Openness nd honesty when things go wrong: the professionl duty of ndour The professionl duty of ndour 1 Every helthre professionl must e open nd honest with ptients when something tht goes wrong with their tretment or re uses, or hs the potentil to use, hrm or distress. This mens tht helthre professionls must: tell the ptient (or, where pproprite, the ptient s dvote, rer or fmily) when something hs gone wrong pologise to the ptient (or, where pproprite, the ptient s dvote, rer or fmily) offer n pproprite remedy or support to put mtters right (if possile) explin fully to the ptient (or, where pproprite, the ptient s dvote, rer or fmily) the short nd long term effets of wht hs hppened. Helthre professionls must lso e open nd honest with their ollegues, employers nd relevnt orgnistions, nd tke prt in reviews nd investigtions when requested. They must lso e open nd honest with their regultors, rising onerns where pproprite. They must support nd enourge eh other to e open nd honest, nd not stop someone from rising onerns. Aout this guidne 1 All helthre professionls hve duty of ndour professionl responsiility to e honest with ptients * when things go wrong. This is desried in The professionl duty of ndour, whih introdues this guidne nd forms prt of joint sttement from eight regultors of helthre professionls in the UK. 2 As dotor, nurse or midwife, you must e open nd honest with ptients, ollegues nd your employers. 3 This guidne omplements the joint sttement from the helthre regultors nd gives more informtion out how to follow the priniples set out in Good medil prtie 2 nd The Code: Professionl stndrds of prtie nd ehviour for nurses nd midwives. 3 Appendix 1 sets out relevnt extrts from Generl Medil Counil (GMC) nd Nursing nd Midwifery Counil (NMC) guidne. This guidne pplies to ll dotors registered with the GMC nd ll nurses nd midwives registered with the NMC ross the UK. * When we refer to ptients in this guidne, we lso men people who re in your re. 1
4 This guidne is divided into two prts. Your duty to e open nd honest with ptients in your re, or those lose to them, if something goes wrong. This inludes dvie on pologising (prgrphs 6 21). Your duty to e open nd honest with your orgnistion, nd to enourge lerning ulture y reporting dverse inidents tht led to hrm, s well s ner misses (prgrphs 22 33). 5 This guidne is for individuls. We reognise tht re is normlly provided y multidisiplinry tems, nd we don t expet every tem memer to tke responsiility for reporting dverse inidents nd speking to ptients if things go wrong. However, we do expet you to mke sure tht someone in the tem hs tken on responsiility for eh of these tsks, nd we expet you to support them s needed. Being open nd honest with ptients in your re, nd those lose to them, when things go wrong Disuss risks efore eginning tretment or providing re 6 Ptients must e fully informed 4, 5 out their re. When disussing re options with ptients, you must disuss the risks s well s the enefits of the options. 7 You or n pproprite person 6 must give the ptient ler, urte informtion out the risks of the proposed tretment or re, nd the risks of ny resonle lterntive options, nd hek tht the ptient understnds. You should disuss risks 7 tht our often, those tht re serious even if very unlikely, nd those tht the ptient is likely to think re importnt. 8 In wht irumstnes do I need to pologise to the ptient? 8 This guidne is not intended for irumstnes where ptient s ondition gets worse due to the nturl progression of their illness. It pplies when something goes wrong with ptient s re, nd they suffer hrm or distress s result. This guidne lso pplies in situtions where ptient my yet suffer hrm or distress s result of something going wrong with their re. 9 When you relise tht something hs gone wrong, nd fter doing wht you n to put mtters right, you or someone from the helthre tem must spek to the ptient. * The most pproprite tem memer will usully e the led or ountle liniin. 9 If this is not you, then you must follow the guidne in prgrph 5. When should I spek to the ptient or those lose to them, nd wht do I need to sy? 10 You should spek to the ptient s soon s possile fter you relise something hs gone wrong with their re. When you spek to them, there should e someone ville to support them (for exmple friend, reltive or professionl ollegue). You do not hve to wit until the outome of n investigtion to spek to the ptient, ut you should e ler out wht hs nd hs not yet een estlished. 11 You should shre ll you know nd elieve to e true out wht went wrong nd why, nd wht the onsequenes re likely to e. You should explin if nything is still unertin nd you must respond honestly to ny questions. 10 You should pologise to the ptient (see prgrphs 13 19). * If the ptient hs died, or is unlikely to regin onsiousness or pity, ptient in prgrphs 9 16 should e red s those lose to the ptient. 2
Wht if people don t wnt to know the detils? 12 Ptients will normlly wnt to know more out wht hs gone wrong. But you should give them the option not to e given every detil. If the ptient does not wnt more informtion, you should try to find out why. If fter disussion, they don t hnge their mind, you should respet their wishes s fr s possile, * hving explined the potentil onsequenes. You must reord the ft tht the ptient does not wnt this informtion nd mke it ler to them tht they n hnge their mind nd hve more informtion t ny time. Sying sorry 13 Ptients expet to e told three things s prt of n pology: wht hppened wht n e done to del with ny hrm used wht will e done to prevent someone else eing hrmed. 12 14 Apologising to ptient does not men tht you re dmitting legl liility for wht hs hppened. This is set out in legisltion in prts of the UK 13 nd the NHS Litigtion Authority lso dvises tht sying sorry is the right thing to do. 12 In ddition, fitness to prtise pnel my 14, 15, 16 view n pology s evidene of insight. 15 When pologising to ptients nd explining wht hs hppened, we do not expet you to tke personl responsiility for something going wrong tht ws not your fult (suh s system errors or ollegue s mistke). But the ptient hs the right to reeive n pology from the most pproprite tem memer (see prgrph 9), regrdless of who or wht my e responsile for wht hs hppened. 16 We do not wnt to enourge formuli pproh to pologising sine n pology hs vlue only if it is genuine. However, when * pologising to ptient, you should onsider eh of the following points. d e You must give ptients the informtion they wnt or need to know in wy tht they n understnd. 17 You should spek to ptients in ple nd t time when they re est le to understnd nd retin informtion. You should give informtion tht the ptient my find distressing in onsiderte wy, respeting their right to privy nd dignity. Ptients re likely to find it more meningful if you offer personlised pology for exmple I m sorry rther thn generl expression of regret out the inident on the orgnistion s ehlf. This doesn t men tht we expet you to tke personl responsiility for system filures or other people s mistkes (see prgrph 15). You should mke sure the ptient knows who to ontt in the helthre tem to sk ny further questions or rise onerns. You should lso give ptients informtion out independent dvoy, ounselling or other support servies tht n give them prtil dvie nd emotionl support. If the ptient needs to give their onsent to proposed investigtion or tretment, then you need to give them enough informtion to mke n informed deision. 11 Legl liility here refers to linil negligene lim. The NHS Litigtion Authority will never withhold over for lim euse n pology or explntion hs een given. 12 For exmple, you ould diret them to Ation ginst Medil Aidents (AvMA) or to their lol Helthwth group in Englnd, Ptient nd Client Counil in Northern Irelnd, the Ptient Advie nd Support Servie in Sotlnd or the Community Helth Counil in Wles. See Ptients help on the GMC wesite (www.gm-uk.org/onerns/21893. sp) or When to mke referrl on the NMC wesite (www. nm.org.uk/onerns-nurses-midwives/onerns-omplintsreferrls/when-to-mke--referrl/) for further informtion. 3
f You should reord the detils of your 18, 19 pology in the ptient s linil reord. A verl pology my need to e followed up y written pology, depending on the ptient s wishes nd on your workple poliy. * Speking to those lose to the ptient 17 If something hs gone wrong tht uses ptient s deth or suh severe hrm tht the ptient is unlikely to regin onsiousness or pity, you must e open nd honest with those lose to the ptient. 3, 20 Tke time to onvey the informtion in ompssionte wy, giving them the opportunity to sk questions t the time nd fterwrds. 18 You must show respet for, nd respond sensitively to, the wishes nd needs of ereved people. You must tke into ount wht you know of the ptient s wishes out wht should hppen fter their deth, inluding their views out shring informtion. You should e prepred to offer support nd ssistne to ereved people for exmple y explining where they n get informtion out, nd help with, dministrtive nd prtil tsks following deth; or y involving other memers of the tem, suh s hpliny or erevement re, 24 stff. 19 You should mke sure, s fr s possile, tht those lose to the ptient hve een offered pproprite support, nd tht they hve speifi point of ontt in se they hve onerns or questions t lter dte. Being open nd honest with ptients out ner misses 20 A ner miss is n dverse inident tht hd the potentil to result in hrm ut did not do so. You must use your professionl judgement when onsidering whether to tell ptients out ner misses. Sometimes there will e informtion tht the ptient needs to know or would wnt to know, nd telling the ptient out the ner miss my even help their reovery. In these ses, you should tlk to the ptient out the ner miss, following the guidne in prgrphs 10 16. 21 Sometimes filing to e open with ptient out ner miss ould dmge their trust nd onfidene in you nd the helthre tem. However, in some irumstnes, ptients my not need to know out n dverse inident tht hs not used (nd will not use) them hrm, nd to spek to them out it my distress or onfuse them unneessrily. If you re not sure whether to tlk to ptient out ner miss, seek dvie from your helthre tem or senior ollegue. Enourging lerning ulture y reporting errors 22 When something goes wrong with ptient re, it is ruil tht it is reported t n erly stge so tht lessons n e lernt quikly nd ptients n e proteted from hrm in the future. 23 Helthre orgnistions should hve poliy for reporting dverse inidents nd ner misses, nd you must follow your orgnistion s poliy. 25 * See ppendix 2 for detil of the sttutory duty of ndour for orgnistions providing helthre. If ptient hs previously sked you not to shre personl informtion out their ondition or tretment with those lose to them, you should respet their wishes. While doing so, you must do your est to e onsiderte, sensitive nd responsive to those lose to the ptient, giving them s muh informtion s you n. 21 For informtion out ptient nd rer support nd dvoy servies, ounselling nd hpliny servies, nd linil ethis support networks, see the dvie nd resoures listed on the Ntionl End of Life Cre Progrmme wesite 22 nd the PllCreNI wesite. 23 This does not inlude dverse inidents tht my result in hrm ut hve not yet done so the ptient must e told out these events nd they must e reported in line with this guidne. 4
24 A numer of reporting systems nd shemes exist round the UK for reporting dverse inidents nd ner misses. d e f Adverse nd ptient sfety inidents in Englnd nd Wles re reported to the Ntionl Reporting nd Lerning System. 26 You must report suspeted dverse drug retions to the UK-wide Yellow Crd Sheme run y the Mediines nd Helthre produts Regultory Ageny (MHRA) nd the Commission on Humn Mediines. 27 You must report dverse inidents involving medil devies to the UK-wide MHRA reporting system. 28 Helthre Improvement Sotlnd hs ntionl frmework, 29 whih outlines onsistent definitions nd stndrdised pproh to dverse inident mngement ross the NHS in Sotlnd. The proedure for the mngement nd follow-up of serious dverse inidents in Northern Irelnd is set out on the Deprtment of Helth, Soil Servies nd Puli Sfety s wesite. 30 In Englnd, generl prtitioners nd other primry medil servies must sumit ll notifitions * diretly to the Cre Qulity Commission (CQC). 25 In ddition to ontriuting to these systems, you should omply with ny system for reporting dverse inidents tht put ptient sfety t risk within your orgnistion (see prgrphs 32 33 on the orgnistionl duty of ndour). If your orgnistion does not hve suh system in ple, you should spek to your mnger nd if neessry rise onern in line with our 32, 33 guidne. 26 Your orgnistion should support you to report dverse inidents nd ner misses routinely. If you do not feel supported to report, nd in prtiulr if you re disourged or prevented from reporting, 34 you should rise onern in 32, 33 line with our guidne. 27 You must not try to prevent ollegues or former ollegues from rising onerns out ptient sfety. If you re in mngement role, you must mke sure tht individuls who rise onerns re proteted from unfir ritiism or tion, inluding ny detriment or dismissl. 32 28 You must tke prt in regulr reviews nd udits 35, 36 of the stndrds nd performne of ny tem you work in, tking steps to resolve ny prolems. You should lso disuss dverse 37, 38 inidents nd ner misses t your pprisl. Additionl duties for dotors, nurses nd midwives with mngement responsiilities nd 39, 40 for senior or high-profile liniins 29 Senior liniins hve responsiility to set n exmple nd enourge openness nd honesty in reporting dverse inidents nd ner misses. Clinil leders should tively foster ulture of lerning nd improvement. 30 If you hve mngement role or responsiility, you must mke sure tht systems re in ple to give erly wrning of ny filure, or potentil filure, in the linil performne of individuls or tems. These should inlude systems for onduting udits nd onsidering ptient feedk. You must mke sure tht ny onerns out the performne of n individul or tem re investigted nd, if pproprite, ddressed quikly nd effetively. * Registered providers in Englnd re required to notify the CQC out ertin inidents. For more informtion see the Notifitions setion on pge 15 of the CQC informtion for ll providers. 31 A fitness to prtise pnel is likely to onsider more serious sntion if there is evidene of filure to rise onern, or 14, 15, 16 of n ttempt to over up. 5
31 If you re mnging or leding tem, you should mke sure tht systems, inluding uditing nd enhmrking, re in ple to monitor, review nd improve the qulity of the tem s work. Appendix 1: Extrts from GMC nd NMC guidne tht re referened in this guidne 2, 25 From Good medil prtie You must work with others to ollet nd shre informtion on ptient experiene nd outomes. You should mke sure tht tems you mnge re ppropritely trined in ptient sfety nd supported to openly report dverse inidents. You should mke sure tht systems or proesses re in ple so tht: n n n n lessons re lernt from nlysing dverse inidents nd ner misses lessons re shred with the helthre tem onrete tion follows on from lerning prtie is hnged where needed. 23 To help keep ptients sfe you must: d e ontriute to onfidentil inquiries ontriute to dverse event reognition report dverse inidents involving medil devies tht put or hve the potentil to put the sfety of ptient, or nother person, t risk report suspeted dverse drug retions respond to requests from orgnistions monitoring puli helth. When providing informtion for these purposes you should still respet ptients onfidentility. 24 You must promote nd enourge ulture tht llows ll stff to rise onerns openly nd sfely. The orgnistionl duty of ndour 32 All helthre orgnistions hve duty to support their stff to report dverse inidents, nd to support stff to e open nd honest with ptients if something goes wrong with their re. Eh of the four UK governments hs onsidered wys to implement the orgnistionl duty of ndour, with some writing it into lw (see ppendix 2). 33 If systems re not in ple in your orgnistion to support stff to report dverse inidents, you should spek to your mnger or senior ollegue. If neessry, you should eslte your onern in line with our guidne on rising 32, 33 onerns. 55 You must e open nd honest with ptients if things go wrong. If ptient under your re hs suffered hrm or distress, you should: put mtters right (if tht is possile) offer n pology explin fully nd promptly wht hs hppened nd the likely short-term nd long-term effets. From Rising nd ting on onerns out ptient sfety 32 13 Wherever possile, you should first rise your onern with your mnger or n pproprite offier of the orgnistion you hve ontrt 6
with or whih employs you suh s the onsultnt in hrge of the tem, the linil or medil diretor or prtie prtner. If your onern is out prtner, it my e pproprite to rise it outside the prtie for exmple, with the medil diretor or linil governne led responsile for your orgnistion. If you re dotor in trining, it my e pproprite to rise your onerns with nmed person in the denery for exmple, the postgrdute den or diretor of postgrdute generl prtie edution. Dotors with extr responsiilities 21 If you re responsile for linil governne or hve wider mngement responsiilities in your orgnistion, you hve duty to help people report their onerns nd to enle people to t on onerns tht re rised with them. 22 If you hve mngement role or responsiility, you must mke sure tht: there re systems nd poliies in ple to llow onerns to e rised nd for inidents, onerns nd omplints to e investigted promptly nd fully you do not try to prevent employees or former employees rising onerns out ptient sfety for exmple, you must not propose or ondone ontrts or greements tht seek to restrit or remove the ontrtor s freedom to dislose informtion relevnt to their onerns e stff who rise onern re proteted from unfir ritiism or tion, inluding ny detriment or dismissl. Also see the rising onerns deision mking tool on the GMC wesite. 41 From Ledership nd mngement for ll dotors 40 24 Erly identifition of prolems or issues with the performne of individuls, tems or servies is essentil to help protet ptients. All dotors 25 You must tke prt in regulr reviews nd udits of the stndrds nd performne of ny tem you work in, tking steps to resolve ny prolems. 26 You should e fmilir with, nd use, the linil governne nd risk mngement strutures nd proesses within the orgnistions you work for or to whih you re ontrted. You must lso follow the proedure where you work for reporting dverse inidents nd ner misses. This is euse routinely identifying dverse inidents or ner misses t n erly stge, n llow issues to e tkled, prolems to e put right nd lessons to e lernt. 27 You must follow the guidne in Good medil prtie nd Rising nd ting on onerns out ptient sfety when you hve reson to elieve tht systems, poliies, proedures or ollegues re, or my e, pling ptients t risk of hrm. d linil stff understnd their duty to e open nd honest out inidents or omplints with oth ptients nd mngers ll other stff re enourged to rise onerns they my hve out the sfety of ptients, inluding ny risks tht my e posed y ollegues or tems Dotors with extr responsiilities 28 If you hve mngement role or responsiility, you must mke sure tht systems re in ple to give erly wrning of ny filure, or potentil filure, in the linil performne of individuls or tems. These should inlude systems for onduting udits nd onsidering ptient feedk. You must mke sure tht ny suh filure is delt with quikly nd effetively. 7
29 If you re mnging or leding tem, you should mke sure tht systems, inluding uditing nd enhmrking, re in ple to monitor, review nd improve the qulity of the tem s work. You must work with others to ollet nd shre informtion on ptient experiene nd outomes. You must mke sure tht tems you mnge re ppropritely supported nd developed nd re ler out their ojetives. e f the views of nyone the ptient sks you to onsult, or who hs legl uthority to mke deision on their ehlf, or hs een ppointed to represent them the views of people lose to the ptient on the ptient s preferenes, feelings, eliefs nd vlues, nd whether they onsider the proposed tretment to e in the ptient s est interests From Consent: ptients nd dotors mking deisions together 4 75 In mking deisions out the tretment nd re of ptients who lk pity, you must: d mke the re of your ptient your first onern tret ptients s individuls nd respet their dignity support nd enourge ptients to e involved, s fr s they wnt to nd re le, in deisions out their tretment nd re tret ptients with respet nd not disriminte ginst them. 76 You must lso onsider: whether the ptient s lk of pity is temporry or permnent g wht you nd the rest of the helthre tem know out the ptient s wishes, feelings, eliefs nd vlues. From Tretment nd re towrds the end of life: good prtie in deision mking 24 84 Deth nd erevement ffet different people in different wys, nd n individul s response will e influened y ftors suh s their eliefs, ulture, religion nd vlues. You must show respet for nd respond sensitively to the wishes nd needs of the ereved, tking into ount wht you know of the ptient s wishes out wht should hppen fter their deth, inluding their views out shring informtion. You should e prepred to offer support nd ssistne to the ereved, for exmple, y explining where they n get informtion out, nd help with, the dministrtive prtilities following deth; or y involving other memers of the tem, suh s nursing, hpliny or erevement re stff. d whih options for tretment would provide overll linil enefit for the ptient whih option, inluding the option not to tret, would e lest restritive of the ptient s future hoies ny evidene of the ptient s previously expressed preferenes, suh s n dvne sttement or deision From The Code: Professionl stndrds of prtie nd ehviour for nurses nd midwives 42 Preserve sfety You mke sure tht ptient nd puli sfety is proteted. You work within the limits of your ompetene, exerising your professionl duty of ndour nd rising onerns immeditely whenever you ome ross situtions tht put ptients or puli sfety t risk. You tke neessry tion to del with ny onerns where pproprite. 8
14 Be open nd ndid with ll servie users out ll spets of re nd tretment, inluding when ny mistkes or hrm hve tken ple To hieve this, you must: 14.1 t immeditely to put right the sitution if someone hs suffered tul hrm for ny reson or n inident hs hppened whih hd the potentil for hrm 14.2 explin fully nd promptly wht hs hppened, inluding the likely effets, nd pologise to the person ffeted nd, where pproprite, their dvote, fmily or rers, nd 14.3 doument ll these events formlly nd tke further tion (eslte) if pproprite so they n e delt with quikly. 16 At without dely if you elieve tht there is risk to ptient sfety or puli protetion To hieve this, you must: 16.1 rise nd, if neessry, eslte ny onerns you my hve out ptient or puli sfety, or the level of re people re reeiving in your workple or ny other helthre setting nd use the hnnels ville to you in line with our guidne nd your lol working prties 16.2 rise your onerns immeditely if you re eing sked to prtise eyond your role, experiene nd trining 16.3 tell someone in uthority t the first resonle opportunity if you experiene prolems tht my prevent you working within the Code or other ntionl stndrds, tking prompt tion to tkle the uses of onern if you n 16.5 not ostrut, intimidte, vitimise or in ny wy hinder ollegue, memer of stff, person you re for or memer of the puli who wnts to rise onern, nd 16.6 protet nyone you hve mngement responsiility for from ny hrm, detriment, vitimistion or unwrrnted tretment fter onern is rised. For more informtion, plese visit: www.nm.org.uk/rising onerns. Appendix 2: The sttutory duty of ndour for re orgnistions ross the UK Englnd The CQC hs put in ple requirement for helthre providers to e open with ptients nd pologise when things go wrong. This duty pplies to ll registered providers of oth NHS nd independent helthre odies, s well s providers of soil re from 1 April 2015. The orgnistionl duty of ndour does not pply to individuls, ut orgnistions providing helthre will e expeted to implement the new duty throughout their orgnistion y mking sure tht stff understnd the duty nd re ppropritely trined. Regultion 20 of the Helth nd Soil Cre At 2008 (Regulted Ativities) Regultions 2014 intends to mke sure tht providers re open nd trnsprent in reltion to re nd tretment with people who use their servies. It lso sets out some speifi requirements tht providers must follow when things go wrong with re or tretment, inluding informing people out the inident, providing resonle support, giving truthful informtion nd pologising when things go wrong. The CQC n proseute for reh of prts 20(2) nd 20(3) of this regultion. 16.4 knowledge nd t on ll onerns rised to you, investigting, eslting or deling with those onerns where it is pproprite for you to do so 9
Northern Irelnd In Jnury 2015, former Northern Irelnd Helth Minister Jim Wells MLA nnouned plns to introdue sttutory duty of ndour for Northern Irelnd. This nnounement followed the pulition of the Donldson Report, 43 whih exmined the governne rrngements for mking sure helth nd soil re is of high qulity in Northern Irelnd. The nnul report of the hief medil offier for Northern Irelnd 2014, pulished in My 2015, restted the ommitment to introdue sttutory duty of ndour in Northern Irelnd. 44 In response to the Donldson review the Minister nnouned plns to introdue sttutory duty of ndour for Northern Irelnd. Tht duty me to prominene in Englnd s result of onlusions from the Frnis report puli inquiry into the Mid Stffordshire NHS Foundtion Trust. Openness nd trnspreny re ruil elements of ptient sfety. When things go wrong, ptients, servie users nd the puli hve right to expet tht they will e ommunited with in n honest nd respetful mnner nd tht every effort will e mde to orret errors or omissions nd to lern from them to prevent reurrene. The Helth nd Soil Cre servie in Northern Irelnd lredy opertes under sttutory duties of oth qulity nd involvement. Meningful enggement with ptients nd lients, rers nd the puli will improve the qulity nd sfety of servies. It is not the intention of the duty of ndour to promote ulture of fer, lme nd defensiveness in reporting onerns out sfety nd mistkes when they hppen. Sotlnd The Helthre Qulity Strtegy for NHS Sotlnd 45 is iming to hieve n NHS ulture in whih re is onsistently person-entred, linilly effetive nd sfe for every person, ll the time. The Sottish Ptient Sfety Progrmme 46 is ntionl inititive tht ims to improve the sfety nd reliility of helthre nd redue hrm. Following puli onsulttion etween Otoer 2014 nd Jnury 2015, the Sottish Government pulished the Helth (Too, Niotine et. nd Cre) (Sotlnd) Bill on 5 June 2015. 47 The purpose of the duty of ndour provisions of the Bill re to support the implementtion of onsistent responses ross helth nd soil re providers when there hs een n unexpeted event or inident tht hs resulted in deth or hrm, tht is not relted to the ourse of the ondition for whih the person is reeiving re. The duty of ndour proedure (whih will e set out in regultions to e mde using powers in the Bill) will emphsise lerning, hnge nd improvement three importnt elements tht will mke signifint nd positive ontriution to qulity nd sfety in helth nd soil re settings. The new duty of ndour on orgnistions will rete legl requirement for helth nd soil re orgnistions to inform people (or their fmilies/ rers ting on their ehlf) when they hve een hrmed (physilly or psyhologilly) s result of the re or tretment they hve reeived. There will e requirement for orgnistionl emphsis on stff support nd trining to ensure effetive implementtion of the orgnistionl duty. Wles The Ntionl Helth Servie (Conerns, Complints nd Redress Arrngements) (Wles) Regultions 2011 ple numer of duties on responsile odies providing NHS re. This inludes duty to e open when hrm my hve ourred: where onern is notified y memer of the stff of the responsile ody, the responsile ody must, where its initil investigtion determines tht there hs een moderte or severe hrm or deth, dvise the ptient to whom the onern reltes, or his or her representtive, of the notifition of the onern nd involve the ptient, or his or her representtive, in the investigtion of the onern. 10
The Welsh Government s Helth nd Cre Stndrds Frmework, 48 inludes stndrd lled listening nd lerning from feedk. In meeting this stndrd, the frmework dvises tht helth servies re open nd honest with people when something goes wrong with their re nd tretment. The stndrds provide frmework for how servies re orgnised, mnged nd delivered on dy-to-dy sis. The Minister for Helth nd Soil Servies hs onfirmed tht findings from the reent independent reviews of omplints hndling y NHS Wles 49 nd of Helthre Inspetorte Wles 50 will inform n NHS Wles Qulity Bill Green Pper y the end of 2015, whih is likely to inlude further onsidertion of duty of ndour. Referenes 1 Generl Chiroprti Counil, Generl Dentl Counil, Generl Medil Counil, Generl Optil Counil, Generl Osteopthi Counil, Generl Phrmeutil Counil, Nursing nd Midwifery Counil, Phrmeutil Soiety of Northern Irelnd (2014) The professionl duty of ndour ville t: www.gm-uk.org/joint_ sttement_on_the_professionl_duty_of_ ndour_final.pdf_58140142.pdf (essed 16 June 2015) 2 Generl Medil Counil (2013) Good medil prtie ville t: www.gm-uk.org/gmp, prgrphs 24 nd 55 3 Nursing nd Midwifery Counil (2015) The Code: Professionl stndrds of prtie nd ehviour for nurses nd midwives ville t: www.nm.org.uk/ode (essed 15 June 2015), setion 14 4 Generl Medil Counil (2008) Consent: ptients nd dotors mking deisions together ville t: www.gm-uk.org/onsent 5 Nursing nd Midwifery Counil (2015) The Code: Professionl stndrds of prtie nd ehviour for nurses nd midwives ville t: www.nm.org.uk/ode (essed 15 June 2015), setion 4.2 6 Generl Medil Counil (2008) Consent: ptients nd dotors mking deisions together ville t: www.gmuk.org/onsent, prgrphs 26 27 7 Generl Medil Counil (2008) Consent: ptients nd dotors mking deisions together ville t: www.gmuk.org/onsent, prgrphs 28 36 8 The Supreme Court (2015) Judgment: Montgomery (Appellnt) v Lnrkshire Helth Bord (Respondent) (Sotlnd) ville t: https://www.supremeourt.uk/ses/dos/ uks-2013-0136-judgment.pdf (essed 15 June 2015), prgrphs 86 91 9 Generl Medil Counil (2014) Guidne for dotors ting s responsile onsultnts or liniins ville t www.gm-uk.org/ guidne/ethil_guidne/25335.sp (essed 18 June 2015) 10 Generl Medil Counil (2013) Good medil prtie ville t: www.gm-uk.org/gmp, prgrph 31 11 Generl Medil Counil (2008) Consent: ptients nd dotors mking deisions together ville t: www.gm-uk.org/onsent, prgrphs 13 17 12 NHS Litigtion Authority Sying Sorry ville t: www.nhsl.om/clims/douments/ Sying%20Sorry%20-%20Leflet.pdf 13 Compenstion At 2006 (Englnd nd Wles) ville t: www.legisltion.gov.uk/ ukpg/2006/29/pdfs/ukpg_20060029_ en.pdf, setion 2 11
14 Generl Medil Counil (due for pulition in 2015) Sntions guidne for the Medil Prtitioners Triunl Servie s fitness to prtise pnels nd for the Generl Medil Counil s deision mkers 15 Nursing nd Midwifery Counil (2012) Inditive sntions guidne to pnels ville t: www. nm.org.uk/glolssets/sitedouments/ftp_ informtion/inditive-sntions-guidne. my-12.pdf 16 Nursing nd Midwifery Counil (2014) Guidne for deision mkers on insight, remedition nd risk of reourrene ville t: www. nm.org.uk/glolssets/sitedouments/ ftp_informtion/remedition-guidne.pdf 17 Generl Medil Counil (2008) Consent: ptients nd dotors mking deisions together ville t: www.gmuk.org/onsent, prgrphs 20 21 18 Generl Medil Counil (2013) Good medil prtie ville t: www.gm-uk.org/gmp, prgrph 21 19 Nursing nd Midwifery Counil (2015) The Code: Professionl stndrds of prtie nd ehviour for nurses nd midwives ville t: www.nm. org.uk/ode, setion 14.3 20 Generl Medil Counil (2013) Good medil prtie ville t: www.gm-uk.org/gmp, prgrphs 33, 65 nd 68 23 PllCreNI Understnding Pllitive nd End of Life Cre ville t: www.pllreni.net 24 Generl Medil Counil (2010) Tretment nd re towrds the end of life: good prtie in deision mking ville t: www.gm-uk.org/ endoflife, prgrph 84 25 Generl Medil Counil (2013) Good medil prtie ville t: www.gm-uk.org/gmp, prgrph 23 26 Ntionl Helth Servie Report ptient sfety inident ville t: www.nrls.nps.nhs.uk/ report--ptient-sfety-inident/ (essed 16 June 2015) 27 Mediines nd Helthre produts Regultory Ageny Yellow Crd: Helping to mke mediines sfer ville t: https://yellowrd.mhr. gov.uk 28 Mediines nd Helthre produts Regultory Ageny Reporting dverse inidents involving medil devies ville t: www.mhr.gov.uk/sfetyinformtion/ Reportingsfetyprolems/Devies/index.htm 29 Helthre Improvement Sotlnd (2015) Lerning from dverse events through reporting nd review: A ntionl frmework for Sotlnd ville t: www. helthreimprovementsotlnd.org/ our_work/governne_nd_ssurne/ mngement_of_dverse_events/ntionl_ frmework.spx 21 Generl Medil Counil (2013) Good medil prtie ville t: www.gm-uk.org/gmp, prgrph 33 22 NHS Improving Qulity End of Life Cre ville t: www.nhsiq.nhs.uk/improvementprogrmmes/long-term-onditions-ndintegrted-re/end-of-life-re.spx 30 Deprtment of Helth, Soil Servies nd Puli Sfety Proedure for the Mngement nd Follow up of Serious Adverse Inidents ville t: www.dhsspsni.gov.uk/sikground 12
31 Cre Qulity Commission (2015) Duty of ndour: Informtion for ll providers: NHS odies, dult soil re, primry medil nd dentl re, nd independent helthre ville t: www.q.org.uk/sites/defult/ files/20150327_duty_of_ndour_guidne_ finl.pdf 32 Generl Medil Counil (2012) Rising nd ting on onerns out ptient sfety ville t: www.gm-uk. org/risingonerns 33 Nursing nd Midwifery Counil (2013) Rising onerns: guidne for nurses nd midwives ville t: http://www.nm.org.uk/ stndrds/guidne/rising-onernsguidne-for-nurses-nd-midwives/(essed 15 June 2015) 34 Generl Medil Counil (2014) Ntionl trining survey 2014: ullying nd undermining ville t: www.gm-uk.org/nts_ullying_ nd_undermining_report_2014_final. pdf_58648010.pdf 35 Nursing nd Midwifery Counil (2015) The Code: Professionl stndrds of prtie nd ehviour for nurses nd midwives ville t: www.nm.org.uk/ode (essed 15 June 2015), setion 23 36 Generl Medil Counil (2013) Good medil prtie ville t: www.gm-uk.org/gmp, prgrphs 22 23 37 Generl Medil Counil (2012) Supporting informtion for pprisl nd revlidtion ville t: www.gm-uk.org/dotors/ revlidtion/revlidtion_informtion.sp, p 8 38 Nursing nd Midwifery Counil will e pulishing guidne on revlidtion in utumn of 2015. This will e ville t: www.nm.org.uk/ stndrds/revlidtion/ 39 Nursing nd Midwifery Counil (2015) The Code: Professionl stndrds of prtie nd ehviour for nurses nd midwives ville t: www.nm. org.uk/ode, setions 16.6 nd 25.2 40 Generl Medil Counil (2012) Ledership nd mngement for ll dotors ville t: www. gm-uk.org/ledership 41 Generl Medil Counil Rising nd ting on onerns out ptient sfety: deision mking tool ville t: www.gm-uk.org/guidne/ ethil_guidne/deision_ tool.sp (essed 15 June 2015) 42 Nursing nd Midwifery Counil (2015) The Code: Professionl stndrds of prtie nd ehviour for nurses nd midwives ville t: www.nm. org.uk/ode, setions 14 nd 16 43 Donldson L, Rutter P, Henderson M (2014) The Donldson Report: the right time, the right ple ville t: www.dhsspsni.gov.uk/ ldreport270115.htm 44 Deprtment of Helth, Soil Servies nd Puli Sfety (2015) Your helth mtters: the nnul report of the hief medil offier for Northern Irelnd 2014 ville t: www.dhsspsni. gov.uk/hief-medil-offier-nnulreport-13-14.pdf 45 The Sottish Government (2010) NHS Sotlnd Qulity Strtegy putting people t the hert of our NHS ville t: www.sotlnd.gov.uk/ Pulitions/2010/05/10102307/0 (essed 15 June 2015) 46 Sottish Ptient Sfety Progrmme ville t: www. sottishptientsfetyprogrmme.sot. nhs.uk 13
47 The Sottish Government (2015) Helth (Too, Niotine et. nd Cre) (Sotlnd) Bill ville t www.sottish.prliment.uk/ prlimentryusiness/bills/89934.spx 48 Welsh Government (2015) Helth nd Cre Stndrds Frmework ville t: www.wles. nhs.uk/governne-emnul/how-thehelth-nd-re-stndrds-re-st (essed 15 June 2015) 49 Welsh Government (2014) Using the gift of omplints ville t: www.gov.wles/ topis/helth/pulitions/helth/reports/ omplints/?lng=en 50 Helthre Inspetorte Wles (2014) Report of review in respet of: Arrngements put in ple y Aneurin Bevn Helth Bord (ABHB) following the deth of Miss A in 2010 ville t: www.hiw.org.uk/sitesplus/douments/1047/ Aneurin%20Bevn%20-%20CP%20 Review%20-%20Report%20-%202014-03- 19.pdf Pulished June 2015 2015 Generl Medil Counil Nursing nd Midwifery Counil The GMC is hrity registered in Englnd nd Wles (1089278) nd Sotlnd (SC037750) The NMC is hrity registered in Englnd nd Wles (1091434) nd in Sotlnd (SC038362) Code: GMC/OHWTGO/0615 14