Duty of Candour Policy

At Etre Beau we operate a duty of candour policy to ensure that we are open, honest and supportive if there was to be an unexpected or unintended incident resulting in harm.

We promote a culture of openness and truthfulness is a prerequisite to improving the safety of patients, staff and visitors as well as the quality of healthcare systems.

 Who has Duty of Candour responsibilities

The duty applies to Etre Beau as an organisation and any person within Etre Beau organisation has a responsibility for:

Carrying out the duty of candour procedure

Undertaking any training required by regulations

Providing training, supervision and support to any person carrying out any part of the duty of candour procedure as required by the regulations

Reporting annually on the duty

What qualifies as an incident which would activate the duty?

 The duty of candour procedure must be carried out by the responsible person as soon as practicable after becoming aware of an unexpected or unintended incident resulting in harm or death, as defined by The Health (Tobacco, Nicotine etc. and Care) (Scotland) Act 2016. This includes incidents in the reasonable opinion of a registered health professional that has resulted in or could result in or could result in:

  • Death of the person
  • A permanent lessening of bodily, sensory, motor, physiologic or intellectual functions
  • An increase in the person’s treatment
  • Changes to the structure of a person’s body
  • The shortening of life expectancy of the person
  • An impairment of the sensory, motor or intellectual functions of the person which has lasted or is likely to last for a continuous period of at least 28 days.
  • The person is experiencing pain or psychological harm which has been, or is likely to be, experienced by the person for a continuous period of at least 28 days.
  • The person requires treatment by a registered health professional in order to prevent –
  1. The death of the person
  2. An injury to the person which, if left untreated, would lead to one or more of the outcomes mentioned above.


What is the procedure?

 The key stages pf the duty of candour procedure are to:

  1. Notify the person affected (or family/ relative where appropriate)
  2. Provide an apology (Use the 4 R’s – Reflect, Regret, Reason, Remedy)
  3. Carry out a review into the circumstances leading to the incident
  4. Offer an and arrange a meeting with the person affected with an account of the incident and/or their family, where appropriate
  5. Provide the person affected with an account of the incident
  6. Provide information on the further steps taken
  7. Make available, or provide information about, support to persons affected by the incident
  8. Prepare and publish an annual report on the duty of candour


Monitoring and Reporting

 The responsible person must publish an annual report. The report should include:

  • Information about the number and nature of incidents to which the duty has applied
  • An assessment of the extent to which the responsible person carried out the elements of the duty
  • Information about the responsible person’s policies and procedures including information about:
    1. Procedures for identifying and reporting incidents
    2. Support available to staff and to persons affected by incidents

All patient safety incidents, regardless of harm, are to be reported to the Clinic Operations Manager, Clinical Director and noted in the incidents and/or the adverse reactions log. As soon as possible after the incident, a suitable member of staff will notify the patient, or relevant person, verbally (face to face where possible) unless the person cannot be contacted in person or declines notification, that the incident has occurred. This initial notification must be provided as soon as is practicable and will include:

Within 28 days of the incident:

  • Investigate the incident and provide a report outlining an explanation of the events and circumstances which resulted in the incident.
  • Provide and maintain written records of the interactions with the patient or relevant person
  • If the incident is being investigated as a Serious Incident, or an external investigation is underway, then the 28 day limit may be exceeded to comply with the limits of the external investigation.

Staff who wish to raise a concern.

There may be occasions when a member of staff witnesses or becomes aware of something within Etre Beau that gives them cause for concern. In these circumstances the member of staff should:

  • Make an immediate note of their concern, recording relevant details such as what was said/ witnessed, date, time and details of other people involved.
  • Raise their concern with their Manager and/or refer to the Etre Beau Whistleblowing Policy which provides further guidance.


Duty of Candour Report 2023