Duty of Candour in Maternity
Standard Operating Procedure for Managing Duty of Candour in Maternity

Key Points

  • All Staff, including Obstetricians, need to identify and report notifiable patient safety incidents.
  • The DoC is primarily concerned with harm to the patient, not whether the incident was caused by negligence or error. The intention is to ensure patients receive timely information about adverse events, regardless of the cause.

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Abbreviations

DoCDuty of candour
HIEHypoxic ischemic encephalopathy
ICUIntensive Care Unit
NNUNeonatal Unit
PPHPostpartum haemorrhage
SOPStandard Operating Procedure

1. Introduction

This SOP outlines how healthcare professionals in maternity care fulfil the Duty of Candour as required by regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. It ensures timely, open, and honest communication with parents (or birthing people) and their representatives following a healthcare incident during pregnancy, birth, or postpartum care.

2. Key Terms

  • Notifiable Patient Safety Incident: An unexpected event during care causing moderate harm or above (including lasting psychological harm) to the mother, baby, or both. This includes near misses. Fault or consent for complications does not exclude an event from being considered.

A notifiable patient safety incident must meet all three of the following criteria:

  • It must be unintended or unexpected.

  • It must have occurred during provision of care.

  • It must, in the opinion of a reasonable healthcare professional, have already or may result in death, severe or moderate harm (levels of harm are explained in Appendix 1).

3. Responsibilities

  • All Staff including Obstetricians: Identify and report notifiable patient safety incidents through the InPhase system.

  • Obstetrician or Midwife responsible for care

    • Make initial contact with the parents (or birthing person) as soon as possible. This should be a face-to-face meeting or a phone call, depending on the situation and emotional state.

    • Answer questions and address concerns raised by the parents (or birthing person) and their representative.

    • Document the communication in the mother's medical record (EPIC).

    • Notify the Maternity Patient Safety team of the incident.

  • Maternity Patient Safety Team

    • Provide a written follow-up Duty of Candour letter within 14 days, using templates available in EPIC.

    • Save the DoC letter in both EPIC and InPhase.

4. Initial Communication Content

  • A sincere apology for the incident.

  • A clear explanation of what happened, using understandable language, and respecting emotional well-being.

  • Potential consequences for mother’s and baby's health, presented objectively.

  • Actions taken to address the incident and prevent future occurrences (if applicable).

  • Information on the complaints process (if applicable).

5. Documentation

The individual communicating with the parents (or birthing person) must document the conversation in the mother's medical record (EPIC), including:

  • Date and time of communication.

  • Method of communication (e.g., face-to-face meeting, phone call).

  • Staff involved.

  • Summary of information conveyed.

  • Questions, concerns raised, and responses provided.

  • Parents' (or birthing person's) emotional state during communication.

6. Identifying DoC Situations (All Staff)

  • All staff are responsible for identifying potential DoC incidents, including:

    • Unintended or unexpected incidents with potential or actual harm to mother, baby, or both (e.g., complications during delivery, medication errors, communication breakdowns).

    • Near misses.

    • Parental (or birthing person's) complaints.

  • Examples of notifiable safety incidents in maternity (DoC)

    • Shoulder dystocia.

    • Postpartum haemorrhage (PPH > 2000ml).

    • Uterine rupture.

    • Neonatal hypoxic ischemic encephalopathy (HIE).

    • Medication errors.

    • Failure to identify or respond to fetal distress.

    • Episiotomy/perineal tear complications.

    • Delayed diagnosis of pre-eclampsia/eclampsia.

    • Birth injuries requiring additional treatment or extended stay for the baby or the mother.

    • Traumatic caesarean section leading to long-term psychological distress.

    • Maternal ICU admissions.

    • Maternal readmissions.

    • Stillbirth.

    • Neonatal death.

    • Maternal death.

    • All unexpected term admissions to the Neonatal Unit (NNU) exceeding 24 hours.

  • If uncertain about DoC application, discuss with the Patient Safety Midwives, who can be contacted by phone:

    • Wexham Office: 0300 6154560

    • Frimley Office: 0300 6136272

This list is not exhaustive; any unexpected or unintended incident causing moderate or higher harm qualifies as a notifiable safety incident.

Key Point to Emphasise

  • Focus on Harm, Not Blame: The DoC is primarily concerned with harm to the patient, not whether the incident was caused by negligence or error. The intention is to ensure patients receive timely information about adverse events, regardless of the cause.

7. Conclusion

This SOP promotes transparency and open communication with families following healthcare incidents in maternity care. By following these guidelines, staff can fulfil their Duty of Candour obligations and ensure a supportive environment for families experiencing unexpected outcomes.