Duty of Candour Annual Report 2018/19
Riverside Medical Practice, Inverness
An important part of this duty is that we publish an annual report which describes how NHS Highland has operated the duty of candour procedures during the time between 1 April 2018 and 31 March 2019.
All health and social care services in Scotland have a duty of candour. This is a legal requirement which means that when unintended or unexpected events happen that result in death or harm as defined in the Act, the people affected understand what has happened, receive an apology, and are informed by the organisation what has been learned and how improvements for the future will be made.
About NHS Highland
Riverside Medical Practice serves a population of circa 10,000 patients across inner city and suburban areas of Inverness. There is a wide ranging demographic served by the practice. Our aim is to provide high quality care for every person who uses our services.
How many incidents happened to which the duty of candour applies?
Between 1 April 2018 and 31 March 2019, there was 1 incident where the duty of candour applied. These are unintended or unexpected incidents that result in death or harm as defined in the Act, and do not relate directly to the natural course of someone’s illness or underlying condition. Riverside Medical Practice identified these incidents through our significant event analysis procedures that are established within the practice. Over the time period for this report we carried out several significant event analyses. These events include a wider range of outcomes than those defined in the duty of candour legislation as we also include adverse events that did not result in significant harm but had the potential to cause significant harm. Significant event analyses are also undertaken where there is no harm to patients or service users, but there has been a significant impact to service or care delivery.
We identify through the significant event analysis process if there were factors that may have caused or contributed to the event, which helps to identify duty of candour incidents.
Type of unexpected or unintended incident (not related to the natural course of someone’s illness or underlying condition)
Number of times this happened (between 1 April 2018 and 31 March 2019)
A person died
A person incurred permanent lessening of bodily, sensory, motor, physiologic or intellectual functions
A person’s treatment increased
The structure of a person’s body changed
A person’s life expectancy shortened
A person’s sensory, motor or intellectual functions was impaired for 28 days or more
A person experienced pain or psychological harm for 28 days or more
A person needed health treatment in order to prevent them dying
A person needing health treatment in order to prevent other injuries as listed above
To what extent did Riverside Medical Practice follow the duty of candour procedure?
When we realised the events listed above had happened, we followed the correct procedure in 1 occasion (100% of the time). This means we informed the people affected; apologised to them; offered to meet with them; reviewed what happened and what could have been better and fed back the findings to the people affected if this was their wish.
Information about our policies and procedures
Every SEA event is reported through our local reporting system as set out in our SEA management procedures. Through our SEA management procedures we can identify incidents that trigger the duty of candour procedure.
Each adverse event is reviewed to understand what happened and how we might improve the care we provide in the future. The level of review depends on the severity of the event as well as the potential for learning.
Recommendations are made as part of the adverse event review, and the clinician(s) involved in each SEA takes action to implement these recommendations. These are followed up until conclusion.
Staff receive training on adverse event management and incident reporting as part of their induction and this took place throughout 2018 to highlight the procedures for escalating cases which had the potential to meet duty of candour.
We know that adverse events can be distressing for staff as well as people who receive care. We have support available for all staff.
What has changed as a result?
We have made a number of changes following review of this adverse event which have been identified as meeting the criteria of duty of candour. Please see the following cases as examples:
· We have implemented a pharmacist-based protocol for adding medicines to repeat medication lists
· We have written to secondary care to highlight potential risks of requesting prescriptions of medication without specified dosing
This is the first year of the duty of candour being in operation and it has been a year of learning and refining our existing adverse event management processes to include the organisational duty of candour requirements. As a practice, we have allocated responsibility for this report to a clinician and have highlighted DoC processes through a series of meetings and information dissemination.
As required, we have submitted this report to Scottish Ministers and we have also placed it on our website.
If you would like more information about this report, please contact us using these details: Riverside Medical Practice, Ness Wall, Ballifeary Lane, Inverness, IV3 5PW.