Giles Maskell: True candour

Currently the approach taken to duty of candour implies a false dichotomy between “things going well” and “mistakes being made”

Candour is a word that was rarely heard in hospital until relatively recently. Its traditional meaning was more or less synonymous with “frankness” or “honesty.” In his report into Mid Staffordshire NHS Foundation Trust, Robert Francis applied a specific definition in the context of healthcare: “The volunteering of all relevant information to persons who have or may have been harmed by the provision of services, whether or not the information has been requested and whether or not a complaint or a report about that provision has been made.” 

Following one of his recommendations, this has subsequently been enshrined in UK law as a statutory duty of candour on NHS organisations, regulated by the Care Quality Commission. Some organisations have already been fined for failing to take adequate measures to comply with this duty.

No one can seriously question the principle that in most circumstances doctors should be honest with their patients. One problem however is that the approach currently being taken to this duty of candour implies a false dichotomy between “things going well” and “mistakes being made”. It seems to be predicated on the notion that the normal state of affairs in healthcare is for things to go well, and that only occasionally will mistakes be made and harm result. My experience suggests otherwise.

As I get older and more and more of my friends and relatives require healthcare, it seems to me that things very rarely go entirely well. It may be something as simple—to us—as failure to insert a cannula at the first attempt, but it’s often a lot more serious. Over the years, close friends and members of my immediate family have been subject to numerous adverse events including misdiagnosis and delayed diagnosis. There have been errors of omission, of process, and of communication as well as sundry medication errors including administration of toxic doses, and on one occasion administration of the wrong chemotherapeutic agent. These errors have spanned primary, secondary, and tertiary care, public and private sectors, hospitals little-known and world-famous. 

Maybe my friends and family are particularly unlucky, but conversations with others who have found themselves in the role of concerned medical friend or relative suggest that there is more to it than that. I work in a specialty in which we have become more and more conscious of our errors in recent years—estimated at 3-5% in routine daily practice and much higher for the interpretation of more complex studies—and making the reasonable assumption that radiologists are not the only doctors who make mistakes, this shouldn’t come as a huge surprise.

It has been estimated that for a single elective surgical admission, well over 100 people are involved in a patient’s care. How likely is it that all of them and the equipment they use will have performed at the highest level at the same time? That none of those people was feeling ill, tired, distracted or depressed that day and consequently performed below par? Accepting our own fallibility and that of the systems in which we work is not to doubt the skill, commitment and good intentions of those delivering the care, nor to question our duty to learn from mistakes and suboptimal outcomes.

I suggest that if we really want to be honest with patients, we could offer the following truly candid statement to almost every patient at the end of an episode of care:

Given the uncertainties inherent in the course of human health and disease, the complexities of healthcare and the manifold disadvantages facing us—not least our own human frailty—things went about as well as could have been expected. To be perfectly honest they could probably have gone a bit better.

Giles Maskell is a radiologist in Truro. He is past president of the Royal College of Radiologists.

Competing interests: None declared.