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

Annex E – Annual Report Templates

Relevant information

These report templates are designed to support responsible persons to produce a report which reflects their own circumstances.

Be sure that people cannot be identified in your annual report. When there is a small number of incidents, you may choose to follow NHS conventions around deductive identification in respect of an incidence of 5 or less, or whether in these circumstances to provide actual numbers. You should aim to be as transparent as possible.

The purposes of the report should be:

• to articulate, in broad terms, how the local learning system identified and implemented change as a result of incidents to which the duty has applied, and subsequent reviews undertaken
• to encourage responsible persons to self-reflect on how the duty is being embedded and how the quality of services can be continually improved
• to provide information about the responsible person’s policies and procedures, including about:
• procedures for the identification and reporting of incidents
• support available to staff
• support for any relevant person affected by incidents
• to provide public assurance that the organisational duty of candour is being embedded in the sectors to which it applies
• to contribute to the Care Inspectorate’s, Healthcare Improvement Scotland’s and the Scottish Government’s wide evidence base about the provision of social care and health services

Template Report A – Annual Report Template

[This report template is for when events triggering the organisational duty of candour have occurred in the preceding year. This is a suggestion; you are welcome to modify or use your own template.]

All health and social care services in Scotland have an organisational duty of candour. This is a legal requirement which means that when certain types of incidents happen, the people affected understand what has happened, receive an apology, and the organisation(s) learns how to improve for the future.

An important part of this duty is that we provide an annual report about the organisational duty of candour in our services. This report describes how [organisation’s name] has operated the organisational duty of candour during the time between 01 April [YYYY] and 31 March [YYYY]. We hope you find this report informative.

If you have any questions or would like more information about [organisation’s name], please feel free to contact us at: [email address/phone number].

About [your organisation]

[Organisation’s name] is a [type of organisation] in [location / area in Scotland] for [who you serve / numbers]. We provide [details of services and any additional information].

Information About Our Policies and Procedures

In this section, we suggest sharing some information on your organisation’s approach to the organisational duty of candour. It would be helpful for your report to outline:

• how and which staff receive training on the organisational duty of candour
• when they receive this training
• what is the procedure when an incident triggers the organisational duty of candour
• what support is available to your staff
• what support is available to the relevant person

Training and Support for staff

All new staff receive an induction pack on the organisational duty of candour once they start in the role. Included within this pack is the link to the Joint Commission’s compassionate communications training, and local guidance on the organisational duty of candour in our organisation. We are clear to our staff that serious mistakes can be distressing for them, as well as for the people receiving care and treatment and their families. We have occupational welfare support in place for our staff if they have been affected by an organisational duty of candour incident. We also signpost them to links such as [Breathing Space – include organisations that staff are signposted to], for additional support and wellbeing. Moreover, we include information about the organisational duty of candour in our whistleblowing policy and values training, and vice versa.

Where something has happened that triggers the organisational duty of candour, staff at our organisation report to a care home manager / chief nursing lead who has responsibility for ensuring that the organisational duty of candour procedure is followed. They record the incident and report it, as necessary, to the Care Inspectorate / Healthcare Improvement Scotland / Scottish Ministers. When an incident has happened, [explain what happens next for staff, relevant persons, senior management etc.]. Our external confidential employee counselling service is available to all staff at any time but if organisational duty of candour is triggered, this is explicitly mentioned to staff via an organisational duty of candour help pack that we provide. Senior management meet with staff to provide support and emphasise that the purpose of the duty is learning and improving, not blame. They will also reemphasise that an apology is not an admission of negligence.

Recommendations are made as part of the Duty of Candour review, and local management teams develop improvement plans to meet these recommendations.

Support for the relevant person(s)

When the relevant person and their family / support system are affected by an incident that activates the organisational duty of candour, we arrange for them to have access to our organisation’s welfare support and provide contact details for Mind to Mind | NHS inform^[33] if they wish to receive external support.

How many incidents have occurred where the organisational duty of candour has applied / applies?

In the last year, there have been [xx] incidents to which the organisational duty of candour applied. These are incidents that have happened which are unintended or unexpected, and do not relate directly to the natural course of someone’s illness or underlying condition.

[You may wish to say here about how these incidents were identified. For example, an NHS Health Board may have identified via their adverse event management process, whereas an independent organisation may have a specific procedure they follow. Please share what you think would be helpful for people reading this report. Remember to avoid jargon if possible, or if you use technical / local terms – offer a brief explanation of these].

Over the time period for this report, there have been [xx] incidents where the Organisational Duty of Candour procedure was carried out. These events include a wider range of outcomes than those defined in the organisational duty of candour legislation as we also include significant adverse event reviews and adverse events that did not result in significant harm but had the potential to cause significant harm.

The following table provides a detailed breakdown of each large-scale adverse event that occurred over the period of this report. The intention is to understand the scale of harm from each event.

To what extent did [your organisation] follow the Organisational Duty of Candour procedure?

When we realised the events listed above had happened, we followed the procedure fully in 8 out of 12 instances (66% of instances). This means:

• we informed the people affected, apologised to them and arranged meetings with them, and met them
• we also took on board their views and listened to their concerns
• internally, senior staff reflected on the events and identified where systems went wrong and what how we could do better
• this information was shared with all our staff through our “All staff meetings” that happen once a month, and in support and development

In four instances, we did not follow the procedure fully. This was because three people could not be contacted. We have a record of each of the three attempts for contact that we made. For the fourth person, they requested that we did not contact them after our initial contact. We noted this down, but we still offered to share a copy of the review report with them, which they declined. We have kept a record of the review report, and we will gladly provide them with a copy, if they would like to receive it at a later date.

One person, deemed to have limited capacity, had no family nor advocate to whom we could formally apologise. We used alternative forms of communication, including pictures, to help this person understand the incident and our ongoing procedure.

We received positive feedback from several people about how staff managed the challenging conversations, and noted they appreciated staff’s sensitivity. In one instance, because the process was delayed, we received some feedback from a person that we could have kept them more up-to-date on how the process was progressing.

What has changed as a result? / What have we learnt?

[In this section, you should share examples of learning reviews and changes to your system that have happened. It is again helpful for people reading this report to see areas of reflection and action when unexpected or unintended incidents occur.]

We have made a number of changes to our policies and procedures as a result of organisational duty of candour procedures. There are [XX] significant changes that we would like to feature:

• We invited a family to talk about their experience of the review process at an event attended by our staff. Following the family’s helpful feedback, we reviewed and updated our adverse event management policy to include a template for a holding letter that we can send to families to keep them informed when there are delays in the process, and how they can contact us if they have any questions / concerns.
• In response to a fall, a resident explained that it would be useful to ensure that there are two members of staff to help her access the step down into the garden. We have ensured that residents who need additional support to go outside receive that support and are looking at how we can remove the step altogether.
• Following an incident where a person developed an air embolus directly associated with the removal of a Central Venous Cannula (CVC), we rapidly disseminated a risk awareness notice to make all staff aware that only a fully air occlusive dressing should be applied to a CVC site, and the safest dressing to use is a hydrocolloid dressing.
• We made a change to our policies and procedures because of the organisational duty of candour. We have reviewed the way in which we provide meals and snacks to children to ensure that allergies are known to all staff and that staff are confident about how they can avoid harm arising from them.
• Alongside reporting these events to the Care Inspectorate, we shared our learning experiences with CCPS to enable other provider colleagues to benefit from our learning.
• Our annual report has become an item for our Trustees to discuss at their Board meeting and is included in our Risk register monitoring, which has helped to promote aware of the duty and has helped learning from incidents feed into our governance systems.

Other Information

As required by the legislation, we have notified [ the Care Inspectorate/Scottish Ministers/Healthcare Improvement Scotland] that this report has been published [on our website/office building] [include hyperlink or if a hard copy is placed in your office or building, note this]. We have also shared it with [e.g. Adverse Events Community of Practice or stakeholders].

The organisational duty of candour lead in [NHS Board] is [name]. [Organisations may find it useful to include a named contact for the person who is responsible for organisational duty of candour].

Template Report B – Nil Report Template

[This report template is for when no events triggering the organisational duty of candour have occurred in the preceding year. This is a suggestion; you are welcome to modify or use your own template.]

All health and social care services in Scotland have an organisational duty of candour. This is a legal requirement which means that when certain types of incidents happen, the people affected understand what has happened, receive an apology, and the organisation(s) learns how to improve for the future.

An important part of this duty is that we provide an annual report about the organisational duty of candour in our services. This report describes how our organisation, [organisation’s name], has operated the organisational duty of candour during the time between 01 April [20XX] and 31 March [20XX].

If you have any questions or would like more information about [organisation’s name], please feel free to contact us at: [email address/phone number].

How many incidents happened to which the organisational duty of candour applies?

In the last year, there have been no incidents to which the organisational duty of candour applied.

Information About Our Policies and Procedures

[In this section, we suggest sharing some information on your organisation’s approach to the organisational duty of candour. It would be helpful for your report to outline:

• how and which staff receive training on the organisational duty of candour
• when they receive this training
• what is the procedure when an incident triggers the organisational duty of candour
• what support is available to your staff
• what support is available to the relevant person

Where something has happened that triggers the organisational duty of candour, our staff report this to [staff member’s name/responsibility]. The [staff member] records the incident and reports as necessary to [relevant organisation]. When an incident has happened [explain the process once the organisational duty of candour is activated and what staff are expected to do].

[Optional] What have we learned?

Although no incident has taken place, you may wish to share any information on updated policies, training, reflections etc. that have happened in your organisation this year. This can be a way of demonstrating to people that the organisation still engages with the duty, even when it is not activated.

Training and Support for staff

All new staff learn about the organisational duty of candour at their induction. We know that serious mistakes can be distressing for staff as well as people who receive care and treatment and their families. We therefore have occupational welfare support in place for our staff if they have been affected by an organisational duty of candour incident.

Support for relevant persons

Where a relevant person (i.e., children, patients, families, etc.) is affected by the incident that activated the organisational duty of candour, we provide them with links to wellbeing support services.

We hope you find this report useful.

Template Report C – An Addendum Report

There may be times when organisations have organisational duty of candour procedures in progress when the annual report is due. This means it can be difficult to record in the annual report the number of ‘live’ cases at the end of the financial year. Some organisations, in previous years, have published an addendum halfway through the year. Below, an addendum template is provided should organisations wish to use one. This can be added onto the end of the annual report or published separately. If published separately, it would be helpful if you can provide your contact details in the addendum, for ease of access of readers.

Organisations are not obligated to produce nor publish an addendum to their annual report part way through the year; this is optional.

Organisational Duty of Candour Addendum Update – [Date, e.g. December 2023]

As reported in the Organisational Duty of Candour Annual Report 01 April [YYYY] and 31 March [YYYY], there were some delays in the completion process of some reports, due to [summarise reasons for delays].

As a result, it was agreed and outlined, in our Organisational Duty of Candour Annual Report [date], that this Addendum would be produced and published [online/physical location]. It includes details of any additional organisational duty of candour procedures as well as those not yet concluded.

By [date] the figures increased from the [XX] reported to a total of [XX] incidents between 01 April [YYYY] and 31 March [YYYY]. [XX] of these procedures are complete and the types of incidents are listed in the table below.

The [XX] completed procedures were assessed to ensure all the necessary steps of the procedure have been followed, and that an apology was provided, patients and/or relatives were informed and invited to participate in the review and copies of the final report were shared.

Of the [XX] completed procedures, and of those completed procedures [XX] cases [you can choose to provide a percentage here] did not fully meet the requirements as set out in the legislation. This was due to [provide details] [e.g., no family to contact and therefore the report was not shared, and one person asked not to be contacted – we recorded attempts to contact them and their preference to not be contacted.]

We hope you find this addendum helpful.