Organisational Duty of Candour: non-statutory guidance - revised March 2025

12. Review

Organisations must carry out a review of the circumstances which they consider led, or contributed to, the unintended or unexpected incident. The legislation does not specify the manner in which the review is undertaken, but it is likely that this will be one of a range of review processes that are already undertaken, such as:

• a Significant Adverse Event Review (SAER)^[26]
• a Learning Review of the sort undertaken by child, adult and public protection committees
• a Team Based Quality Review (TBQR) (sometimes called a Morbidity and Mortality [M&M] review)
• a Child Death Review^[27]
• a Death Certification Review^[28]
• a Maternity Adverse Event Review^[29]

As part of the review, organisations must seek the views of all relevant persons and take account of any views expressed. This can be facilitated through a supportive relationship with each relevant person, arrangements that ensure review processes consider their views, and a review that can demonstrate how these views have been considered.

In the case of adverse events affecting multiple people where a relevant person is not identified until the conclusion of the review, the organisational duty of candour process must be activated again, providing any additional relevant persons identified with the opportunity to fully engage in the process. Responsible persons will also need to consider any action required to consider issues raised by such relevant persons if these have not been considered as part of the prior review process.

Best practice requires that reviews involve clinical and care professionals with the relevant subject matter expertise, as appropriate. Unintended or unexpected incidents that have resulted in death or harm require that a systems approach is adopted. This is illustrated in the Systems Engineering Initiative for Patient Safety (SEIPS) model^[30] and the Social Care Institute of Excellence’s Learning Together^[31] model. Organisations may also find the NHS Improvement Just Culture Guide^[32] a helpful resource for framing their reviews. Further resources are available in Annex F.

Organisations must offer to provide the relevant person with details of needs-based services or support. Organisations should consider the relevance of services and support such as counselling, bereavement support and independent advocacy.

In the case where the review is not completed within three months of the procedure start date, the organisation must provide the relevant person with an explanation of the reason for the delay in completing the review.

12.1 Preparing a written report

Organisations must prepare a written report of the review, which must include:

• a description of the manner in which the review was carried out
• a statement of any actions to be taken by the organisation to improve the quality of service it provides and share learning with other persons or organisations to support continuous improvement in the quality of health, care or social work services
• a list of the actions taken as part of the procedure and the date that each action took place

Organisations must include the dates when each step of the organisational duty of candour procedure took place to produce a clear timeline of the procedure from start to finish.

Where possible, the reports should be written in a manner that minimises the need for extensive redaction.

12.2 Sending the report to the relevant person

Organisations must offer to send the relevant person:

• a copy of the written report of the review
• details of further information about actions taken for the purpose of improving the quality of service provided by the organisation or other health, care or social work services
• details of any services or support that may be able to help or support the relevant person, taking into account their needs

Things to consider:

It is important to ensure the written review report is clear and understandable, especially as it will be shared with the ‘relevant person’. It should not contain unnecessary acronyms or abbreviations.

The requirement to provide ‘further information’, in the legislation, recognises that supporting information or further details to explain the conclusions of a review (or why it is thought a particular action will improve quality), can be helpful in demonstrating how improvement implementation will be adopted.

Once the review has been sent to the relevant person or persons (if they wish to receive it), that is considered the end of the review process. If a relevant person does not wish to receive the report, that final contact with them is considered the end of the review process.