Background
Duty of Candour came into force on 1 April 2018 as set out in Part 2 of The Health (Tobacco Nicotine etc and Care) (Scotland) Act 2016. The Duty of Candour Procedure (Scotland) Regulations 2018 set out the organisational legal duty on how to respond to those affected where an unintended or unexpected incident appears to have caused harm or death. Organisations are required to apologise and to meaningfully involve the individual in a review of what happened. When the review is complete, the organisation should agree any actions required to improve the quality of care, informed by the principles of learning and continuous improvement.
In Angus we recognise maintaining trust and effective communication can be difficult when things have gone wrong, but we remain committed to openness and learning which is vital to the provision of safe, effective and person-centred health and social care services.
This report covers Angus social work services, including those delivered within the Angus Health and Social Care Partnership (AHSCP), which have Duty of Candour reporting responsibility. The report covers the period 1 April 2024 to 31 March 2025. During this period, there have been one incident to which the organisational Duty of Candour applied.
Incidents to which the Duty of Candour applies:
| Type of unexpected or unintended incident | Number of times this happened |
|---|---|
| Someone has died | 0 |
| Someone has permanently less bodily, sensory, motor, physiologic or intellectual functions | 0 |
| Someone’s treatment has increased because of harm | 0 |
| The structure of someone’s body changes because of harm | 0 |
| Someone’s life expectancy becomes shorter because of harm | 0
|
| Someone’s sensory, motor, or intellectual functions is impaired for 28 days or more | 0 |
| Someone experienced pain or psychological harm for 28 days or more | 0 |
| A person needed health treatment in order to prevent them dying | 0 |
| A person needing health treatment in order to prevent other injuries | 1 |
| A healthcare infection incident was acquired during treatment | 0 |
To what extent did we follow the Organisational Duty of Candour procedure?
Following the incident where someone required health treatment in order to prevent other injuries the Duty of Candour procedures were followed. The service contacted the individual and the family of the person affected to discuss the incident in an open and transparent manner and acknowledged the serious service failure. The Duty of Candour proceedings were activated, and an unreserved apology was given and followed up in writing. As with responsible person’s requirements a full report was provided to the Care Inspectorate and a reflective learning exercises was undertaken through a Learning Review to fully understand the circumstances which resulted in the serious harm to the adult, and establish the learning from the incident, and identify areas for improvement.
We recognise there is a need to support staff that have been impacted by distressing events alongside the people who receive a service from the Council. Support is provided for all staff through line management structures with managers meeting with staff to debrief following any serious incident. The council has counselling support available through PAM Assist who provide an independent and confidential counselling service to employees.
What has changed as a result?
Following the incident noted in this report a full review was undertaken and the learning has been shared with staff. Angus Council’s Chief Social Work Officer (CSWO) Operation Instruction details the Duty of Candour statutory duties and is reflective of the Government legislation however the review recommended this should be reviewed and amended to include further guidance for staff to assist them during adverse events and stressful situations. Once amended the operational Instruction will be re circulated to staff. The review highlighted the requirement for stricter adherence to protocols by staff, training for staff is being reviewed to ensure it builds on staff knowledge confidence.
Information about our policies and procedures
Where something has happened to trigger the Duty of Candour, procedures are followed in line with the Duty of Candour Operational Instruction available to staff centrally on the council intranet. This instruction applies to all AHSCP and children and families social work staff. It details what action staff must take and how they must behave in accordance with our duty to be open, honest, and supportive when there is an unexplained or unintended incident resulting in death or harm. As noted above further guidance is being provided to support the CSWO Operational Instruction.
Duty of Candour training continues to be available to all staff through an E-Learning resource and forms part of new staff induction. Staff are also provided with guidance and advice regarding their responsibilities under the Duty of Candour by responsible managers of all residential houses, respite units and care services.
Our policies and procedures are kept under regular review and where required updated as a result of Duty of Candour incidents, learning from mistakes, complaints, and other forms of feedback from those who use care services. We remain committed to openness and learning which is vital to the provision of safe, effective, and person-centred health and social care services.
As required, we will publish this report on Angus Council website and submit the link to the report to the Care Inspectorate.
For further information in respect of this report, please contact People@angus.gov.uk
Approved by: Kirsty Lee, Chief Social Work Officer
Date: 22 April 2025