Recurring concern
Failure of Duty-of-Candour processes for significant incidents
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Request correctionFirst reported 6 Mar 2015•Latest report 15 Dec 2025
What this concern includes
Includes failures of an explicitly identified Duty-of-Candour process or its dedicated disclosure, evidence, investigation, reflection or learning controls where the failure concerns significant incidents, deaths or other serious safety events.
Not included
- Excludes generic investigation, documentation, communication or learning failures that are not explicitly tied to a Duty-of-Candour obligation or process.
- Excludes failures concerning routine communication with patients or families where no Duty-of-Candour process is identified.
- Excludes unrelated incident-classification, clinical-assessment, staffing or operational-control failures.
- Reports
- 10
- Individual concerns
- 11
- Date range
- 2015–2025
- Stated actions
- 10
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
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Concerns raised1
Failure to comply with Regulation 20 statutory duty of candour
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Report identified care concerns through the incident reporting system and provide Duty of Candour, investigation and learning.
Stated by University Hospitals Plymouth NHS Trust
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Concerns raised1
Failure to act with candour in post-death investigations
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Use Reports to Prevent Future Deaths to identify safety themes and disseminate learning through guidance, bulletins and group safety-lead meetings.
Stated by HM Prison and Probation Service
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
The existing approach of allowing juries to determine findings, without routine formal admissions, is considered to meet the duty of candour.
Stated by HM Prison and Probation Service
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Position
Overlapping organisations, separate officer statuses, and late Ministry disclosure made admissions without trespassing on inquest evidence difficult.
Stated by Sodexo
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Concerns raised1
Failure to disclose evidence relevant to deaths to the coroner under the duty of candor
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Review internal legal and governance processes to maintain clear records of disclosure.
Stated by Chelsea and Westminster Hospital NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Position
The response addresses only concerns within NHS England’s national policy and programme remit, excluding hospital-specific matters.
Stated by NHS England
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Position
Chelsea and Westminster NHS Foundation Trust should respond to concerns specific to its hospital and care.
Stated by NHS England -
Position
The Trust disputes that the court was not provided with required evidence when requested, stating disclosure occurred before the inquest.
Stated by Chelsea and Westminster Hospital NHS Foundation Trust
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Concerns raised1
Delays in fulfilling Duty of Candour obligations
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Consider duty-of-candour review findings alongside manager-regulation consultation findings while developing healthcare candour policy.
Stated by Department of Health and Social Care
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The delay in executing the Duty of Candour was not considered a breach of the Health and Social Care Regulations.
Stated by Care Quality Commission
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Concerns raised2
Failure to make agreed factual admissions of shortcomings during death in custody inquests
Lack of a culture of candour and staff reflection after deaths in custody
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Remind staff through senior leaders and the legal team to provide fully transparent statements and live evidence during death-in-custody investigations.
Stated by HM Prison and Probation Service -
Action
Seek admissions where appropriate when assisting coroners to establish the circumstances of deaths in custody.
Stated by HM Prison and Probation Service
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Concerns raised1
Failure to comply with the Statutory Duty of Candour by sharing investigation findings and prevention steps
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Request information demonstrating the Trust’s compliance with the Regulation 20 duty of candour.
Stated by Care Quality Commission
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Where HSIB undertakes a maternity investigation, a separate local patient safety learning response is not required under PSIRF.
Stated by NHS England
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Position
The identified care, evidence-handling, Duty of Candour and investigation concerns fall outside HEE’s current role and statutory responsibilities.
Stated by NHS England
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Concerns raised1
Failure to disclose the DNACPR error to the family under the Duty of Candour
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to contact the patient’s family in line with the duty of candour
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Commence a serious incident investigation to review the care provided.
Stated by United Lincolnshire Teaching Hospitals NHS Trust
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Concerns raised1
Lack of a duty-of-candour procedure for significant incidents
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Interference with candid disclosure of the circumstances of a death
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Audit the accuracy of medical-record information and remind medical and midwifery staff of their candour duties.
Stated by United Lincolnshire Teaching Hospitals NHS Trust -
Action
Embed the duty of candour into complaints and serious-incident systems, with compliance reported to the Quality Governance Committee.
Stated by United Lincolnshire Teaching Hospitals NHS Trust
Data last updated 7 September 2026