Exam Pass Notes - GOC Standard 19: Duty of Candour in Optical Practice

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Key takeaways

• Candour = prompt, honest communication when care, dispensing, admin, environmental or data issues cause or risk harm/distress.
• All registrants owe a professional duty of candour under GOC Standard 19; providers in England may also have a statutory duty (CQC Reg 20).
• Immediate behaviours matter: early acknowledgement, a sincere apology, plain factual explanation, safety actions, and a clear plan for investigation and follow-up.
• Apology is humane and generally not an admission of legal liability; document everything, involve indemnity early if harm may lead to claims.
• Near misses often merit brief disclosure when there was exposure to risk, inconvenience, or distress.
• Learning loop (capture → analyse → act → verify → share) closes the patient-facing and governance cycle.

Definition & purpose

• Candour: open, truthful communication when standards fall short - protects patients, preserves trust, prevents escalation, and enables system learning.
• Functions as a clinical safety behaviour: prevents secondary harm, sustains therapeutic relationships, and reduces complaints/litigation.

When the duty is triggered

• Triggered when care/dispensing/administration/environment/data handling causes or exposed a person to risk, harm, loss or significant distress.
• Intent is irrelevant: unintended consequences count.
• Typical triggers in optical practice:
• Missed/delayed urgent referral (e.g., flashes/floaters → retinal detachment).
• Incorrect prescription or transposition errors causing symptoms.
• Dispensing errors (wrong lenses, PD/height mistakes leading to falls).
• Data breaches (email to wrong recipient, visible screens).
• Environmental incidents (trip/slip, chemical exposure).
• Faulty equipment degrading diagnostic images (e.g., OCT calibration fault).
• Use screening questions: Did our action/inaction cause or risk harm? Would a reasonable clinician inform the patient? Would you want to know?

Immediate actions checklist (first hour)

1. Ensure patient safety: arrange urgent clinical care if needed (e.g., ophthalmology referral, stop contact lens wear).
2. Acknowledge promptly (phone call preferable); apologise without delay.
3. Explain briefly what is known, what is being checked, and immediate safety steps.
4. Agree who will provide updates, by when, and a named contact.
5. Contain/mitigate (replace spectacles, transport support, stop dangerous devices, recall emails if possible).
6. Record the verbal contact in notes (who spoke, when, content, apology given).
7. Triage harm level; inform indemnity if moderate/greater harm or if litigation likely.
8. Plan written follow-up within agreed timeframe.

Communication & apology - practical scaffold

Conversation scaffold:

• Thank for time and ask if this is a good moment.
• Acknowledge and apologise: "I'm sorry this happened."
• Plain description of facts known (no speculation).
• Immediate safety/clinical steps taken.
• Outline investigation plan and timescales.
• Practical supports (remake, transport, expedited review).
• Confirm named contact, how to complain/seek ombudsman, and next update date.

Helpful short phrases:

• "I'm sorry this happened and for the impact on you."
• "Here is what we know right now and what we are checking."
• "We will update you by [date]; if we cannot, we will call to explain the delay."
• "We have arranged [urgent review / no-cost remake / transport] and will confirm this in writing."

Do's and Don'ts

• Do: be timely, factual, humane; offer practical remedies; document preferences.
• Don't: use conditional minimising language ("if"/"but"), speculate on blame, over-promise, or say "I'm sorry you feel that way."

Apology core elements

• Explicit apology; brief factual description; recognition of impact; immediate actions; what will change; written confirmation.

Documentation: what to record (minimum dataset)

• Date/time of the event and of recognition.
• Who was involved (staff + patient / representative).
• Factual account (what happened, avoiding blame/speculation).
• Harm/risk grading and rationale.
• Apology offered (when, by whom) and format (verbal/written).
• Patient preferences for updates and communication format.
• Immediate actions and clinical mitigations (who did what).
• Investigation plan, owners, due dates, and learning items routed to governance.
• Cross-references: patient clinical notes ↔ incident analysis (kept separate, linked).
• Storage and access: secure, role-based.

Tools to standardise

• Candour policy and decision flowchart/triage.
• Letter templates and phone-record templates.
• Incident and learning registers; verification/audit checklist.

Sample brief written line to document (exam-style)

• "Called patient 10:20 01/05 - apologised; explained that referral not sent; arranged urgent ophthalmology review today; written follow-up promised by 03/05; incident logged; owner: Practice Manager; review date: 17/05."

Operationalising candour in practice

Core elements to embed:

• Policy + triage flow (near miss vs minor vs moderate/major harm).
• Templates (phone script, candour letter).
• Private space for conversations and accessible written summaries.
• Named roles: who makes the call, who owns the investigation, governance lead and indemnity contact.
• Training inclusive of locums and new starters.
• Contractual clauses with third-party vendors requiring candour collaboration.

Timescales and escalation

• Inform patients "as soon as practicable"; set visible timelines in records (who informed, when, next update).
• England: follow statutory duty requirements for moderate/greater harm (notification, written account, record of apology).
• Data incidents → consider ICO notification if required.
• When criminality suspected or severe harm, seek legal and indemnity advice and preserve evidence.

Apology & liability

• Saying sorry is appropriate and not usually an admission of legal liability. Seek indemnity guidance for wording where legal risk exists.

Triage: deciding level of response

• Immediate verbal apology + written follow-up: most events with harm or risk.
• Formal statutory-style letter: England, moderate/greater harm as per CQC thresholds.
• Brief explanation and apology (no formal candour letter): minor service issues that did not expose risk but caused upset.
• Record rationale when candour not triggered.

Scenario summaries - distilled ideal steps

Missed referral (retinal detachment)

• Prompt call, apology, arrange urgent ophthalmology care, transport if needed.
• Written account: what happened, likely impact, prevention (referral checklist, second-check).
• Inform indemnity, log candour decision, record owners/dates.

Incorrect spectacle prescription

• Call with apology, explain recording error.
• Immediate recheck, no-cost remake, symptom monitoring.
• Update PMS (transposition prompt), peer check for significant Rx changes.

Wrong spectacle lenses causing trip

• Call + apology, clinical review, no-cost remake, practical support (transport/work note).
• Record as incident and candour case; implement bench checks and double-checks.

Contact lens mix-up

• Contact both patients with apology; symptomatic patient assessed immediately; replace lenses free and provide aftercare.
• Change pick-up/identity scripts; review labelling and staffing at peak times.

Email to wrong recipient (data breach)

• Contact affected patient, apologise, request deletion/recall, explain containment and rights.
• Log as data incident; ICO notification if threshold met; disable autocomplete and add dual-check on external emails.

Reception breach (overheard conversation)

• Private apology, explain what happened and remedial steps (voice level, signposting private rooms).
• Record, train staff, update signage and scripts.

Faulty OCT (missed macular oedema)

• Inform patient promptly with apology; urgent review and treatment as needed.
• Notify supplier, add daily calibration checks, second-reader and fault alarms; share learning across sites.

Near miss caught at final check

• Offer brief explanation/apology for delay/inconvenience, outline fix and verification.
• Record near miss, analyse contributory factors, introduce barcode/independent final check.

Learning, audit and verification

Learning loop

• Capture → Analyse (5 Whys or fishbone) → Act (one or two high‑use fixes) → Verify (audits / run charts) → Share (de-identified learning in huddles/governance).

Verification examples

• Short before/after audits, run charts of error types, spot-checks of final checks, calibration log audits.
• Close actions only when verification shows sustained improvement.

Sharing & sustaining

• De-identified case learning in staff meetings; include candour practice in induction.
• Recognise staff who report early; rotate facilitators to build confidence across roles.

Metrics to track

• Time from recognition to apology.
• On-time updates delivered.
• Closure rate of learning actions with verification.
• Patient feedback on clarity/kindness of communication.

Governance & escalation

• Maintain a candour policy, decision flowchart, and learning register linked to incidents/complaints.
• Notify external bodies as required (CQC, ICO, NHS routes).
• Inform indemnity providers early when harm may lead to claims.
• Escalate internally when patterns emerge; add risks to register and assign controls with review dates.
• Provide patients with contacts for complaints/ombudsman and continue local support while formal processes run.

Practical scripts & templates (exam-style handy prompts)

Phone opening

• "Hello, this is [name] from [practice]. Is now a good time? I'm calling because I need to let you know about an issue affecting your care. I'm sorry this happened. Here is what we know..."

Brief written follow-up template items

• Date of call, summary of facts, apology, immediate actions taken, next steps and dates, named contact, where to complain or seek independent review.

Decision log entry (one line)

• "[Date/time] - Candour triggered: missed urgent referral. Verbal apology 10:20. Urgent ophthalmology arranged. Written follow-up due 03/05. Incident logged; owner: PM."

Team reflection & wellbeing

• Personal reflection prompt: what happened, what I said, what the patient needed, where I hesitated, one improvement to try next time.
• Team debrief: one system fix, one communication tweak, one verification step (owner and date).
• Support staff emotionally: scheduled breaks after difficult disclosures, signposted counselling, and visible management support.
• Embed candour in daily routines: huddle prompts ("Any candour updates?"), private spaces, and ready conversation cards.

Quick checklist (one-sheet)

• Is patient safe right now? → Yes/No. If no → immediate care.
• Has someone spoken and apologised? → Yes/No. If no → call now.
• What is known? (2 - 3 bullet facts)
• Immediate safety steps taken (list)
• Named contact and next update date
• Is written follow-up needed? → Yes/No
• Harm graded and indemnity informed? → Yes/No
• Incident logged and learning owner assigned? → Yes/No

Study tip for exams

• Be prepared to: (1) identify trigger, (2) state immediate safety and communication steps, (3) list documentation elements, (4) name escalation routes (CQC/ICO/indemnity), and (5) propose one high‑use system change with a verification method.

End of Pass Notes