a letter for the wrong patient but notices the error before it is sent.
This is a near miss.
It is unlikely to be a statutory notifiable safety incident because no specified harm occurred. It should still be reported so the process can be reviewed.
Scenario 7: Pressure to delay an apology
A staff member says:
“We should not say sorry until the investigation is complete because it may make us legally responsible.”
This is incorrect.
The initial notification should not be delayed until every detail is known. A sincere apology does not by itself amount to an admission of negligence.
Scenario 8: Conflicting explanations
A patient receives one explanation from an administrator and a different explanation from a clinician.
Communication should be coordinated through an authorised lead.
The administrator should not try to resolve the difference by choosing which explanation seems more likely. They should notify the Registered Manager and ensure that the patient receives a clear verified update.
Scenario 9: Patient declines a meeting
A patient states that they do not want a meeting and asks for all communication by email.
The request should be respected where appropriate.
The authorised lead should arrange written communication and document the patient’s preference. The person should not be pressured to attend a meeting.
Scenario 10: Wrong recipient
A candour letter is ready to be emailed. The administrator notices that the address belongs to the patient’s former partner.
The letter must not be sent.
The administrator should verify the authorised recipient and correct contact details. The near miss should be reported where appropriate.
Scenario 11: Possible safeguarding concern
During a candour discussion a young patient states that a family member prevents them from speaking privately and reads all their messages.
The safeguarding concern must be escalated separately.
Duty of candour does not replace safeguarding action.
Scenario 12: Unknown extent of harm
A patient says that an administrative delay caused severe psychological harm. The full clinical effect is not yet known.
The administrator should not decide that the statutory threshold is absent because there is not yet proof that the harm will last 28 days.
The concern should be escalated for professional assessment.
32. Key learning points
Duty of candour means being open and honest when something goes wrong.
WMI Psychiatry has a general responsibility to act openly and transparently.
A notifiable safety incident is a specific legal category.
Not every error, complaint or near miss meets the statutory threshold.
Administration staff must not decide whether the legal threshold has been met.
Possible harm must be escalated promptly.
Immediate patient safety takes priority.
Do not wait for a complaint before reporting an incident.
Do not wait for the investigation to finish before initial candour communication.
Communicate known facts and be honest about uncertainty.
Avoid speculation and blame.
A sincere apology is an important part of candour.
An apology is not automatically an admission of legal liability.
The patient or another lawfully authorised person must receive the appropriate information.
Confidentiality continues to apply.
Communication must be accessible.
Complaints, safeguarding, data protection and CQC reporting may operate alongside duty of candour.
Near misses should still be reported.
Records must be accurate, factual and secure.
Contact attempts must be documented.
Staff must not alter or conceal information.
Patients should receive appropriate updates and written follow-up.
Incidents should lead to learning and improvement.
Staff involved in incidents should receive fair and appropriate support.
Knowledge assessment
Learner instructions
Choose the single best answer.
You must achieve at least 12 out of 15 to pass. Any incorrectly answered safety-critical question must be reviewed even if the overall pass mark is achieved.
Question 1
What does duty of candour mean?
A. Avoiding discussion of an incident until a complaint is received
B. Being open and honest when something has gone wrong
C. Accepting legal liability for every poor outcome
D. Providing information only when requested by CQC
Question 2
Who is responsible for meeting the statutory organisational duty of candour?
A. Only the patient
B. The registered provider and registered manager
C. Only administration staff
D. The organisation’s insurer
Question 3
An administrator receives information that a patient may have been seriously harmed by a delayed message. What should they do?
A. Decide whether the 28-day threshold has been met
B. Wait for a written complaint
C. Escalate the concern promptly to the responsible clinician and Registered Manager
D. Reassure the patient that the delay was harmless
Question 4
Who should decide whether an incident meets the statutory notifiable safety incident threshold?
A. The administrator who received the call
B. An authorised management lead with appropriate healthcare professional input
C. The patient’s relative
D. The first staff member who reads the incident form
Question 5
When should the initial statutory notification normally be made?
A. As soon as reasonably practicable after the organisation becomes aware of the notifiable safety incident
B. Only after the complete investigation
C. Only after legal proceedings begin
D. At the next annual governance meeting
Question 6
Which is the most appropriate statement for an administrator?
A. “The clinician was clearly negligent.”
B. “This definitely meets the legal threshold.”
C. “I am sorry that this has happened. I will escalate it immediately.”
D. “I am sure no lasting harm has been caused.”
Question 7
Which statement about an apology is correct?
A. An apology must be avoided because it always admits negligence
B. An apology is an expression of sorrow or regret and does not by itself admit legal liability
C. An apology should only be given if the patient withdraws their complaint
D. An apology can be replaced by an incident form
Question 8
A family member gives important safety information but is not authorised to receive confidential information. What should the administrator do?
A. Refuse to listen
B. Listen, record and escalate the information without making an unauthorised disclosure
C. Provide the entire clinical record
D. Ask the family member to investigate the incident
Question 9
A complaint reveals a possible patient safety incident. What should happen?
A. Only the complaints process should be used
B. The complaint should be closed
C. The complaint and possible incident should both be managed through the appropriate processes
D. The patient should be asked to choose one process
Question 10
Which is the most appropriate way to describe uncertainty?
A. “Nothing went wrong.”
B. “We know the message was delayed. We are reviewing whether the delay affected your care.”
C. “Someone must be at fault.”
D. “We cannot speak to you until we know every detail.”
Question 11
What should happen if the relevant person cannot be contacted?
A. The incident should be removed from the record
B. Proportionate contact attempts should be made and recorded
C. Confidential details should be left on every available voicemail
D. A neighbour should be given the information
Question 12
Which statement about near misses is correct?
A. They should never be reported if no harm occurred
B. They automatically meet the statutory duty of candour threshold
C. They should be reported so risks and system weaknesses can be identified
D. They should be deleted from the audit trail
Question 13
What should an administrator do if a candour letter appears to be addressed to the wrong recipient?
A. Send it because it has already been approved
B. Stop the communication and verify the authorised recipient
C. Send it to both addresses
D. Post the letter in an internal messaging group
Question 14
Which is an appropriate incident record?
A. “The patient was looking for somebody to blame.”
B. “The administrator was careless.”
C. “The patient reported attending the emergency department. The responsible clinician was informed at 10:15 am.”
D. “This incident was not serious.”
Question 15
Which best describes the administration team’s role?
A. Determine legal liability and explain clinical causation
B. Recognise concerns, protect immediate safety, preserve information, report promptly and support authorised communication
C. Conduct the clinical investigation independently
D. Decide whether the incident needs to be disclosed to the patient
Learner declaration
Learner’s name: ______________________________
Role: ______________________________
Date completed: ______________________________
Attempt number: ______________________________
I confirm that:
I have completed the full module.
I understand what duty of candour means.
I understand the difference between general openness and the statutory notification process.
I know that I must not decide whether the legal threshold has been met.
I know how to contact the Registered Manager.
I know how to contact the responsible clinician.
I understand that possible patient harm must be escalated promptly.
I understand that urgent safety action must not be delayed.
I know what I may and may not say to a patient.
I understand the purpose of an apology.
I understand that an apology is not automatically an admission of liability.
I know that confidentiality continues to apply.
I understand that complaints and incidents may require separate processes.
I know how to submit an incident report.
I understand that near misses should be reported.
I understand that records must not be altered or concealed.
I know where the Duty of Candour Policy is stored.
Signature: ______________________________
Score: ______ / 15
Result: Pass / Further learning required
Safety-critical errors reviewed: Yes / No / Not applicable
Manager or assessor: ______________________________
Renewal date: ______________________________
Manager’s marking guide
Question 1
Correct answer: B
Duty of candour requires openness and honesty when something goes wrong during care or treatment.
Question 2
Correct answer: B
The statutory organisational duty applies to the registered provider and registered manager. Staff support the organisation in meeting that duty.
Question 3
Correct answer: C
Possible serious harm requires prompt clinical and management escalation. Administration staff must not assess the legal or clinical threshold themselves.
Question 4
Correct answer: B
The decision should be made through the authorised governance process with appropriate healthcare professional input.
Question 5
Correct answer: A
The relevant person must be notified as soon as reasonably practicable. The organisation must not wait for the full investigation before giving the initial notification.
Question 6
Correct answer: C
The administrator may express sincere regret and confirm immediate escalation. They should not speculate about negligence, causation or the legal threshold.
Question 7
Correct answer: B
An apology is an expression of sorrow or regret. It does not by itself amount to an admission of negligence or breach of statutory duty.
Question 8
Correct answer: B
Staff can receive information without making a confidential disclosure. The information should be recorded and passed to the appropriate person.
Question 9
Correct answer: C
A complaint may reveal a safety incident. Both processes may be required and neither should improperly delay the other.
Question 10
Correct answer: B
The wording distinguishes established facts from a matter which still requires investigation.
Question 11
Correct answer: B
Proportionate attempts should be made using approved contact details. Every attempt should be recorded while confidentiality is protected.
Question 12
Correct answer: C
Near misses can reveal unsafe systems and prevent future harm. They should be reported even where the statutory candour threshold is not met.
Question 13
Correct answer: B
The communication must be stopped until the recipient’s identity, authority and contact details have been verified.
Question 14
Correct answer: C
The record contains the patient’s reported information, the action taken and a precise time. It avoids speculation and blame.
Question 15
Correct answer: B
Administration staff recognise concerns, support immediate safety, preserve information, escalate promptly and assist with authorised communication. They do not determine clinical causation or legal liability.
Questions 3, 4, 5, 6, 8, 9, 11, 13 and 15 are safety-critical.
For every incorrectly answered safety-critical question the manager should:
discuss the correct response with the learner
record that the answer was reviewed
ask the learner to explain the correct escalation procedure
confirm that the learner knows how to contact the Registered Manager and responsible clinician
require reassessment if understanding remains uncertain
A learner must not be recorded as competent if they remain uncertain about:
escalating possible patient harm
obtaining urgent clinical help
the prohibition on making their own statutory threshold decision
the requirement not to delay initial notification unnecessarily
protecting confidentiality
preserving records and evidence
managing complaints and incidents through the appropriate processes
stopping communication addressed to an incorrect or unauthorised recipient
reporting mistakes honestly
CQC and governance implementation requirements
Before issuing this module WMI Psychiatry should:
confirm whether the Regulation 20 independent-provider threshold described in this module matches its registered legal status
approve a current Duty of Candour Policy
identify the Duty of Candour Lead
complete all contact and escalation details
define urgent and out-of-hours escalation arrangements
ensure staff can access the incident reporting system
define where duty of candour records will be stored
establish who may decide whether the statutory threshold is met
ensure an appropriate healthcare professional contributes to threshold decisions
establish who is authorised to contact the relevant person
provide templates for initial and written notifications
provide guidance on apologies
establish a process for identifying the relevant person
include procedures for children and patients who may lack capacity
provide interpreters and reasonable adjustments where required
coordinate incident, complaint, safeguarding and data protection processes
establish how statutory CQC notifications will be considered
maintain secure records of conversations, letters and contact attempts
record reasons for threshold decisions
ensure the initial notification is not delayed until the full investigation is complete
provide appropriate updates during longer investigations
record actions arising from incidents
assign responsibility and deadlines for improvement actions
review incidents through clinical governance meetings
audit compliance with Regulation 20
ensure senior leaders review delays or omissions in candour communication
provide support to patients and families
provide fair support to staff involved
encourage reporting of errors and near misses
prohibit deliberate concealment or alteration of records
retain the learner’s answers, score, declaration and attempt number
record completion in the staff training matrix
document review of safety-critical errors
provide annual refresher training
update the module following material changes in legislation, CQC guidance or WMI Psychiatry procedures
The module supports compliance with Regulation 20 but does not replace:
the Duty of Candour Policy
clinical judgement
incident investigation
complaints handling
safeguarding procedures
data protection procedures
statutory notifications
professional regulatory guidance
legal advice where required
supervision and management oversight
