DOI: 10.1111/tog.

12586 2019;21:165–8
The Obstetrician & Gynaecologist
Commentary
http://onlinetog.org

Duty of candour: the obstetrics and gynaecology

perspective
Thomas G. Gray MRCOG MSc,
a
Swati Jha MD FRCOG
b,
* Helen Bolton DLM PhD MRCOG
c

a
Subspecialty Trainee in Urogynaecology, Sheffield Teaching Hospitals NHS Foundation Trust, Level 4, Jessop Wing, Tree Root Walk,
Sheffield S10 2SF, UK
b
Consultant Gynaecologist, Subspecialist in Urogynaecology, Sheffield Teaching Hospitals NHS Foundation Trust, Level 4, Jessop Wing, Tree Root
Walk, Sheffield S10 2SF, UK
c
Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Box 242, Department of Gynaecological Oncology, Cambridge
CB2 0QQ, UK
*Correspondence: Swati Jha. Email: Swati.Jha@sth.nhs.uk

Accepted on 6 January 2019.

non-disclosure include negligible perception of patient harm,

Introduction
The word candour describes a quality of being open and
honest. An ethical duty of candour (DoC) has always existed
and has been a cornerstone of medical practice but was not
always enforced in law. In 2015, the General Medical Council
(GMC) document Openness and honesty when things go
wrong: the professional duty of candour was published and sent
to doctors with a licence to practice1 This lays out the
responsibilities of individuals when things go wrong. DoC
has now become a legal requirement and is a contractual duty
imposed on all NHS organisations.
There are two types of DoC: statutory and professional.
Statutory DoC applies to organisations and all care providers
registered by the Care Quality Commission (CQC). In
contrast, professional DoC applies to individuals and is
defined as ‘a professional responsibility to be honest with
patients when things go wrong’. Although there is
considerable overlap, there are several key differences
between the two. In obstetrics and gynaecology, where the
cost of harm can be catastrophic, it is important that
clinicians appreciate the implications of DoC within their
practice. The aim of this article is to equip doctors working
within obstetrics and gynaecology with an understanding of
DoC, addressing current training gaps on this topic and
helping to support implementation into clinical practice,
especially around knowing when and how to appropriately
and correctly apologise to patients/relatives as per the
DoC guidance.
Rationale for the ‘disclosure gap’
NHS enquiries and studies assessing disclosure habits among
UK doctors have identified that there is failure to disclose
errors to patients in as many as 70–97% of cases.2,3 Reasons for
fear of litigation and fear of organisational reprisal.4 This is
pertinent in obstetrics and gynaecology, with current
workforce challenges and persistent issues around
undermining within the specialty. It can be psychologically
difficult for doctors to admit mistakes, partly because they have
a professional and personal commitment to help patients,5 but
also because they may fear the personal consequences. Some
doctors may feel paternalistic and will want to protect patients
from the effects that difficult information can have upon them.
Statutory duty of candour
Public enquiries into high-profile failings in NHS care have
been key drivers in the development of statutory DoC. The
Bristol Enquiry (2001)6 emphasised the need to be open
about mistakes and led to the establishment of the National
Patient Safety Agency. Following the Mid-Staffordshire NHS
Foundation Trust Public Enquiry, the Francis Report (2013)3
recommended a statutory DoC obligation to be imposed on
all healthcare providers and registered healthcare
practitioners. This became statute in November 2014,
mandating that all CQC-registered healthcare providers
must comply. In 2015, following the Morecambe Bay
Investigation, the Kirkup Report7 commended the
introduction of the DoC for all NHS professionals and
recommended that this should be extended to include the
involvement of patients and relatives in the investigation of
serious incidents. Scandals within maternity services in both
Mid Staffordshire3 and Morecambe Bay7 therefore had an
impact on DoC legislation.
Statutory DoC is a corporate, as opposed to professional,
obligation and applies when a threshold of moderate harm
(or worse) has been breached. The DoC guidance8 does not
clearly state what constitutes harm or distress, but the

ª 2019 Royal College of Obstetricians and Gynaecologists 165

 Duty of candour in O and G

National Patient Safety Agency, whose function is now

carried out by NHS Improvement, defined levels of harm as
low, moderate, severe and death9; the NHS now also uses
these terms to define levels of harm. It would seem logical
that any adverse event of moderate or greater severity, which
would usually trigger incident reporting, should be explained
to the patient and an apology given. The guidance states that
‘providers are not required by the regulation to inform a
person using the service when a “near miss” has occurred,
and the incident has resulted in no harm to that person’.8
‘Near misses’ are covered by professional DoC, with further
details below.
Guidance8 states that harm should be assessed in the
‘reasonable opinion of a healthcare professional’, with the
emphasis on being open if there is any doubt. Individual
clinicians should be encouraged to seek advice from
appropriate colleagues and their organisation’s managers in
cases where there is uncertainty. Doctors with management
roles must be responsible for ensuring systems for incident
reporting are in place and supported, as well as encouraging a
culture of openness and honesty. Once such an event has
arisen, the organisation must take the following steps:
 The patient should be informed of the incident, preferably
in person, as soon as reasonably practical. Patients must be
provided with a written account of the discussion, and
copies of correspondence must be kept by
the organisation.
 A full explanation should be given, including details of any
further investigations that will be carried out.
 An apology should be offered, and reasonable support
should be provided for the patient.
 Organisations must keep a written record of the
notification to the patient.
Examples of statutory DoC are given in Table 1.
Professional duty of candour
GMC guidance1 on professional DoC consists of two parts: the
first states the duties of doctors to their patients, and the
second concerns the duties of a doctor to the organisation they
work for, including their role in incident reporting.
Professional DoC applies whenever patients have suffered
harm or distress when something has gone wrong with their
care. There is no defined threshold of harm that needs to be
met for the duty to arise. For ‘near miss’ episodes (i.e. care has
gone wrong, but fortunately the patient came to no harm), the
GMC has advised clinicians to use their professional
judgement when deciding whether to tell patients about the
error,1 but, in reality, following professional DoC should
include telling patients when a near miss has occurred. When
there is uncertainty, it may be helpful to seek advice from
senior colleagues or a clinical director. The duties of the
healthcare professional for professional DoC include:
 Telling the patient (or, when appropriate, the patient’s
family or carer) when something has gone wrong.
 Apologising to the patient (or, when appropriate, the
patient’s advocate, carer or family).
 Offering an appropriate remedy or support to put matters
right where possible.
 Giving the patient a full explanation of the short and long-
term effects of what has happened.
Examples of professional DoC are given in Table 2.
Apologising
The DoC guidance8 gives specific details on how to make an
appropriate apology (Box 1), while making it clear that an
apology does not equate to admitting legal liability. The UK
Compensation Act (2006)12 also reassures clinicians that

Table 1. Examples of when statutory duty of candour should be

applied
Obstetrics
Injury to a baby during delivery,
requiring treatment or admission
to the special care baby unit
Obstetric anal sphincter injury
occurring during instrumental
delivery
Gynaecology
An intraoperative visceral injury
Delay in diagnosing ectopic
pregnancy because of
misinterpretation of levels of
human chorionic gonadotropin,
resulting in collapsed patient
and emergency surgery
Table 2. Examples of when professional duty of candour should be
applied
Obstetrics
Any abrasion to a baby during
caesarean delivery, requiring no
intervention
Stitch taken through rectum at
suturing of perineal tear
identified at per rectum exam,
requiring stitches to be taken
down and tear re-repaired
Gynaecology
Any tear to the cervix occurring
during surgical management of
miscarriage requiring suturing
Any diathermy burn to a patient's
skin at edge of incision during a
laparotomy

Delay in induction of labour Incorrect reporting of ultrasound Dural puncture during epidural Difficulty gaining entry at
resulting in intrauterine fetal findings in early pregnancy anaesthetic laparoscopy resulting in surgical
death emphysema and bruising

166 ª 2019 Royal College of Obstetricians and Gynaecologists


Box 1. How you should apologise in line with professional duty of
candour guidance
Who should apologise: the lead or accountable clinician (usually the
consultant) should speak to the patient.
Timing of the apology: as soon as practicably possible, but ensuring
the patient can retain the information.
Who should be present: someone should be present to support the
patient. This may be a family member, carer or an advocate from the
healthcare team.
What you should tell the patient in the apology: all you know
and believe to be true about what went wrong and why and what the
likely consequences are going to be.
How you should apologise: considerately and in a personalised way.
Ideally use the words “I am sorry. . .”, as opposed to a more general
expression of regret about the incident on the organisation’s behalf.
How you should give information: in a way the patient, carers and
family can understand.
How you should record the apology: details of the apology should
be recorded in the notes.
offering an apology does not equate to an admission of blame
or negligence for harm that has occurred.
Obstetrics and gynaecology is a high-risk specialty,
receiving 15% of claims against hospital specialties and
accounting for 50% of the value of all claims.11 Therefore,
apologies that admit fault can create anxiety for professionals,
fearing that admission may increase the possibility of
financial claims or professional sanction. However, an
appropriate apology may instead prevent the issue
escalating into a formal complaint or legal action for
negligence. The DoC guidance8 also suggests that a fitness
to practice panel may view an apology as evidence of insight,
although few doctors working in obstetrics and gynaecology
are likely to find this reassuring.
Challenges posed by duty of candour
DoC guidance8 also deals with reporting incidents when
something has gone wrong with a patient’s care, so that
lessons can be learnt quickly and patients protected from
future harm. Obstetrics and gynaecology departments must
have a functional policy for reporting adverse events and near
misses and should support individuals reporting these. There
are many challenges for implementing the guidance laid out
by DoC, and these include funding, staffing levels in the
current climate and shifting long-held ingrained opinions
about the role of doctors and medical paternalism.
Candour and consent
Professional DoC mandates doctors to be open and honest with
patients at all times, not just when things go wrong. This
extends to making decisions together, and consequently
requires a candid approach to providing information before
beginning treatment or providing care. Patients must be fully
ª 2019 Royal College of Obstetricians and Gynaecologists
Gray et al.
informed about their care options, including risks and available
alternatives. This is in line with the principles laid out in the
Montgomery v Lanarkshire Healthboard ruling,10 which
clarified the standards required for informed consent. The
principles of explaining all options for treatment, including no
treatment, the pros and cons of each option and ensuring these
are underlined by written information, appropriate use of
decision aids, and ensuring all options are well documented in
the medical notes is essential for the practice of modern
obstetrics and gynaecology. Healthcare professionals must be
open about all reasonable treatment options for patients, even if
they are unable to provide a treatment within their
organisation. Although the Montgomery ruling requires
patients to be informed about alternatives, it does not
mandate the healthcare professional to provide all these
procedures. Rather, each clinician should be able to refer the
patient to another clinician who can potentially provide the
alternative procedures they are unable to provide themselves.
Maternity care presents unique challenges around consent,
especially in the delivery suite setting, where there may be only
one safe option for treatment and decisions need to be made
quickly. Many women find that pain and exhaustion affect
their ability to make decisions during labour,13 and therefore
‘best interests’ and paternalism around decision making can
still potentially dominate. A culture of only informing patients
in detail about normal birth in the antenatal period is
potentially harmful in this context, as women will not be able
to make informed decisions without appropriate information.
To mitigate this, improved antenatal education and individual
discussion of potential interventions in labour should equip
women to be better able to understand and make decisions
regarding their intrapartum care. This truly individualised
approach to all women may be challenging to provide with
current limited resources.
The challenges of consent in the light of DoC are also
pertinent in gynaecological practice, where patients should be
informed of all the surgical and non-surgical options
available to treat their condition. This will include the pros
and cons of each and the provision of detailed written
information, decision aids and time to make an informed,
shared decision. The recent concerns about the use of vaginal
mesh to treat incontinence in urogynaecology highlight the
importance of demonstrating that patients with such
conditions have detailed discussions about all surgical
alternatives and conservative management.
Conclusion
There is evidence that DoC guidance8 is still not reaching all
frontline staff, despite the high-profile introduction of the
guidance. Each obstetrics and gynaecology department
should ideally be providing information to staff about DoC
and ensuring that departmental procedures and guidelines
167
 Duty of candour in O and G
are in place to support staff with implementing DoC in day-
to-day practice.
In particular, there is currently a paucity of teaching and
training available on this subject, compared with other
communication skills for obstetricians and gynaecologists,
such as breaking bad news. Teaching rarely extends to
conducting the challenging conversations that are required
for disclosure of errors or mistakes. Education and practical
training may be beneficial in helping obstetricians and
gynaecologists implement the principles and practices into
their daily practice.
Disclosure of interests
There are no conflicts of interest.
Contribution to authorship
TG researched the manuscript, SJ instigated the manuscript.
All authors wrote, edited and approved the final version of
the manuscript.
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ª 2019 Royal College of Obstetricians and Gynaecologists