Duty of Candour Policy

1. Policy aim

It is Autism and ADHD Diagnostic Centre's policy to:

• promote a culture that encourages and supports candour, openness and honesty at all levels within the organisation
• acknowledge, apologise and explain when things have gone wrong to clients and their families
• conduct objective and comprehensive investigations into "notifiable safety incidents" which provide assurance to clients, their families and all stakeholders that the company is committed to learn from and reduce the risk of recurrence of similar incidents
• engage and empower clients and their families in the investigation process, leading to co-production and co-design of services
• respect the wishes of clients and their families if they do not want to be involved with any stage of the investigation process
• provide support for all colleagues involved with a "notifiable safety incident" in accordance with a "just culture"
• comply with statutory and professional duty of candour guidelines

2. What is duty of candour?

2.1 Duty of candour is the act of being honest with clients and their families when avoidable harm has happened in our care. It underpins a safety culture which exonerates blame and focuses on learning, leading to improved client outcomes and experience.

2.2 The organisational duty of candour provisions of the Health (Tobacco, Nicotine etc. and Care) (Scotland) Act 2016 (the Act) and the Duty of Candour Procedure (Scotland) Regulations, revised March 2025, set out the procedure that organisations providing health services, care services and social work services in Scotland are required by law to follow when there has been an unintended or unexpected incident that results in death or harm (or additional treatment is required to prevent injury that would result in death or harm).

2.3 Following the Francis Inquiry in 2013, which found serious failings in openness and transparency at Mid Staffordshire NHS Foundation Trust, the statutory duty of candour was brought into law in 2014 for all NHS Trusts and 2015 for all other providers of health and social care.

2.4 Every organisation covered by the duty of candour legislation is regarded as a "responsible person", as defined in section 25 of the Act.

2.5 There is also a professional duty of candour, which is regulated by professional bodies including the General Medical Council (GMC), the General Dental Council (GDC) and the Nursing and Midwifery Council (NMC).

3. Purpose

To ensure that the infrastructure is in place to support all colleagues to be open and honest with clients and their families following an incident, complaint or claim.

Under the duty of candour provisions in Part 2 of the Health (Tobacco, Nicotine etc. and Care) (Scotland) Act 2016, the Scottish Government describes the purpose of the duty of candour provisions as:

"To support the implementation of consistent responses across health and social care providers when there has been an unexpected event or incident that has resulted in death or harm, that is not related to the course of the condition for which the person is receiving care."

4. Scope

This policy applies to all colleagues working for the Autism and ADHD Diagnostic Centre. It is also available to clients, their families and the public.

5. Duties

5.1 Responsibility for the development, maintenance, review and implementation of this policy lies with the Autism and ADHD Diagnostic Centre's Clinical Governance Group, whose members include the Company Directors, the Service Manager and clinician representation. Their key duties are to:

• provide support and guidance to colleagues on the duty of candour process
• ensure the duty of candour process is followed
• identify any staff support requirements
• ensure clients, their families and/or their carers have the opportunity to be involved in the investigation
• ensure the incident reporting system database is updated with full details, including assurance that the duty of candour process has been followed and feedback has been given to clients, their families and/or their carers
• ensure the incident is investigated appropriately
• ensure colleagues involved in the incident receive feedback and are given the opportunity to give an account of their personal experience of being involved in the investigation process
• ensure assurance of learning from incidents has been actioned

5.2 The Company Directors are responsible for:

• actively championing the Duty of Candour Policy by promoting an open and just culture that fosters peer support and discourages the attribution of blame
• ensuring the most appropriate colleague is identified to meet the client and/or their families, carers or their "relevant person". For the purpose of this policy, this colleague is known as the lead investigating officer. In choosing the lead investigating officer, consideration is given to seniority, relationship to the person using the service, and experience and expertise in the type of incident that has occurred, to ensure the lead investigating officer is credible to clients, families and carers.

5.3 The Service Manager is responsible for ensuring:

• the infrastructure is in place to support openness between colleagues, clients and their families, carers or representatives
• an appropriate support mechanism is in place for colleagues involved in a client safety incident

5.4 All colleagues are expected to adhere to this policy. Colleagues will also be aware of the relevant requirements regarding the duty of candour as set out in their professional regulatory body's code of conduct.

All colleagues are responsible for ensuring that client safety incidents are acknowledged and reported via the incident reporting system as soon as they are identified. Where a client, their family and/or carer informs us that something untoward has happened, it must be taken seriously from the outset. Any concerns should be treated with compassion and understanding by all colleagues.

6. Policy detail

6.1 In the event of any incident that compromises client safety, regardless of the level of harm, saying sorry is the right thing to do. Saying sorry is not admitting fault, nor is it an admission of liability.

6.2 As soon as you are able (within 24 hours), a verbal apology should be made to the client and/or their "relevant person".

6.3 The verbal apology should be recorded in the client's case file. State who you have apologised to, the time and date the apology was made, how you said sorry, and what you are apologising for.

6.4 Provide a true account of what happened and explain whatever you know at that point.

6.5 Explain to the client and/or their "relevant person" what further enquiries or investigations you believe to be appropriate at that point.

6.6 Full duty of candour requirements apply where an incident results in:

• the death of a client due to treatment received or not received
• severe harm: in essence, permanent serious injury as a result of care or support provided, or not provided
• moderate harm: non-permanent serious injury or prolonged psychological harm
• a moderate increase in treatment: an unplanned return to surgery, an unplanned re-admission, a prolonged episode of care, extra time in hospital or as an outpatient, cancelling of treatment, or transfer to another treatment area

6.7 Notification happens once it has been established that a client has come to avoidable harm while under the care of the Autism and ADHD Diagnostic Centre. This is decided at a multi-professional incident review meeting. The lead investigating officer will be identified at this review meeting.

6.8 Once it has been established that an incident meets the notifiable safety incident threshold, the client and/or their "relevant person" must be informed as soon as practicable. This will be completed by an Autism and ADHD Diagnostic Centre Company Director.

6.9 The client and/or their "relevant person" must be given an account, to the best of the informant's knowledge, of all the facts known about the incident at the point of notification.

6.10 The client and/or their "relevant person" must be advised, where possible, what further enquiries into the incident are deemed appropriate.

6.11 A verbal apology must be given to the client and/or their "relevant person".

6.12 Once the verbal apology has been made, it will be followed up in writing in an initial duty of candour letter within 5 working days. The written apology needs to be open, honest and specific. The letter will include the points raised in 6.9 and 6.10 and provide the contact details of the lead investigating officer. Any further updates on the progress of the investigation will also be included.

6.13 There may be occasions where the "relevant person" cannot be contacted or declines to engage with the lead investigating officer. In these circumstances, all attempts to contact or speak to the "relevant person" must be documented in a written record which is kept securely by the lead investigating officer.

6.14 Once the notifiable safety incident investigation is complete (within sixty working days), the client and/or their "relevant person" will receive a final duty of candour letter summarising the findings of the investigation. A date and time will be offered to meet with the client and/or "relevant person" to provide a copy of the final report, if they wish to receive it. This will take place within ten working days of the final report being submitted to the Clinical Governance Group.

It is best practice for the findings to be discussed with the client and/or their "relevant person" by the lead investigating officer face to face. The minutes of the meeting should be recorded and kept securely by the nominated lead person.

6.15 If the client or "relevant person" does not want a copy of the final report, or does not want to meet with the nominated lead person, this should be documented in the same manner as set out in this guidance.

Supporting colleagues in notifiable safety incidents

6.16 Colleagues involved in a notifiable safety incident can be understandably upset and distressed for a multitude of reasons. Although Autism and ADHD Diagnostic Centre supports a no-blame culture, colleagues may doubt their professional practice and question whether there were adequate systems and processes in place to reduce the risk of the incident occurring.

6.17 In line with the duty of candour principles, Autism and ADHD Diagnostic Centre welcomes the views of all those who have provided care, in these or any circumstances, as an opportunity to learn and continually improve client safety and experience.

6.18 Any colleague who wishes to raise a concern about client safety and/or care provision is advised to speak to the Service Manager in the first instance. If this is not appropriate because there is a conflict of interest, the colleague should contact any of the Company Directors.

Putting clients and their families at the centre of notifiable safety incidents

6.19 Autism and ADHD Diagnostic Centre will make every effort to involve clients, their families and/or carers in notifiable safety incident investigations. The ultimate aim of their involvement is to achieve a learning organisation where they become central to the co-production and co-design of neurodevelopmental services.

Particular client circumstances

6.20 Someone may act on behalf of the person who was harmed if the client:

• has died
• is under 16 years of age and not competent to make decisions about their care or the consequences of the notifiable safety incident
• is over the age of 16 years and lacks capacity

This is in accordance with the Adults with Incapacity (Scotland) Act 2000.

6.20 (i) When a client has died

When an incident has resulted in a client's death, it is crucial that communication is sensitive, empathic and open. It is important to consider the emotional state of bereaved relatives and carers and to involve them in deciding when it is appropriate to discuss what has happened.

The client's family and/or carers will likely require information on the process that will follow to identify the cause or causes of death. They may also need emotional support. Establishing open channels of communication may also allow the family and/or carer to indicate if they need bereavement counselling or assistance at any stage.

Duty of candour discussions and any investigation take place before a Fatal Accident Inquiry. In certain circumstances it may be appropriate to wait for police investigations to take place, if required, before holding duty of candour discussions with the client's family and/or carer. In any event, an apology and sincere condolences must be issued as soon as possible after the client's death.

6.20 (ii) Children

The legal age of maturity for giving consent to treatment is 16. It is the age at which a young person acquires full rights to make decisions about their own treatment, and their right to confidentiality becomes vested in them rather than their parents or guardians. However, it is still good practice to encourage competent children to involve their families in decision making.

Children under the age of 16 can consent to their own treatment if they are believed to have enough intelligence, competence and understanding to fully appreciate what is involved in their treatment. This is known as being Gillick competent. Where a child is judged to have the cognitive ability and emotional maturity to understand the information provided, they should be involved directly in the duty of candour process after a notifiable safety incident.

The opportunity for parents to be involved should still be provided and would be seen as good practice, unless the child expresses a wish for them not to be involved.

Where children are deemed not to have sufficient maturity or ability to understand, consideration needs to be given to whether information is provided to the parents alone or in the presence of the child. In these instances, the parents' views should be sought.

6.20 (iii) Clients with cognitive impairment

A client with a cognitive impairment should, where possible, be involved directly in communications about what has happened. An advocate with appropriate skills should be involved with the client to assist in the communication process.

The client may have authorised a person to act on their behalf through a lasting power of attorney. In these cases, steps must be taken to ensure this extends to decision making and to medical care and treatment of the client. The duty of candour discussion would be held with the holder of the power of attorney.

6.20 (iv) Clients with a learning disability

Where a client has difficulty expressing their opinion, an assessment should be made about whether they are also cognitively impaired (see above). If the client is not cognitively impaired, they should be supported in the duty of candour process by alternative communication methods, for example the opportunity to write questions down, or easy read information on what happened. Where necessary, support from an advocate may help the client during the duty of candour process, ensuring the client's views are considered and discussed.

6.20 (v) Clients with language or cultural considerations

The need for translation and advocacy support, and any particular cultural needs, must be considered when planning to discuss notifiable safety incident information. It is worthwhile obtaining advice from an advocate or translator before the meeting on the most sensitive and supportive way to discuss the information.

6.20 (vi) Clients with communication needs

Some clients may have particular communication difficulties, such as a hearing impairment. Plans for the meeting should fully consider these needs.

Knowing how to enable or enhance communication with a client is essential to an effective duty of candour process, focusing on the needs of the individual and their family. Advice should be sought from a recognised speech and language therapist on appropriate communication with individuals who may have complex communication difficulties.

7. Process for monitoring compliance

7.1 Individual

All registered healthcare professionals must act in line with their regulatory professional body's code of conduct or standards. "The Code" of the Nursing and Midwifery Council (NMC), under the domain of "Preserve safety", states:

"Be open and candid with all service users about all aspects of care and treatment, including when any mistakes or harm have taken place."

To achieve this, you must:

• act immediately to put right the situation if someone has suffered actual harm for any reason, or an incident has happened which had the potential for harm
• explain fully and promptly what has happened, including the likely effects, and apologise to the person affected and, where appropriate, their advocate, family or carers
• document all these events formally and take further action (escalate) if appropriate so they can be dealt with quickly

7.2 Team and service

The Clinical Governance team will monitor all incidents of "moderate" harm and above. Once it has been established that a client has come to "moderate", "severe" or "catastrophic" harm, the Chair of the Clinical Governance team will request that an investigation is undertaken and the duty of candour process will be implemented in full.

The first stages of the duty of candour process should already have been initiated at that point: a face-to-face verbal apology should have been made to the client and/or their "relevant person", and this should be documented in the client's case file.

7.3 Healthcare Improvement Scotland

This policy has been written to comply with the organisational duty of candour provisions of Part 2 of the Health (Tobacco, Nicotine etc. and Care) (Scotland) Act 2016 and the Duty of Candour Procedure (Scotland) Regulations 2018, and to reflect the requirements and expectations of Healthcare Improvement Scotland.

A duty of candour report will be completed at the end of each financial year, providing information about when and where Autism and ADHD Diagnostic Centre has applied the duty of candour. This report will be published on our website and shared with Healthcare Improvement Scotland.

Read our latest Duty of Candour Annual Report.

8. Training

Training on duty of candour will be completed by all new staff on induction. Updated training will be provided regularly through Autism and ADHD Diagnostic Centre's development events, or on staff request via supervision.

9. Learning and service development

Autism and ADHD Diagnostic Centre's clinical governance structure will ensure all identified recommendations are actioned following all notifiable safety incident investigations, and compliance is monitored through regular audit.

10. Definitions

Act in an open and transparent way

Clear, honest and effective communication with clients, their families and carers throughout their care and treatment, including when things go wrong, in line with the definitions below.

Openness

Enabling concerns and complaints to be raised freely without fear, and questions asked to be answered.

Transparency

Allowing the truth about performance and outcomes to be shared with staff, people who use the service, the public and regulators.

Candour

Any person who used the service and was harmed by the provision of a service is informed of the fact and an appropriate remedy offered, regardless of whether a complaint has been made or a question asked about it.

Apology

An expression of sorrow or regret in respect of a notifiable safety incident. It is not an admission of guilt.

Appropriate written records

Records that are complete, legible, accurate and up to date. Every effort must be made to ensure records are updated without delay.

Cancelling treatment

Where planned treatment is not carried out as a direct result of the notifiable safety incident.

Notifiable safety incident

Any unintended or unexpected incident that occurred in respect of a service user during the provision of a regulated activity that, in the reasonable opinion of a healthcare professional, could result in, or appears to have resulted in:

• Moderate harm: harm that has required a moderate increase in treatment, and significant but not permanent harm. A moderate increase in treatment means, for example, an unplanned return to surgery, an unplanned readmission, or a prolonged episode of care.
• Prolonged pain: pain which a service user has experienced, or is likely to experience, for a continuous period of at least 28 days.
• Prolonged psychological harm: psychological harm which a service user has experienced, or is likely to experience, for a continuous period of at least 28 days.
• Severe harm: a permanent lessening of bodily, sensory, motor, physiological or intellectual functions, including removal of the wrong limb or organ or brain damage, that is related directly to the incident and not related to the natural course of the service user's illness or underlying condition.

Relevant person

The person who is receiving services, or someone acting lawfully on their behalf where the person has died, is under 16 and not competent to make a decision about their care and treatment, or is 16 or over and lacks capacity in relation to the matter, in accordance with the Adults with Incapacity (Scotland) Act 2000.

Written notification

A notification given or sent to the relevant person in writing, containing the information provided in any initial notification made in person, details of any enquiries to be undertaken, the results of any further enquiries into the incident, and an apology (as defined above).

11. Associated documents

• Autism and ADHD Diagnostic Centre Complaints Policy
• Autism and ADHD Diagnostic Centre Induction Policy