Recurring concern
Failure of Duty-of-Candour processes for significant incidents
- Reports that mention this concern
- 10
- Times this concern has been raised
- 11
- Stated actions linked to this concern
- 10
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.
What is 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.
Trends
Reports over time
Reports mentioning this concern, 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.
Reports and published responses 10 reports
See individual reports that have raised this concern, and the actions taken in response
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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.
Linked response
- University Hospitals Plymouth NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
University Hospitals Plymouth NHS Trust
Report identified care concerns through the incident reporting system and provide Duty of Candour, investigation and learning.
-
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.
Linked responses
- HM Prison and Probation Service
- Sodexo
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
HM Prison and Probation Service
Use Reports to Prevent Future Deaths to identify safety themes and disseminate learning through guidance, bulletins and group safety-lead meetings.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
-
HM Prison and Probation Service
The existing approach of allowing juries to determine findings, without routine formal admissions, is considered to meet the duty of candour.
-
Sodexo
Overlapping organisations, separate officer statuses, and late Ministry disclosure made admissions without trespassing on inquest evidence difficult.
-
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.
Linked responses
- Chelsea and Westminster Hospital NHS Foundation Trust
- NHS England
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
Chelsea and Westminster Hospital NHS Foundation Trust
Review internal legal and governance processes to maintain clear records of disclosure.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
-
NHS England
The response addresses only concerns within NHS England’s national policy and programme remit, excluding hospital-specific matters.
-
NHS England
Chelsea and Westminster NHS Foundation Trust should respond to concerns specific to its hospital and care.
-
Chelsea and Westminster Hospital NHS Foundation Trust
The Trust disputes that the court was not provided with required evidence when requested, stating disclosure occurred before the inquest.
-
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.
Linked responses
- Care Quality Commission
- Department of Health and Social Care
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
Department of Health and Social Care
Consider duty-of-candour review findings alongside manager-regulation consultation findings while developing healthcare candour policy.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Care Quality Commission
The delay in executing the Duty of Candour was not considered a breach of the Health and Social Care Regulations.
-
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.
Linked response
- HM Prison and Probation Service
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
HM Prison and Probation Service
Remind staff through senior leaders and the legal team to provide fully transparent statements and live evidence during death-in-custody investigations.
-
HM Prison and Probation Service
Seek admissions where appropriate when assisting coroners to establish the circumstances of deaths in custody.
-
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.
Linked responses
- Care Quality Commission
- NHS England
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
Care Quality Commission
Request information demonstrating the Trust’s compliance with the Regulation 20 duty of candour.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
-
NHS England
Where HSIB undertakes a maternity investigation, a separate local patient safety learning response is not required under PSIRF.
-
NHS England
The identified care, evidence-handling, Duty of Candour and investigation concerns fall outside HEE’s current role and statutory responsibilities.
-
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
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.
Linked response
- United Lincolnshire Teaching Hospitals NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
United Lincolnshire Teaching Hospitals NHS Trust
Commence a serious incident investigation to review the care provided.
-
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
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.
Linked response
- United Lincolnshire Teaching Hospitals NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
United Lincolnshire Teaching Hospitals NHS Trust
Audit the accuracy of medical-record information and remind medical and midwifery staff of their candour duties.
-
United Lincolnshire Teaching Hospitals NHS Trust
Embed the duty of candour into complaints and serious-incident systems, with compliance reported to the Quality Governance Committee.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026