25 September 2020
For the first time a NHS Trust has been prosecuted for an admitted breach of its statutory duty of candour.
Author: Hylton Armstrong
Written by Hylton Armstrong Background Mrs Elsie Woodfield was 91 years old when she suffered a perforated oesophagus during an endoscopy in December 2017. The procedure was abandoned, and Mrs Woodfield was transferred for observation, but later collapsed and died. It was subsequently found that the University Hospitals Plymouth NHS Trust had not communicated what had happened with Mrs Woodfield’s family in an open and transparent way prior to her death, nor had it apologised for what had happened to her in a timely way. The Care Quality Commission (CQC) then brought a prosecution at the Plymouth Magistrates Court for a failure to comply with Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Law Regulation 20 requires that registered persons must act in an open and transparent way with relevant persons in relation to care and treatment provided to service users in carrying on a regulated activity. In particular as soon as reasonably practicable after becoming aware that a ‘notifiable safety incident’ has occurred a registered person must take various action including: notify the relevant person that the incident has occurred, provide reasonable support, provide an account, advise what further enquires are believed to be appropriate, and offer an apology. In relation to a health service body a ‘notifiable safety incident’ means any unintended or unexpected incident that occurred in respect of a service user during the provision of a regulated activity that, in the reasonable opinion of a health care professional, could result in, or appears to have resulted in:
- the death of the service user, where the death relates directly to the incident rather than to the natural course of the service user's illness or underlying condition, or
- severe harm, moderate harm or prolonged psychological harm to the service user.
30 November 2023