Healthcare workers' 'duty of candour'.

political analyst

This article, which was published in February of last year, concerns the findings of the inquiry into the deaths of children who had hyponatraemia, which is a shortage of sodium in the bloodstream, and the cover-up of the circumstances of the deaths in Northern Ireland.

https://www.newsletter.co.uk/news/ni-could-be-alone-if-it-criminalises-individual-medics-over-duty-candour-110502

That inquiry had been led by judge Sir John O’Hara and focussed on hyponatraemia, a shortage of sodium in the blood. It found four of the five deaths were preventable.

Summarising the findings of his 14-year £13.8m inquiry, the judge had said some people behaved “evasively”, “dishonestly” and had to have the truth “dragged out” of them.

One of his recommendations was for “a statutory duty of candour”, backed up by the threat of “criminal liability”.

This should mean “every healthcare organisation and everyone working for them must be open and honest in all their dealings with patients and the public [his emphasis]”.

The Department of Health then began to consider these findings and a group called the “duty of candour workstream” was set up.

Some of its research has just been released this week, and found that where such laws exist elsewhere they only apply to organisations – not to the individual nurses and doctors on the hospital floor.

“The research conducted for this paper could find no example of a government introducing such a duty with criminal sanctions for its health service staff,” the researchers said.

“The matter has been considered at length by the other three countries in UK and has been rejected by England and Scotland with Wales yet to announce an outcome to its consultation... A statutory duty on individuals has not been applied elsewhere.”

They added: “[It] is clear from developments elsewhere in the UK and other jurisdictions that the concept of a statutory duty of candour on organisations has been accepted and has been or is in the process of being enabled by legislation.

“A statutory duty on individuals has not been applied elsewhere. The inquiry report while recommending such a duty acknowledges that the issues involved are not straightforward and that there are matters for legitimate debate.”

When it came to arguments against applying criminal offences to individual staff, the researchers noted that Sir Liam Donaldson – who had looked into the matter for the department in 2014 – believed “the threat of criminal sanctions on staff could promote a culture of fear rather than openness”.

This has echoes of a leaked letter the Irish News said it had obtained last year in the wake of the hyponatraemia inquiry, written by a senior British Medical Association figure in Northern Ireland to members.

Considering it was decided not to have 'candour' legislation that would criminalise employees for failing to disclose information in England after the Stafford Hospital scandal, why would it be regarded as necessary to have such legislation in Northern Ireland, given that it is, like England and Wales, a common-law jurisdiction in the UK?

Isn't be sanctioned by the Medical Council (up to and including being struck off) a sufficient punishment?

It sounds like a witch-hunt against front-line healthcare workers.

PS: Although the article was published last year, the Northern Ireland Assembly has yet to discuss the matter - given that it resumed business only four months ago. Therefore, in my view, it's still relevant in the Current Affairs forum.

Coroner's court is fun for nobody.

One eyed Jack

political analyst wrote: »

It sounds like a witch-hunt against front-line healthcare workers.

It sounds like an argument that people in positions of responsibility should be held accountable for their actions, rather than being able to hide behind their hospital’s legal teams.

lozenges

One eyed Jack wrote: »

It sounds like an argument that people in positions of responsibility should be held accountable for their actions, rather than being able to hide behind their hospital’s legal teams.

That's like saying that any time you make a mistake or error in work, you accept the risk of being personally sued and held criminally responsible.

Expecting healthcare workers to never make a mistake or an error is bizarre. If you were told that the standard in your own job was that you were not permitted to make any mistake or error, ever, and if you did you could go to jail you would laugh at them (and hopefully resign).

It's a ridiculous mindset. Professional sanctions already exist to deal with serious breaches. Defensive medicine is already a thing because of the risk of being sued as it stands. It doesn't benefit patients.

All that will happen if criminal sanctions are brought in is that healthcare will become even less attractive, more staff will leave and an already creaking and struggling healthcare system will become even worse than it is now, because it will be even more understaffed than it is currently.

One eyed Jack

lozenges wrote: »

That's like saying that any time you make a mistake or error in work, you accept the risk of being personally sued and held criminally responsible.

Expecting healthcare workers to never make a mistake or an error is bizarre. If you were told that the standard in your own job was that you were not permitted to make any mistake or error, ever, and if you did you could go to jail you would laugh at them (and hopefully resign).

It's a ridiculous mindset. Professional sanctions already exist to deal with serious breaches. Defensive medicine is already a thing because of the risk of being sued as it stands. It doesn't benefit patients.

All that will happen if criminal sanctions are brought in is that healthcare will become even less attractive, more staff will leave and an already creaking and struggling healthcare system will become even worse than it is now, because it will be even more understaffed than it is currently.

That’s certainly another way of looking at it. However I think the idea is to prevent this sort of thing -


Summarising the findings of his 14-year £13.8m inquiry, the judge had said some people behaved “evasively”, “dishonestly” and had to have the truth “dragged out” of them.


It’s not about criminalising people who make mistakes, it’s not even about expecting that people will never make mistakes, but rather it’s about holding people accountable when they do make mistakes that cause outcomes like this -

It all follows an inquiry last year into the deaths of five children in Northern Irish hospitals between 1995 and 2003.

That inquiry had been led by judge Sir John O’Hara and focussed on hyponatraemia, a shortage of sodium in the blood. It found four of the five deaths were preventable.


This really isn’t any different to most people’s employment, they generally don’t need to be told that the standard is that they aren’t permitted to make mistakes, because they are expected to be competent professionals with a high degree of responsibility.

Degrees of responsibility don’t get much higher than decisions that could make the difference between recovery and death, and in those positions I don’t think it’s unusual to expect that staff would conduct themselves with integrity and take responsibility for their mistakes rather than as I suggested hiding behind their hospital’s legal teams and having to have the truth dragged out of them during an investigation into the cause of the patient’s death in order that future cases could be prevented.

I’m well aware that defensive medicine is a thing, and it certainly does have a chilling effect on the decisions that medical staff can make in any given circumstances, but this isn’t about preventing medical staff from practicing medicine, it’s about holding them accountable when they make mistakes.

If it’s introduction causes people to think twice about a career in medicine because they will be held accountable for their actions, I honestly can’t say that’s a bad thing. I’d rather be understaffed with competent staff any day than a full staff who were so incompetent that they tried to cover up their mistakes rather than take any responsibility or be held accountable for their actions.

Standard expectation in any employment really, that staff would conduct themselves with integrity, and it’s the same in any employment that a person could face criminal charges if they break the law.

2u2me

One eyed Jack wrote: »

I’d rather be understaffed with competent staff any day than a full staff who were so incompetent that they tried to cover up their mistakes rather than take any responsibility or be held accountable for their actions.

I'd guess the mistakes made are more 'once in a lifetime' type of thing rather than the same people making mistakes over and over again.

I'd prefer to put in place a better system that prevents errors rather than rallying with our pitchforks. To err is human.

Surely there are oversight committees?

One eyed Jack

2u2me wrote: »

I'd guess the mistakes made are more 'once in a lifetime' type of thing rather than the same people making mistakes over and over again.

I'd prefer to put in place a better system that prevents errors rather than rallying with our pitchforks. To err is human.

Surely there are oversight committees?

There are all sorts of oversight committees, and there are hospital management and teams of lawyers, hence why there is a need for legislation regarding a duty of candour - honesty and integrity, so that if someone does goof, they aren’t trying to cover it up and it having to be dragged out of them. That’s what a duty of candour means, it’s not a witch-hunt, it’s an expectation that staff take responsibility for their actions and when they make mistakes, be honest and admit it, in order to prevent it from happening again to anyone else.

lozenges

One eyed Jack wrote: »

There are all sorts of oversight committees, and there are hospital management and teams of lawyers, hence why there is a need for legislation regarding a duty of candour - honesty and integrity, so that if someone does goof, they aren’t trying to cover it up and it having to be dragged out of them. That’s what a duty of candour means, it’s not a witch-hunt, it’s an expectation that staff take responsibility for their actions and when they make mistakes, be honest and admit it, in order to prevent it from happening again to anyone else.

Healthcare is a job, a profession. Yes, sanctions should be applied if people don't meet their obligations. Professional sanctions relating to their job. Which already exist. Could they be enforced better? Possibly, yes, but that's a different argument.

The same as if you don't meet expectations in your job you can be fired, but not sent to jail.

It sounds in your first post that you think healthcare staff aren't held accountable if and when errors occur. What do you think An Bord Altranais and the Medical Council are for? Held accountable doesn't necessarily = jail. Suspension or permanent revoking of a professional licence and thus end of a career is pretty serious.

I didn't mean that it would put potential candidates off doing medicine or nursing or allied health. I mean that people who are currently working in those jobs will leave. They're generally intelligent and hardworking, and could easily find other work which is rewarding and where they're not at risk of criminal convictions in the course of their work.

And if you're implying that you've never made a mistake in your job, you're being untruthful. Which you seem to disapprove of. Everyone - without exception - makes mistakes.

One eyed Jack

lozenges wrote: »

Healthcare is a job, a profession. Yes, sanctions should be applied if people don't meet their obligations. Professional sanctions relating to their job. Which already exist. Could they be enforced better? Possibly, yes, but that's a different argument.

The same as if you don't meet expectations in your job you can be fired, but not sent to jail.

Ahh now, there’s a difference between covering up failure to meet expectations or failure to meet obligations, and covering up something which could constitute a criminal offence. I’m expected in my job to adhere to these standards -


This should mean “every healthcare organisation and everyone working for them must be open and honest in all their dealings with patients and the public [his emphasis]”.


The difference I suppose between the liability I could incur for my employer if I make a mistake is that I could lose a client an awful lot of money. The difference in the medical profession with regard to potential liability is far more obvious if they make a mistake. In the same way as I’m held accountable and I’m responsible if I make a mistake, I would be expected to own it, rather than try and cover it up and try to avoid responsibility.

lozenges

One eyed Jack wrote: »

Ahh now, there’s a difference between covering up failure to meet expectations or failure to meet obligations, and covering up something which could constitute a criminal offence. I’m expected in my job to adhere to these standards -


This should mean “every healthcare organisation and everyone working for them must be open and honest in all their dealings with patients and the public [his emphasis]”.


The difference I suppose between the liability I could incur for my employer if I make a mistake is that I could lose a client an awful lot of money. The difference in the medical profession with regard to potential liability is far more obvious if they make a mistake. In the same way as I’m held accountable and I’m responsible if I make a mistake, I would be expected to own it, rather than try and cover it up and try to avoid responsibility.

Absolutely, they should own it and should be subject to sanctions if they don't. Professional sanctions, not sent to jail. Because who decides if they're 'covering it up' or being honest? There was a journal article during the cervical check scandal where Simon Harris stated that he felt he was being given the runaround by the HSE because he was being faxed pages instead of computer readable documents scanned (I'm paraphrasing but that was the gist).
He obviously has no idea how the HSE is run because in the majority of departments fax machines are what is there and are used every day. He decided that this was deliberately obstructive behaviour (again according to the article) when to me that's just how information is communicated day to day in that organisation. Should those admin staff go to jail for deliberately obstructing the cervical check inquiry?

A culture of fear and blame and scapegoating is not the way to get people to be honest about acknowledging errors.

2u2me

One eyed Jack wrote: »

hence why there is a need for legislation regarding a duty of candour - honesty and integrity, so that if someone does goof, they aren’t trying to cover it up and it having to be dragged out of them. That’s what a duty of candour means, it’s not a witch-hunt, it’s an expectation that staff take responsibility for their actions and when they make mistakes, be honest and admit it, in order to prevent it from happening again to anyone else.

Its just that in the OP it mentions specifically " One of his recommendations was for “a statutory duty of candour”, backed up by the threat of “criminal liability”.

I would be happy with a duty of candour as long as the threat of criminal liability was removed or at least was only available for the very worst of cases.

lozenges

2u2me wrote: »

Its just that in the OP it mentions specifically " One of his recommendations was for “a statutory duty of candour”, backed up by the threat of “criminal liability”.

I would be happy with a duty of candour as long as the threat of criminal liability was removed.

It already exists, it's called open disclosure. It's active policy in the HSE currently. As it should be to be fair!

One eyed Jack

lozenges wrote: »

Absolutely, they should own it and should be subject to sanctions if they don't. Professional sanctions, not sent to jail. Because who decides if they're 'covering it up' or being honest? There was a journal article during the cervical check scandal where Simon Harris stated that he felt he was being given the runaround by the HSE because he was being faxed pages instead of computer readable documents scanned (I'm paraphrasing but that was the gist).
He obviously has no idea how the HSE is run because in the majority of departments fax machines are what is there and are used every day. He decided that this was deliberately obstructive behaviour (again according to the article) when to me that's just how information is communicated day to day in that organisation. Should those admin staff go to jail for deliberately obstructing the cervical check inquiry?

I don’t think they should go to jail because someone isn’t familiar with the procedures, and whether their behaviour is obstruction or not is decided by an inquiry if one is deemed necessary, it depends on the circumstances involved whether the obstruction rises to the level of a potential criminal offence.

lozenges wrote: »

A culture of fear and blame and scapegoating is not the way to get people to be honest about acknowledging errors.

I don’t see it that way though, I see it as expecting people to conduct themselves in a professional manner means they have an obligation to be open and honest and acknowledge errors so that they can be addressed and processes improved to minimise the risk of the same errors happening again. I’d wonder about the culture in a work environment if people thought accountability meant fear and blame and scapegoating, because that’s not the kind of attitude or behaviour I would expect of someone who considers themselves a professional.

Imagine you were a patient and you were being lied to about your treatment, you’d be miffed if you discovered later that you had been misled. It’s something that happens far too often in medicine, with unfortunate outcomes for patients.

political analyst

One eyed Jack wrote: »

Ahh now, there’s a difference between covering up failure to meet expectations or failure to meet obligations, and covering up something which could constitute a criminal offence. I’m expected in my job to adhere to these standards -


This should mean “every healthcare organisation and everyone working for them must be open and honest in all their dealings with patients and the public [his emphasis]”.


The difference I suppose between the liability I could incur for my employer if I make a mistake is that I could lose a client an awful lot of money. The difference in the medical profession with regard to potential liability is far more obvious if they make a mistake. In the same way as I’m held accountable and I’m responsible if I make a mistake, I would be expected to own it, rather than try and cover it up and try to avoid responsibility.

But that issue is already dealt with by the law as it stands, i.e. perverting the course of justice.

political analyst

One eyed Jack wrote: »

I don’t think they should go to jail because someone isn’t familiar with the procedures, and whether their behaviour is obstruction or not is decided by an inquiry if one is deemed necessary, it depends on the circumstances involved whether the obstruction rises to the level of a potential criminal offence.





I don’t see it that way though, I see it as expecting people to conduct themselves in a professional manner means they have an obligation to be open and honest and acknowledge errors so that they can be addressed and processes improved to minimise the risk of the same errors happening again. I’d wonder about the culture in a work environment if people thought accountability meant fear and blame and scapegoating, because that’s not the kind of attitude or behaviour I would expect of someone who considers themselves a professional.

Imagine you were a patient and you were being lied to about your treatment, you’d be miffed if you discovered later that you had been misled. It’s something that happens far too often in medicine, with unfortunate outcomes for patients.

I thought any member of front-line staff who is involved in the patient's case - whether it's a junior physician or a nurse - is authorised to tell the patient all the relevant details, regardless of what the consultant may think.

political analyst

One eyed Jack wrote: »

There are all sorts of oversight committees, and there are hospital management and teams of lawyers, hence why there is a need for legislation regarding a duty of candour - honesty and integrity, so that if someone does goof, they aren’t trying to cover it up and it having to be dragged out of them. That’s what a duty of candour means, it’s not a witch-hunt, it’s an expectation that staff take responsibility for their actions and when they make mistakes, be honest and admit it, in order to prevent it from happening again to anyone else.

Of course, that's what was recommended by the inquiry but, obviously, a recommendation is just that. After all, in his report on the Stardust tragedy, Judge Ronan Keane recommended the establishing of a national fire authority and ........

Some of the politicians at Stormont may be concerned about the possibility of being accused of giving front-line health service personnel a slap in the face in the aftermath of the current pandemic.

lozenges

One eyed Jack wrote: »

I don’t think they should go to jail because someone isn’t familiar with the procedures, and whether their behaviour is obstruction or not is decided by an inquiry if one is deemed necessary, it depends on the circumstances involved whether the obstruction rises to the level of a potential criminal offence.


I don’t see it that way though, I see it as expecting people to conduct themselves in a professional manner means they have an obligation to be open and honest and acknowledge errors so that they can be addressed and processes improved to minimise the risk of the same errors happening again. I’d wonder about the culture in a work environment if people thought accountability meant fear and blame and scapegoating, because that’s not the kind of attitude or behaviour I would expect of someone who considers themselves a professional.

Imagine you were a patient and you were being lied to about your treatment, you’d be miffed if you discovered later that you had been misled. It’s something that happens far too often in medicine, with unfortunate outcomes for patients.

Of course staff have an obligation to be open and honest. But in no other profession does not doing your job mean you can be criminally sanctioned. The consequences for not meeting your professional obligations should be related to your profession. Not criminalised.

As for the culture of the organisation - I'm sure you've worked in some organisations where there's a great culture and some less so. If you think that the HSE is run like an American tech company you are profoundly naive. Yes, the culture has to change but criminalising people will achieve the opposite of that.

On that point you mentioned in an earlier post that you'd rather have hospitals be more understaffed as long as the staff were competent. Those two things affect each other. If you have staff who are overworked, demoralised and sleep deprived they will be substantially less competent than those who arent.

If they work in a service which is chronically understaffed the above are more likely to happen. If the organisation isnt an attractive place to work, competent people (at least some) will emigrate, meaning the organisation now has to accept some less competent staff and leave some posts unfilled. Its a vicious circle.

The way to improve this situation is not to make an already unattractive work environment even more punitive. Laws such as perjury already exist.

mariaalice

Strengthening HIQA and other monitoring and professional organisations is the way to go.

There needs to be a lot more definable minimum standard of care so it is very clear who should have done what. Who, What, Where, When. Why.

mariaalice

In other words, no hypothetical question, or question involving particular persons and actions, can arise without reference to these circumstances, and no demonstration of such a question can be made without using them.

https://en.wikipedia.org/wiki/Five_Ws

lozenges

mariaalice wrote: »

Strengthening HIQA and other monitoring and professional organisations is the way to go.

There needs to be a lot more definable minimum standard of care so it is very clear who should have done what. Who, What, Where, When. Why.

As with many other issues, the issue is enforcement and proper application of already existing regulations, not the need for introduction of new ones.

mariaalice

lozenges wrote: »

As with many other issues, the issue is enforcement and proper application of already existing regulations, not the need for introduction of new ones.

I did not say bring in new ones just strengthening of the existing ones.

lozenges

mariaalice wrote: »

I did not say bring in new ones just strengthening of the existing ones.

I know, I was agreeing with you!

political analyst

The legislation recommended in Northern Ireland could put frontline healthcare workers in a difficult position.

For example, if a person who has suffered horrific injuries in a tragic incident in which he or she lost loved ones, doctors may be pushed into informing the survivor of the tragedy at an earlier-than-appropriate time and thus cause the survivor to go into shock, thus aggravating the trauma.