Duty of Candour (Openness & Apology)

SJT Textbook: Duty of Candour (Openness & Apology)

Duty of Candour MSRA

This guide covers the Duty of Candour MSRA scenarios you will face in the exam. Candidates often worry that saying “sorry” admits legal liability. This guide clarifies why the GMC and CQC actually *require* that apology to pass the Professional Dilemmas paper.

🎥 Video Lesson (YouTube)

🎧 Podcast Lesson (Spotify / Apple / Amazon)

🎯 THE CORE PRINCIPLE

The duty of candour means being open and honest with patients (and those close to them where appropriate) when something goes wrong with their care. Professionally, you must tell the patient, give a sincere apology, explain what is known and what is not yet clear, offer remedial action and support, and participate in reviews and learning.

Organisationally, the statutory duty of candour under CQC Regulation 20 applies when an incident meets the threshold of a notifiable safety incident: it is unintended or unexpected, occurs during regulated activity, and results in (or could result in) death, severe or moderate harm, or prolonged psychological harm. In these cases, the provider must notify, apologise, provide a written account, and keep records.

In the SJT, high-scoring actions always prioritise patient safety, early honest communication, appropriate escalation through governance/Regulation 20 where indicated, and good documentation. Low-scoring actions delay disclosure, minimise or hide harm, blame others, or ignore formal processes.

⚡ HIGH-YIELD ACTIONS (What Scores Points)

1. Make the situation clinically safe first (treat harm, prevent further injury, seek senior help).
2. Arrange to speak to the patient (and those close to them if appropriate) promptly and in private.
3. Give a clear, sincere apology for what has happened, without being defensive or speculative.
4. Explain what is known now, acknowledge uncertainty, and outline immediate next steps and support.
5. Escalate through local incident reporting systems and notify clinical governance or risk management early.
6. Recognise when harm meets notifiable safety incident thresholds and ensure the Regulation 20 process is followed (notification, apology, written account, record).
7. Offer ongoing support, signposting to PALS or advocacy services where appropriate.
8. Document the event and conversations carefully: who was present, what was said, what actions were taken, and the plan for investigation and follow-up.

To score highly in Duty of Candour MSRA ranking questions, you must demonstrate “Action + Apology.” An apology without a remedy is just empty words.

Traps revolve around delay, secrecy, poor documentation, shifting responsibility, and protecting the organisation over the patient. Good options favour early honest contact, formal reporting, and learning.

💬 MODEL PHRASES (Use These in SJT Logic)

* “We will investigate what went wrong, and we will share the findings with you, including any changes we make as a result.”
* “Saying sorry is not about blame; it is about being open and putting things right as far as we can.”
* “I will record our discussion in your notes and notify the clinical governance team so the formal duty of candour process is followed.”
* “If you would find it helpful, I can arrange further support, and you can also speak with PALS for independent advice.”

Safe first • Open now • Remedy and support • Reg 20 if threshold • Your note in the record.

📋 QUICK FAQ

Is apologising an admission of legal liability?
No. CQC, GMC and NHS Resolution all emphasise that a sincere apology is expected and does not amount to admitting legal liability.

Do I have to tell the patient about near misses or minor harm?
Yes, professional duty of candour means being open whenever care has caused harm or could reasonably cause worry or distress. The statutory Regulation 20 process may not be triggered if thresholds are not met, but professional candour still applies.

Who should speak to the patient after a serious incident?
Usually the most appropriate senior clinician involved in or responsible for their care. They should apologise, explain what is known, outline further steps, and act as a point of contact.

What exactly is a notifiable safety incident under Regulation 20?
An unintended or unexpected incident during regulated activity which, in the reasonable opinion of a healthcare professional, has resulted in or might result in death, severe harm, moderate harm, or prolonged psychological harm (with specific CQC definitions).

What needs to be documented?
Factual details of the incident, who was involved, what was said to the patient and when, safety actions taken, whether Reg 20 applies, incident reporting numbers, and the agreed plan for follow-up and sharing outcomes.

📚 GMC ANCHOR POINTS

• Be open and honest with patients when things go wrong, including apologising and explaining fully and promptly (GMC Good medical practice 2024).
• Tell patients about mistakes, offer appropriate remedy and support, and participate in reviews and learning (GMC/NMC professional duty of candour guidance).
• Work with your organisation to ensure incidents are reported, investigated and learned from (GMC Good medical practice – patient safety and quality).
• Recognise and follow legal and regulatory duties, including CQC Regulation 20 in England for notifiable safety incidents.

💡 MINI PRACTICE SCENARIO

A patient receives the wrong dose of an IV antihypertensive, causing transient hypotension and nausea. They recover fully with observation and fluids. You discover the error later in the shift.

Best action: Make sure the patient is clinically stable, then meet them promptly to apologise, explain what happened as far as is known, report the incident via the local system, and record the discussion.

Why: Professional duty of candour applies even if long-term harm is unlikely: the patient deserves an apology and explanation, and the organisation needs to learn from the incident. Regulation 20 may not be triggered, but openness and reporting are still required.

🎯 KEY TAKEAWAYS

✓ Duty of candour combines personal professional openness and organisational Regulation 20 duties.
✓ Apology should be early, sincere and focused on the patient’s experience, not blame.
✓ Regulation 20 applies when notifiable safety incident thresholds are reached and requires notification, apology, written account and records.
✓ Incident reporting, governance involvement and good documentation are integral to high-scoring actions.
✓ Delaying disclosure, minimising harm, avoiding records, or bypassing formal routes are all low-scoring patterns.

🔗 RELATED TOPICS

* → Responding to Patient Complaints
* → Incident Reporting and PSIRF
* → Speaking Up and Whistleblowing
* → Patient Confidentiality Principles
* → Professionalism and Maintaining Trust

📖 FULL PRACTICE QUESTIONS

Example SJT — Best of 3 (8 options; choose three)

Scenario

You are the medical registrar on call. A patient on your ward was given 10 times the prescribed dose of a sedative overnight due to a transcription error. They became hypotensive and excessively drowsy but recovered without lasting harm after fluids and observation. They are now stable and asking why they feel so groggy this morning. The incident has been highlighted by nursing staff, and your consultant is in clinic.

Options:
A. Wait for the full investigation report before saying anything so that you “do not give incorrect information.”
B. Tell the patient that “these things happen sometimes” but avoid mentioning the error to prevent them losing confidence.
C. Meet the patient as soon as possible, apologise sincerely, explain that a medication error occurred, describe what is known and what is being investigated, and document the discussion and incident report.
D. Ask a junior FY1 to apologise briefly without details while you move on to other tasks.
E. Tell the patient that the nurse was at fault and that you will make sure they are disciplined.
F. Reassure the patient that they are fine now and that “there is no need to worry about the past.”
G. Complete a formal incident report, notify the ward manager or governance team, and ensure the organisational candour process is started if required.
H. Post anonymised details of the error on your personal social media as an example of “how dangerous hospitals can be.”

Example SJT — Rank 5 (best → worst)

Scenario

A patient had a laparoscopic cholecystectomy at your trust. Two days later they developed severe abdominal pain and sepsis. Imaging showed a retained surgical swab, and they required an unplanned return to theatre and a prolonged HDU stay. The error is recognised as a notifiable safety incident under CQC Regulation 20. The patient is now awake and asking what went wrong.

Options:
A. Along with the consultant surgeon, meet the patient and those close to them today, apologise sincerely, explain what is known about the retained swab and its consequences, outline further investigations and support, notify governance, and ensure the full Regulation 20 process including a written account and recorded apology is completed.
B. Wait until the root cause analysis is completely finished before speaking to the patient so you can avoid “guessing” any details.
C. Write only a minimal entry in the notes and advise the team not to put too much detail in case of legal issues.
D. Ask a junior doctor to apologise very briefly without mentioning the swab and avoid involving governance to “protect the Trust’s reputation.”
E. Tell the patient that sometimes “things happen in surgery” and suggest they raise concerns with PALS if they want more information, but do not disclose the retained swab.