Policy Date: 01 May 2025
Authorised by: Dr Victoria McBride
Approved by: Dr Victoria McBride, Clinical Director
Issue Date: 01 May 2025
Version No: 1.1
Next Review: 01 August 2026 (or sooner if required)

1. Policy Statement

Courtyard Health Clinic is committed to delivering high-quality, safe, and person-centred care. We uphold openness, transparency, and candour in accordance with the Health (Tobacco, Nicotine etc. and Care) (Scotland) Act 2016, the Duty of Candour Procedure (Scotland) Regulations 2018, and Healthcare Improvement Scotland (HIS) guidance.

This policy outlines how we identify, respond to, and learn from incidents that trigger the statutory Duty of Candour, and how we report and communicate this publicly and meaningfully.

2. Scope

This policy applies to all staff, contractors, and clinical professionals at Courtyard Health Clinic and covers all services delivered. It aligns with applicable legislation and regulatory guidance for independent healthcare services in Scotland.

3. Definitions and Trigger Events

The Duty of Candour applies when an unintended or unexpected incident occurs during healthcare provision that results in (or could have resulted in):

• Death (not linked to natural progression of a condition)
• Permanent lessening of bodily, sensory, motor, or intellectual functions
• Increased treatment to prevent death or serious harm
• Structural changes to the body
• Impairment lasting ≥28 days
• Shortening of life expectancy
• Significant psychological harm/distress lasting ≥28 days
• A requirement for intervention to prevent any of the above

Examples: misdiagnosis, medication errors, procedural mistakes, etc. If there’s uncertainty, staff must escalate for senior clinical review.

4. Duty of Candour Procedure

When an incident meets the threshold:

• Notify the patient (or representative) within 10 working days
• Apologise (verbally and in writing)
• Explain the facts and provide an opportunity for questions
• Offer a meeting (face-to-face or virtual)
• Provide written documentation, updates, and final reports
• Signpost to support services (e.g. counselling, advocacy)
• Record all communications/actions in patient records and the internal incident log
• Review the incident (root cause analysis) and share learning

5. Openness and Transparency Principles

We promote a culture that encourages learning, not blame.

Key principles:

• Prompt acknowledgment and investigation of all incidents
• Timely, truthful communication
• Sincere, blame-free apologies
• Continuity of care and appropriate follow-up
• Confidentiality and dignity for all involved
• Cross-disciplinary involvement
• Sharing lessons through clinical governance

6. Support for Patients and Staff

For patients/carers:

• Interpreter or communication aids
• Advocacy/counselling referrals
• Written info and regular follow-up
• Referral to alternative care where needed

For staff:

• Access to debriefing, clinical supervision
• Employee assistance and mental health support
• Encouragement of open discussion in a supportive setting

7. Written Notification and Documentation

Written communication will include:

• A factual description of what happened
• A clear, written apology
• A summary of investigation findings
• Contact information for further support

All correspondence is logged in the patient record and in the clinic’s incident reporting system.

8. Communication with Patients and Families

We will make all reasonable efforts to communicate with affected individuals.

If a patient declines to engage, this is documented and respected. Conversations will be handled sensitively, and patients will be given control over how they wish to receive information and support.

9. Training and Governance

All staff receive training on Duty of Candour responsibilities, including how to:

• Recognise trigger events
• Communicate apologies effectively
• Support affected individuals
• Document actions

Clinical governance meetings are used to discuss incidents and embed learning.

10. Annual Reporting

Courtyard Health Clinic will prepare and publish an annual Duty of Candour report at the end of each financial year. This report includes:

• Number and nature of incidents
• Description of incidents where the procedure was triggered
• How the procedure was followed
• Lessons learned
• Improvements implemented
• Training completed
• Support provided to staff and patients
• Any updates to policies/procedures

Availability:

The report will be published on our website and made available in the clinic (e.g., in the waiting area or upon request).

Even if no incidents occurred, we will produce a brief report noting that, along with training and preparedness updates.

11. Review of the Policy

This policy will be reviewed annually, or sooner if there are changes in legislation, HIS guidance, or internal procedures.

12. Guidance and Further Reading

• Health (Tobacco, Nicotine etc. and Care) (Scotland) Act 2016
• Duty of Candour Procedure (Scotland) Regulations 2018
• Scottish Government Duty of Candour Guidance
• Healthcare Improvement Scotland: Independent Healthcare Standards
• General Medical Council and NMC Candour Guidance