Duty of candour applied to hospital acquired thrombosis
Nigel Hawkes (1) highlights several of the difficulties in applying statutory duty of candour. We would additionally like to highlight the difficulty and potential inconsistency between Trusts in applying duty of candour to hospital acquired thrombosis (HAT). NHS England requires that Trusts perform root cause analysis (RCA) for all hospital acquired thromboses (HAT). HATs are notifiable incidents (moderate-severe harm) until investigated by RCA. RCA demonstrates that about 20% HATs are 'potentially preventable', associated with inadequate thromboprophylaxis, and 80% occur despite exemplary thromboprophylaxis (2, Guy's and St Thomas' NHS Foundation Trust data unpublished). According to the national reporting criteria for HAT, an RCA is reported as 'potentially preventable' if there is any deviation from local VTE guidelines, which vary between Trusts; and there is no evidence that a limited error, such as single missed dose of thromboprophylaxis, would result in actual harm. HAT RCA is often a slow process (up to 6 months) and the patient may no longer be under follow-up. At what point of the HAT process should patients be informed?
On 27th April 2015 we held an open multi-disciplinary meeting* with patient involvement to discuss these issues. After discussion, the group arrived at an algorithm. We felt that if RCA found no errors in hospital care then it was not necessary to inform the patient of the results. However, it was agreed that best practice would be that patients are made aware that a VTE within 90 days of admission automatically results in an investigation, that this investigation might take several months, and that they would be informed if there were any significant omissions in their care (recommend that this information is included in patient information leaflets). It was agreed that for ‘potentially preventable’ HATs that an expert group should make a judgement as to whether on the balance of probabilities the error(s) resulted in significant clinical harm. The group unanimously agreed that if errors were potentially causal then this must be told to the patient. The group was split approximately 50:50 on whether the patient should be informed if an error had been made which was unlikely to be causal, highlighting the difficulty and potential inconsistency between Trusts in applying duty of candour to HAT.
1 Hawkes N. Admitting when mistakes are made. BMJ 2015; 351:h4474.
2 Roberts LN, Porter G, Barker RD, Yorke R, Bonner L, Patel RK, Arya R. Comprehensive VTE prevention program incorporating mandatory risk assessment reduces the incidence of hospital-associated thrombosis. Chest 2013; 144, 1276-81.
Financial support provided by a British Society of Haematology Meeting Support grant.
Competing interests: No competing interests