2 An open and transparent NHS |
Open culture and professional
17. Healthcare professionals have an unambiguous
professional duty to raise with the relevant authorities any concerns
which they may have about the safety and quality of care being
delivered to patients. Managers do not operate within the same
framework of regulated professional obligations but they should
also be expected to raise concerns about matters affecting patient
safety and care quality and to be able to do so openly and without
suffering personal detriment.
18. The Committee believes that Trusts and other
care providers have a fundamental duty to establish an environment
where concerns about patient safety and care quality raised by
clinicians or managers are addressed openly and directly.
19. Robert Francis told the Committee that an essential
element of the recommendations in his report was that "there
should be no obstruction to individuals, or groups of individuals,
raising honestly-held concerns about patient safety":
They need to be listened to. If there is to be
a penalty, it should be to penalise those who do not exercise
their responsibility to raise those things, not the other way
He went on to say that
There needs to be full protection for people
who genuinely raise concerns rather than the extremely complex
system we have at the moment. If we did that, we would not have
to be talking about whistleblowers. We could talk about everybody
contributing to a safe system and being welcomed for so doing.
The principal changes necessary to establish a genuinely
open culture are discussed below.
20. Robert Francis told the Committee that his recommendations
came as a package, which had five principal themes. One of these
was the promotion of openness, transparency and candour, not just
in relation to individual incidents of harm but in more general
That is a package. It is about candour to patients,
but it is also about honesty with the public, commissioners and
[T]here is a little bit of confusion often in
what we mean by a duty of candour. Conventionally, the discussion
has been in terms of candour about honesty to the patient, in
telling a patient who has been harmed or might have been harmed
by care the truth about that. There is a wider field of candour,
which I distinguish by calling it "openness and transparency",
which is about the truth as to more general information concerning
21. The Committee agrees with Robert Francis that
the key requirement is for a culture change within the NHS which
values openness and transparency in all care deliverynot
just when things go wrong. The duty of candour does not simply
arise in cases of service failure; the requirement for an open
culture which encourages challenge is fundamental to the delivery
of high quality care.
THE EXISTING DUTY AND PRACTICE OF
CANDOUR IN THE NHS
22. During the course of the Committee's 2011 inquiry
into complaints and litigation, the Government announced that
it would introduce a new requirement on NHS providers, in their
contracts with commissioners, to be open and transparent in admitting
mistakes in their care. NHS England (the NHS Commissioning Board)
has introduced a contractual duty of candour as one of the service
conditions of the NHS standard contract for 2013/14.
23. The new duty in the standard contract applies
to patient safety incidents which result in moderate harm, severe
harm or death (using the definitions provided by the National
Patient Safety Agency) and which are reported to local management
systems. While the contractual duty does not apply to incidents
which result in low or no harm, guidance to providers requires
these incidents to be reported to the patient where appropriate.
Under the terms of the contract, the patient (or relative or carer)
must be informed of a suspected or actual patient safety incident
within at the most 10 working days of the report of the incident
to local systems.
24. The terms and definitions for grading patient
safety incidents established by the National Learning and Reporting
System of the National Patient Safety Agency are set out in Table
1. The Committee comments further on the scope of application
of these terms and definitions at paragraph 133 below.
25. The initial notification must be delivered verbally,
and face to face where possible, accompanied by the offer of a
written notification, and recorded for audit. An apology, both
verbally and in writing, must be provided: guidance to providers
makes clear that a sincere apology expressing regret for harm
caused is not tantamount to an admission of liability, and the
risk of litigation should not prevent an apology.
Table 1: National Reporting and Learning System
terms and definitions for grading patient safety incidents
|Grade of patient
|No harm ||Incident prevented - any patient safety incident that had the potential to cause harm but was prevented, and no harm was caused to patients receiving NHS-funded care.
Incident not prevented - any patient safety incident that occurred but no harm was caused to patients receiving NHS-funded care.
|Low harm ||Any patient safety incident that required extra observation or minor treatment and caused minimal harm to one or more patients receiving NHS-funded care.
Minor treatment is defined as first aid, additional therapy, or additional medication. It does not include any extra stay in hospital or any extra time as an outpatient, or continued treatment over and above the treatment already planned; nor does it include a return to surgery or readmission.
||Any patient safety incident that resulted in a moderate increase in treatment and that caused significant but not permanent harm to one or more patients receiving NHS-funded care.
Moderate increase in treatment is defined as a return to surgery, an unplanned readmission, a prolonged episode of care, extra time in hospital or, as an outpatient, cancelling of treatment, or transfer to another area such
as intensive care as a result of the incident.
||Any patient safety incident that appears to have resulted in permanent harm to one or more patients receiving NHS-funded care.
Permanent harm directly related to the incident and not related to the natural course of the patient's illness or underlying condition is defined as permanent lessening of bodily functions, sensory, motor, physiological or intellectual, including removal of the wrong limb or organ, or brain damage.
|Death||Any patient safety incident that directly resulted in the death of one or more patients receiving NHS-funded care.
The death must be related to the incident rather than to the natural course of the patient's illness or underlying condition.
Being open: Communicating patient safety incidents
with patients, their families and carers,
National Patient Safety Agency National Reporting and Learning
Service, November 2009, Appendix B
26. Incident investigation reports must be shared
with the provider's Board or medical director and the appropriate
commissioner promptly following completion of any investigation.
Providers are required to inform the patient's commissioner when
they are communicating with a patient (or relative or carer) about
an incident, though this requirement may be fulfilled by six-monthly
reports as part of contract review.
27. If an incident is not reported, but subsequently
comes to the attention of a commissioner, the commissioner is
required to raise the matter with the provider: if an incident
has not been reported to the patient or to local systems, the
breach of contract should be treated very seriously: where serious
injury or death has ensued, commissioners should consider reporting
to the CQC the provider's failure to notify as a breach of the
provider's registration requirements.
28. The consequences of the breach of the contractual
duty are set out in the contract, and include the commissioner
requiring the chief executive to provide a direct written apology
and explanation to the individual or individuals affected, the
commissioner requiring the provider to publish notification of
the breach on its website, or the commissioner notifying the CQC.
Commissioners may also recover the cost of the episode of care
(or £10,000, where the cost of the episode is unknown) from
29. The principles now set out in the NHS standard
contract with regard to candour with patients are sound, but experience
in Mid Staffs and elsewhere makes it clear that such principles
have in the past been too often honoured in the breach rather
than in the observance. Whatever additional safeguards may be
introduced, the Committee regards the enforcement of these principles
on all providers of NHS services as a fundamental part of the
role of NHS commissioners. Failure to apply to these principles
in practice should be seen as a failure of enforcement by commissioners
as well as a failure of performance by service providers.
30. Furthermore, the Committee believes that in
the requirement for openness and transparency is too narrowly
drawn in the NHS Standard Contract. The requirement for candour
about mistakes should, in truth, be seen as part of a much wider
commitment an open and accountable service. Challenge and debate
about outcomes should occur at all levels of quality achievement
and in all contexts of care, not just at the bottom. Indeed the
Committee believes that if high quality service providers were
to set the pace for openness and transparency by making properly
anonymised information available on a dramatically improved basis,
they would increase the pressure on less good providers to demonstrate
that they were matching their standards to the best. Verbal commitments
to high quality standards are virtually meaningless if no effective
steps are taken to monitor performance.
ACCOUNTABILITY OF COMMISSIONERS
31. In addition to its support for the role of commissioners
in enforcing a new culture of openness on providers, the Committee
also recommended in its 2011 report on Complaints and Litigation
that the NHS Commissioning Board should, when authorising
commissioning bodies, place the commissioners themselves under
a contractual duty of candour to their populations and to their
local HealthWatch organisations.
In response, the Government indicated that it would consult on
"the expectations which should be placed on commissioners
in terms of publicly reporting how often they are made aware of
instances of non-disclosure and what action they have taken as
32. In the event NHS England has not placed commissioners
under any explicit duty of candour either to local populations
or to local HealthWatch organisations. In the Committee's view,
such a duty is vital to build public confidence in the commissioning
system and to ensure that communities can hold their commissioners
of health and care services fully to account for the public money
spent and the services commissioned. An effective duty of candour
on commissioners would also reinforce the requirement for commissioners
to enforce the principles of openness which are set out in the
NHS standard contract between commissioners and providers. The
Committee continues to believe that commissioners should be under
an obligation to collect and publish full information about outcomes
achieved for their communities, including a full account of failures
to deliver acceptable standards of care. By failing to apply a
duty of candour explicitly to commissioners, NHS England is losing
an important opportunity to promote a more open and accountable
culture throughout the NHS.
THE NHS CONSTITUTION
33. The contractual duty of candour between provider
and commissioner, which is accompanied by a revised pledge to
patients in the NHS Constitution: the previous pledge
that when mistakes happen, to apologise, explain
what went wrong and put things right quickly and effectively
has been superseded by the pledge
to ensure that when mistakes happen or if you
are harmed while receiving health care you receive an appropriate
explanation and apology, delivered with sensitivity and recognition
of the trauma you have experienced, and know that lessons will
be learned to help avoid a similar incident occurring again.
34. The Government explains that this new pledge
reflects the introduction of the contractual duty of candour,
and is more specific in acknowledging where mistakes in care have
35. The Committee believes that the new formulation
in the NHS Constitution explaining the duty of candour substantially
understates the importance of a more open culture in the NHS.
Commissioners and providers should be under a duty of openness
about the full range of outcomes achieved, not just about examples
of patient harm. More open accountability for outcomes achieved
would be an important spur to improvements in the quality of care
delivered across the full range of health and care facilities.
It must be driven from NHS England, but it must permeate every
aspect of care provision. It is the role of commissioners to ensure
that the providers of NHS care provide timely, accurate and complete
information to both individual patients and commissioners.
THE FRANCIS RECOMMENDATIONS
36. Robert Francis found that current requirements
in the NHS "do not cover uniformly and consistently the areas
in which [openness, transparency and candour] are needed."
He recommended that the following principles should underpin future
requirements for openness, transparency and candour in the NHS:
· Every healthcare organisation and everyone
working for them, or on their behalf, must be honest, open and
truthful in all their dealings with patients and the public.
· Organisational and personal interests
must never be allowed to outweigh the duty to be honest, open
· Where harm has been, or may have been,
caused to a patient by an act or omission of the organisation
or its staff, the patient (or, if the patient is deceased, any
lawfully entitled personal representative) should be informed
of the incident, given full disclosure of the surrounding circumstances
and be offered an appropriate level of support.
· Full and truthful answers must given to
any question reasonably asked by a patient (or, if deceased, by
any lawfully entitled personal representative) about his or her
past or intended treatment.
· Any statement made to a regulator or a
commissioner in the course of its statutory duties must be completely
truthful and not misleading by omission.
· Any public statement made by a healthcare
organisation about its performance must be truthful and not misleading
In applying these principles Mr Francis made three
recommendations to amend the legal obligations on providers of
37. Mr Francis' first recommendation is that a statutory
obligation to observe a duty of candour should be imposed:
i. on healthcare providers "who believe
or suspect that treatment or care provided by [the provider] to
a patient has caused death or serious injury to a patient to inform
that patient or other duly authorised person as soon as is practicable
of that fact and thereafter to provide such information and explanation
as the patient reasonably may request"; and
ii. on registered medical practitioners and registered
nurses and other registered professionals "who believe or
suspect that treatment or care provided to a patient by or on
behalf of any healthcare provider by which they are employed has
caused death or serious injury to the patient to report their
belief or suspicion to their employer as soon as is reasonably
The provision of information in compliance with this
requirement "should not of itself be evidence or an admission
of any civil or criminal liability, but non-compliance with the
statutory duty should entitle the patient to a remedy".
38. Secondly, Mr Francis recommended that there should
be a statutory duty "on all directors of healthcare organisations
to be truthful in any information given to a healthcare regulator
or commissioner, either personally or on behalf of the organisation,
where given in compliance with a statutory obligation on the organisation
to provide it."
39. Thirdly, Mr Francis recommended that "it
should be made a criminal offence for any registered medical practitioner,
or nurse, or allied health professional or director of an authorised
or registered healthcare organisation:
· Knowingly to obstruct another in the performance
of these statutory duties;
· To provide information to a patient or
nearest relative intending to mislead them about such an incident;
· Dishonestly to make an untruthful statement
to a commissioner or regulator knowing or believing that they
are likely to rely on the statement in the performance of their
Observance of the duty "should be policed by
the Care Quality Commission, which should have powers in the last
resort to prosecute in cases of serial non-compliance or serious
and wilful deception. The Care Quality Commission should be supported
by monitoring undertaken by commissioners and others."
The case for a statutory duty
40. In evidence to us, Robert Francis clarified that
his requirement for a statutory duty of candour filled a gap in
the obligations of NHS organisations to be honest with patients:
In relation to candour to the patient we already
have a professional obligation, in their codes of conduct, on
the part of doctors and nurses to be honest with patients. What
we lack, except by means of guidance, is an obligation on the
part of organisations to be honest with patients. First, the organisation
must have that responsibility, and, in practical terms, it is
the organisation that needs to organise the telling of the patients
quite a lot of the time.
A statutory duty was required as a means to, and
a precondition of, the substantial change in culture which was
required across the NHS. He put it in these terms:
What we have to do is to find a means of making
it the normal thing to do to raise concerns about what is going
on in the hospital and, if necessary, about colleagues. The way
you do that is by making it more difficult not to do that than
it is to do it. I know that sounds slightly counterintuitive,
but we need encouragement, I am afraid, for people to take their
courage and to make it their obligation so that they have at least
the protection, and can say to their colleague, "I am frightfully
sorry but I had do this because if I didn't I could be prosecuted."
That is a pretty good start when talking to your colleagues. I
believe, although it may, when you first think about it, sound
paradoxical, that it will encourage openness as the norm at a
stage before you need to talk about whistleblowers.
He considered that the contractual duty of candour
owed by a provider to a commissioner did not go far enough:
The reason I think it should be a statutory duty
is that it is all very well having a contractual obligation to
a commissioner, but the reality is that the obligation is to the
patient. There needs to be that direct relationship, which needs
to be recognised and [. . .] it follows that there will be a remedy
involved if that was breached in itself. So there is that duty
enforced by a sanction, which means that anyone who gets in the
way of that duty deliberately should be subject to criminal sanction.
By way of illustration, he referred to a case which
had come to light during the inquiry where a consultant's report
relevant to the death of a patient consequent on treatment at
Stafford General Hospital had been withheld from a coroner's inquest,
and from the family, on the basis of legal advice given by the
Mid Staffordshire Trust's legal department "because it was
believedhonestly believedby those doing it that
it was in the trust's best interests to do that, which is, I am
afraid, not a happy story for my profession."
41. This case was discussed at length in Robert Francis'
report. Mr Francis
criticised the Mid Staffordshire Trust over the failure to disclose
to a coroner material which might have been of assistance to him,
and concluded that in such circumstances the primary consideration
for a Trust's solicitors should be "whether the information
in the solicitor's possession would, or could, reasonably be considered
to be of assistance to the Coroner, whether or not it showed the
trust in a poor light."
In the case in question, Mr Francis concluded that "the only
possible answer" was that the material should have been disclosed.
The trust and confidence of the bereaved family in the Trust had
been seriously damaged by the concealment of the report: that
concealment "caused more distress than disclosure could ever
42. Mr Francis observed that existing guidance requiring
trusts and clinicians to be open with patients and bereaved families
about adverse incidents, and to offer them full explanations of
what occurred, "should be a very significant factor to be
taken into account in deciding where the interests of a trust
lie". The inquiry
had heard that there was no duty in laweither in statute
or in common lawfor those in possession of factual information
concerning a death to volunteer such information to a coroner,
and he therefore concluded that many other solicitors acting for
and advising Trusts would have acted no differently. He therefore
believed that there was
an urgent need for unequivocal guidance to be
given to trusts and their legal advisers and those handling disclosure
of information to coroners, patients and families, as to the priority
to be given to openness over any perceived material interest.
43. Mr Francis was also critical of the way the Trust
had behaved in its response to a civil claim made against the
Trust by the bereaved family. The way the Trust had conducted
the litigation had revealed "some unfortunate characteristics
all too common in clinical negligence claims".
A written apology sent to the family by the Trust Chair, in which
the hope was expressed that a swift settlement would enable the
family "to put this matter behind you and move on",
was described as "formulaic, insensitive, patronising and
likely to exacerbate wounds rather than heal them".
The Trust appeared to have conceded internally that the claim
was indefensible and that it would be reasonable for the Trust
to settle, and did not seek evidence to the contrary: yet it persisted
in denying liability in an attempt to negotiate a lower settlement,
a position "entirely inconsistent with the professed policies
and guidance calling for openness and transparency about adverse
Despite complaints of the bereaved family about the way the settlement
had been handled, the Trust's solicitor maintained that the settlement
had been a success.
44. The Committee believes that a defensive and
sometimes over-legalistic culture which attaches a higher priority
to avoiding liability than improving outcomes represents a pervasive
phenomenon which is not confined to the healthcare system. While
legal accountability is important, it is even more important that
legal advice based on such defensive considerations is not allowed
to impede the proper relationship between clinical professional
and patient, based on sound principles of professional responsibility.
45. Similarly, defensive and over-legalistic considerations
of the best interests of Trusts should not be allowed to override
the duty to be open and transparent with patients and relatives
about adverse incidents, and to provide to them full explanations
of the factors which led to such incidents. It is particularly
important that NHS bodies provide full and candid explanations
to relatives bereaved as a result of an adverse incident.
46. The Committee discussed with Mr Francis the potential
difficulties which a statutory duty of candour might pose for
medical professionals and others involved in patient safety incidents,
where it appeared that a requirement to be open and honest about
any mistakes made might conflict with legal advice from a provider,
with an eye to admissions of liability, about what admissions
should or should not be made.
47. While Mr Francis recognised that medical professionals
required to be open and honest about errors might, in admitting
mistakes, open themselves to the possibility of professional misconduct
proceedings, he thought that professional regulators would be
far more lenient on those who owned up to errors with a serious
effect on patient safety than they would on those who denied or
sought to cover up their lapses:
We need a situation where the legal advice is
going to be, "I know this is unfortunate, but you are going
to be better off by telling them about it and being honest and
open about it than not."
REACTIONS TO THE FRANCIS RECOMMENDATIONS
48. In its response to Francis, the Government has
indicated that it will consider a statutory duty of candour on
providers to inform patients or relatives of cases where the provider
believes that treatment or care has caused death or serious injury,
and to explain why. The scope of the duty is to be "carefully
The Secretary of State told the Committee that "we think
that providers should have a duty in law to be transparent with
people when they have done harm, and we accept that."
49. The Government has since indicated that the statutory
duty of candour will be introduced as a requirement on providers
registered with the Care Quality Commission, and that provision
for the statutory duty will be made through secondary legislation
rather than on the face of the Care Bill [Lords].
50. The report of the Berwick Review of patient safety
in England also recommended a statutory duty of candour: "where
an incident qualifying as a Serious Incident (as defined by NHS
England) occurs, CQC regulations should require that the patient
or carers affected by the incident be notified and supported."
51. Berwick also, however, enters some important
caveats about the scope of a statutory duty, and indeed about
the scope of the contractual duty in the NHS Standard Contract.
The Berwick Review eschews "an automatic 'duty of candour'
where patients are told about every error or near miss, as this
will lead to defensive documentation and large bureaucratic overhead
that distracts from patient care". Berwick does recommend
that "patients should be given all the information they ask
for" and suggests the commissioning of research "to
study how proactive disclosure of serious incidents, and the process
of engaging with patients in relation to less serious incidents,
can best be supported."
52. The Government plans to work with professional
regulators to see "what more can be done to encourage professionals
to be candid with their patients at all times".
This falls short of Robert Francis' recommendation for a specific
duty of candour on medical professionals to report to their employer
a belief or suspicion that treatment provided to a patient has
caused death or serious injury.
53. Berwick explicitly does not support the Francis
recommendation of a statutory duty for healthcare workers to report
beliefs or suspicions about serious incidents to employers, considering
that this duty "is adequately addressed in relevant professional
codes of conduct and guidance".
THE ROLE OF CRIMINAL SANCTIONS FOR
INDIVIDUALS AND HEALTHCARE ORGANISATIONS
54. The Government has expressed caution about introducing
criminal offences to apply to individuals working in healthcare
settings, arguing that they may unintentionally introduce a "culture
of fear", preventing lessons from being learned. However
the Government agrees that "robust action" should be
taken in instances where staff are "obstructively dishonest".
In addition, criminal sanctions are proposed for staff who deliberately
allow fundamental standards of care
to be breached. Ministers plan to take advice from the professional
regulators and to consider the findings of the Berwick Review
on the appropriateness of criminal sanctions to be applied below
55. The Berwick Review expresses extreme caution
about any proposal to apply criminal sanctions to individual staff
working in healthcare settings. Such sanctions should only be
applied in cases where individuals are demonstrably guilty of
wilful or reckless neglect, and only then in accordance with several
stringent criteria concerning, for example, the severity of the
case and the level of culpability of the individual. The Committee
addresses these matters further at paragraph 115 below.
56. Berwick does concur with Francis in recommending
that leaders in healthcare organisations "who deliberately
withhold information or who provide misleading information"
should be subject to penalties.
57. The Government proposes that care providers who
"knowingly supply wrong information" or who "deliberately
withhold information from families about serious harm or death"
are to be subject to additional legal sanctions at a corporate
level. Provision for a new offence and for penalties have now
been introduced as part of the Care Bill [Lords]:
· Clause 81 of the Bill introduces a new
criminal offence, to apply to care providers as corporate bodies.
Any such provider who supplies information required by statute
or another legal obligation which is materially false or misleading
commits an offence. 
· Clause 82 of the Bill provides that a
care provider convicted of an offence is liable to a fine on conviction,
with the option for the sentencing court to impose on the provider
a remedial order (requiring the provider to put right the misleading
information and any materially relevant deficiency in its practices),
a publicity order (requiring the provider to publicise the fact
of the conviction, details of the offence and the fine imposed
and details of any remedial order made), or both.
The Committee's view
58. In its 2011 report on Complaints and Litigation
the Committee reached the following conclusion on the introduction
of a statutory duty of candour:
The Committee does not think that placing further
statutory duties on the NHS will produce the shift in culture
that is required to ensure that patients get full disclosure of
information when things go wrong. The emphasis on the importance
of culture change [. . .] may have more impact than further statutory
59. The Committee is mindful that NHS history
is littered with examples of well-intentioned changes which have
been superimposed on existing arrangements without sufficient
attention being paid to the way in which it is proposed that the
new arrangements will interact with existing processes. It is
striking, for example, that the clauses in the Care Bill [Lords]
which are intended to establish a criminal offence of providing
false and misleading informationin effect criminalising
a breach of the proposed statutory duty of candourhave
specified neither the types of provider, nor the types of information
to which the offence will apply, leaving both to be specified
later in regulations.
60. The Committee remains to be persuaded of the
case for the introduction of a statutory duty in addition to existing
contractual duties and professional obligations. It is not clear
that the proposed duty, the terms of which remain to be defined
in secondary legislation, will constitute an effective means of
achieving the fundamental culture change which is required within
61. The Committee continues to believe that it
is mistake to think of the requirement for a more open culture
specifically in the context of failures of care. The culture change
which is required within the NHS requires greater openness across
the full range of its activitiesincluding examples of care
that do not match current best practice, as well as overt failure.
62. The Berwick Review recommends the commissioning
of research into how best to support the proactive disclosure
of serious incidents and the process of engaging with patients
in relation to less serious incidents. While further research
into these matters is necessary, and is likely in the medium term
to make a positive contribution to candid dialogue between providers
and patients, it should not delay the implementation of measures
designed to entrench a culture of openness and candour across
the full range of NHS activities.
14 Q34 Back
Service Condition (SC) 35. The standard contract is available
at http://www.england.nhs.uk/wp-content/uploads/2013/03/contract-service.pdf Back
NHS Commissioning Board, 2013/14 NHS Standard Contract: technical
contract guidance, 4 February 2013, available at http://www.england.nhs.uk/wp-content/uploads/2013/02/contract-tech-guide.pdf Back
Health Committee, Sixth Report of Session 2010-12, Complaints
and Litigation, HC 786-I, para 82 Back
Government Response to the House of Commons Health Select Committee
Sixth Report of Session 2010-11: Complaints and Litigation,
Cm 8180, para 73 Back
Francis Report, recommendations 173-177, chapter 22 Back
Francis Report, recommendation 181, chapter 22 Back
Francis Report, recommendation 182, chapter 22 Back
Francis Report, recommendation 183, chapter 22 Back
Francis Report, recommendation 184, chapter 22 Back
Mr Francis clarified that the situation might equally apply to
professionals who might otherwise be subject to disciplinary sanction
by their professional bodies. Back
Francis Report, paras 2.164 - 2.210: the case in question
is the death of John Moore-Robinson. Back
Ibid., para 2.204 Back
Ibid., para 2.209 Back
Ibid., para 2.204 Back
Ibid., para 2.206 Back
Ibid., para 2.210 Back
Ibid., para 2.186 Back
Ibid., para 2.210 Back
Patients First and Foremost, Cm 8576, para 2.31 Back
HL Deb, 20 June 2013, column 398 [Earl Howe]. Back
A promise to learn - a commitment to act, p. 34 Back
Patients First and Foremost, Cm 8576, para 2.32 Back
A promise to learn - a commitment to act, p. 34 Back
Robert Francis's proposals for fundamental standards of care are
addressed in chapter 3. Back
Patients First and Foremost, Cm 8576, para 2.33 Back
A promise to learn - a commitment to act, p. 33 Back
HL Bill 1 of Session 2013-14. Unless stated otherwise, all references
to clauses in the Care Bill [Lords] are to the print of
the Bill as originally introduced to the House of Lords. Back
HL Bill 1-EN, paras 425-431 Back
Ibid., paras 432-438 Back
Health Committee, Sixth Report of Session 2010-12, Complaints
and Litigation, HC (2010-12) 786, para 80 Back