Bullying - a personal story and some strategies

This is my personal story, only a small story.   

In the early 1990s, in Ancoats Hospital, Manchester I was a Senior House Officer in Orthopaedics. I was warned when I joined about one of the consultants, Mr X, who had a habit of hitting junior doctors assisting him at surgery with instruments when the going got a little difficult. That was the most useful informal induction that I could have ever had. It was bound to happen. I could attempt to prepare for it. 

My options, when it happened, were a) to lodge a formal complaint with the hospital - as though that often did any good to anyone b) to lodge an assault complaint with the police - which may or may not have got any result but the career would have ground to a halt. So possibly option 'a' was better. Hmm.... Time to think, time to plan... I had a plan. 

Then one day, it happened, it was bound to. I was assisting Mr X and his forceps rapped my knuckles. Use some imagination to visualise the scene that I describe next. The instrument I was holding flies off in one direction, I leap sideways and backwards and slump down the theatre wall, wailing and shaking my hand. The theatre nurses go red, Mr X goes pale. I immediately start apologising 'sorry Mr X that must have caught a sensitive nerve or something'. I proceed to take off my gloves and gown; I say 'I will be back soon' and walk off to the coffee room. It was an intermediate type of operation, no harm to patient occurred. 

Very soon Mr X finishes the operation, walks camly across to the coffee room has an arm around my shoulder and says 'Are you okay son?'. I simply mumbled some meaningless neutral words. A few days later, same theatre coffee room, I had a request for Mr X. It was not a busy job, my colleagues were excellent and willing. My main interest was surgery (not orthopaedics) Hence, I wanted to attend Sir Miles Irving's unit at Salford Hospital for half of the week. As a young surgeon in training, preparing for examinations and the unknown future, hungry for every morsel of surgical knowledge and exposure - that was exactly what I wanted then. Mr X's answer, immediately and as expected was 'of course you can'. Apparently Mr X was never so easily convinced to agree to a request. 

It was a trade off. I knew that it would happen. I worried about conventional approaches not benefiting anyone. I was young and proud, I could not simply let it go. So I planned the scenario to get the best benefit for me under the circumstances. What was done to me was illegal, it was assault. Acting as per law would have put my career at risk. We can choose not to press on according to law. That is what I did. I also used intelligence, planning and emotion to use the situation and get what I wanted, my own compensation method. What I asked for was not illegal, it was discretionary and the discretion was used for my benefit. Since then........ I have got older and wiser. Was it ethical? Was it moral? I do not know, the reader can make up his/her own mind about it.

What is bullying?

Bullying carries on. Sometimes bullying these days takes the form of using 'clinical governance', 'patient safety', 'mandatory' issues, 'job planning', 'appraisal', 'pay progression', 'revalidation', in fact the most noble and most benign of tools can become a weapon in the hands of the unworthy.  At the extreme there can be threats of 'disciplinaries', 'NCAS referrals', 'GMC referrals', etc.

Bullying exists when there is a threat present in an atmosphere when it should not be present. 

The difficulty in dealing with bullying is about feeling, perceptions of various parties in the mix such as the victim, perpetrator or investigator. In my view it is not about feelings. There should be a threat, tangible, palpable, hopefully something can be proven, something that has a previous record. For any given person, when observed, measured data shows performance/behaviour within an acceptable band and yet others around this person use their power based on opinions to set or impose conditions when none should be set or imposed then bullying exists. 

TYPES of Bullying and Dealing with it

Bullying due to Pressure: Normal persons can show expressed behaviours of a bully when there are excessive pressures e.g. shortage of resources such as staff, equipment, money or an excess of work such as too many patients or too much regulation. These can be resolved without reference to the bully; simply by providing the right resources and systems. Here, the management becomes responsible for bullying and even more responsible for solving the problem. My personal opinion as an observer of work environment is that expressed bullying behaviour due to work pressures is responsible for about 40% to 50% of all cases of bullying.

Bullying due to personal deficiency of knowledge: People express bullying behaviour expressed initially as aggressiveness and eventually abusive behaviour to camouflage their personal deficiencies of knowledge and the consequent lack of confidence. This sometimes happens consciously but often without people even realising it. Operational data will often identify proof of deficiencies in these individuals; this evidence may not be in the outcomes but in process data. It will be ideal if the individuals are able to recognise this by themselves often they need a little pointer from friendly colleagues. In this case, resolution takes the form of additional development of the individual concerned. Technical development or non-technical development, often both will be needed. Team training could be a route to accomplish this. Again, my personal opinion as an observer of these issues is that this kind of bullying accounts for 40% to 50% of bulliers.

Bullying due to inherent pathological behaviour: A small number of individuals have bullying as a psychological personality trait. These individuals will not recognise themselves or accept the view of others that they have personality issues. These individuals may even often have excellent medical/clinical outcomes. These people often are mis-recognised as excellent performers with an assertive personality and are actually promoted up the hierarchy – they will shine till the day they burn the whole edifice down. We need a mature special method of dealing with these people. These people need to be put in a space with a small group of mature trusted people (staff who are trusted by the individual and by the organisation) so that they can carry on their clinical work without affecting wider morale of the organisation. That would be possible; but it will require immense managerial effort to do so. These individuals should never be given positions of power. A smaller number will play up at the end of all this, they will need to be taken up through formal systems.

Instead of dealing with bullying as above, we currently either ignore it or when we are not able to ignore we deal with it through rules and law. Both are inappropriate.

Individuals coping with bullying

Those of us who are not in a position to implement the above methods will need personal mechanisms to cope. Since the dated example described above, I have been of course bullied. Sometimes I have ignored, sometimes I have suffered it (on one occasion nearly 2 years) for obtaining long term gains, sometimes I have confronted the bully. I have never had to write in an official bullying and harassment complaint; will not hesitate to do that if the circumstances were right. Also never hesitated to wage personal campaigns to make everyone aware of the bully, bullying and mechanisms to cope – never hesitated to retaliate by damaging the image or reputations of bullies; I never do it lightly, only after significant evidence and deep thought. 

In the personal mechanism to cope with bulliers it is important to think, plan and practice extensively on how and when to confront the bully, when done right bullies stop bothering you. I have in my personal capacity helped one or two persons do so. It is sad that we may have to do this to protect ourselves when the systems let us down. Sadly this method only protects us and the bully moves on to someone else.

©M HEMADRI 

Follow me on twitter @HemadriTweets

I have already blogged about some of the organisational principles to resolve bullying titled 'Fearless Healthcare is what we want' http://successinhealthcare.blogspot.co.uk/2012/08/fearless-healthcare-is-what-we-want.html

Francis report - A very brief summary

The long awaited Francis report published in February 2013 makes for compelling reading. It comes at a time when many of us, healthcare professionals, have to deal with  ever increasing pressures to cut costs while at the same time striving to  maintain quality in the care we provide our patients. It is important for all of us to examine this report carefully and assimilate the key messages from it.

BACKGROUND

Robert Francis QC was first commissioned in July 2009 to chair a non-statutory inquiry in the then Mid Staffordshire General Hospital NHS Trust. This was  triggered by the high mortality rates of the trust  in 2007.The results of the first enquiry published in February 2010  concluded that there was a lack of basic care to patients across several wards and departments. The Board was accused of being more interested in achieving FT (Foundation Trust) status and concentrated more on statistics and reports than the outcomes of patient experience. More importantly it was damning on the role played by external organisations such as the PCT (Primary Care Trust) who had not identified the concerns till the investigation by HCC (Health Care Commission) in 2009. The enquiry recommended that Monitor  de‑authorise the Mid Staffordshire NHS Foundation Trust when the power came into effect and suggested that there should be a public enquiry to investigate the issues highlighted in the first enquiry. The Department of Health and the Trust Board accepted all the recommendations of the first enquiry and the second enquiry, now a Public Enquiry was commissioned by the Government under the leadership of Robert Francis QC in June 2010.This report was finally published in February 2013 this year and consisted of over 1000 pages of detailed analysis and recommendations. The  shorter 125 pages of executive summary provide a good feel of the complete report.

THE REPORT

The report  commences with a  consideration of key warning signs  of poor care that  existed  in Mid Staffs that should have triggered corrective action but did not.  The next section  explores issues relating to governance and culture of the Trust. This is followed by an examination of the role of  patient and public involvement groups, the commissioners, the SHA(Strategic Health Authority), and the regulators to understand what went wrong and to consider the role of other organisations. The conclusion of the report deals, with themes relevant  for the present and future with recommendations.

WARNING SIGNS

Robert QC unearths a whole series of events which in itself should have triggered an enquiry as early as 2004 with the loss of star rating when the Commission for Health Improvement (CHI) re-rated the Trust, and it went from a three star trust to zero stars. The HCC commissioned annual surveys of staff and patient opinion revealed that the trust was  in the worst performing 20% in the country. A whistle blowing incident involving a staff nurse’s report in 2007 was also ignored. Against a background of problems the trust announced staff cuts which was not questioned by the SHA. The HCC  meanwhile was preparing to investigate claims of poor care but did not know that at a national level the trust was being  considered  for FT status .Finally, Monitor did not know about HCC’s impending investigation until after it had given the FT status to the hospital in 2009. A breathtaking series of incidents over a period of 5 years  should have alerted someone, somewhere to the magnitude of the problem  unfolding within the hospital walls, but unfortunately did not.

ANALYSIS OF EVIDENCE

The Inquiry report examines the role played by each organisation on what they should have known and done in response to concerns raised. It was critical of the trust board not  responding to the concerns that were raised to it, the SHA for raising these concerns to the Department of Health (DoH) at the time of the FT application and Monitor for awarding the FT status without  properly assessing the trust’s capability of delivering effective patient care. The lack of communication between various organisations was highlighted as the key problem. Further the report highlights the disconnect between  policy decisions being made and their practical implementation. It has been rightly pointed out that the setting of national standards in itself will not  “catch” a Mid Staffordshire but it is more importantly  the establishment of  robust and  effective methods to  police those standards, which will eventually prevent another mid Staffs occurring.

KEY RECOMMENDATIONS

The report makes  290 recommendations and the following are some key ones.

A common culture made real throughout the system-Openness, transparency and candour

The report highlights the need for changing the current  culture of fear to a culture “where the only fear is the failure to uphold the fundamental standards and the caring culture.” The recommendation is that it should be  a criminal offence for any registered doctor or nurse or allied health professional or director of a registered or authorised organisation to obstruct the performance of these duties or dishonestly or recklessly make an untruthful statement to a regulator. 

Monitoring of compliance with fundamental standards

The importance of having clear and simple standards that both providers and patients can understand has been highlighted. These standards should be  informed by an evidence base and  be effectively measurable. The fundamental standards should be policed by a single regulator, the CQC, monitoring both compliance and the governance and financial sustainability. There is a recommendation that  NICE should produce evidence-based tools for establishing the staffing needs of each service.

Enforcement of compliance with fundamental standards

There is an expectation of zero tolerance; with a  service incapable of meeting fundamental standards not being permitted to continue. Further, non-compliance with a fundamental standard leading to death or serious harm of a patient should result in prosecution of as a criminal offence, unless the provider or individual concerned can show that it was not reasonably practical to avoid this.

Effective complaints handling

A new recommendation has been introduced  for an independent investigation of a complaint  to be  initiated by the provider trust under certain circumstances such as   if a complaint amounts to an allegation of a serious untoward incident or a complaint raises substantive issues of professional misconduct or the performance of senior managers.

Applying for foundation trust status

There is an ongoing recommendation for the merger of CQC and Monitor and  numerous suggestions for tightening up the process including physical inspection of site by CQC prior to awarding FT status.

Accountability of board level directors

The report tackles the issue of lack of accountability currently among board level directors.  A finding that a person is not  fit and proper to undertake the role of  Director may henceforth disqualify them  from being a director of any other healthcare organisation and they could themselves  be also reported  to the regulator.

Medical training and education

The report recommends that students and trainees should not be placed in organisations which do not comply with the fundamental standards. Further   those charged with overseeing and regulating these activities should now also make the protection of patients their priority. The General Medical Council’s system of reviewing the acceptability of the provision of training by healthcare providers must include a review of the sufficiency of the numbers and skills of available staff for the provision of training and to ensure patient safety in the course of training. 

Caring, compassionate and considerate nursing

The report has asked for an increased focus on a culture of compassion and caring in nurse recruitment, training and education. The report would like to see ward nurse managers work in a supervisory capacity and  not be office bound. The Nursing and Midwifery Council should introduce a system of revalidation similar to that of the GMC with a Responsible Officer for nursing in each trust. To tackle the issues of poor care noted among elderly patients, one suggestion is to create a new status of a registered older person’s nurse.

Quality accounts with information about an organisation’s compliance or non-compliance with the fundamental standards  should be made available on each trust’s website.

Robert QC has recommended that every organisation should announce at the earliest , its plans on how it was going to accept and implement the recommendations and within the year, publish a report with its progress towards these recommendations.

It is important that we participate in these changes in our organisation and make the improvements happen.

CONCLUSION

The Bristol enquiry was a wakeup call to the medical profession and it was believed, at the time, that lessons would be learnt. However this  do not appear to be the case and the Francis  report proves this.   The word “hindsight” occurred at least 123 times in the transcript of the oral hearing  and “benefit of hindsight” 378 times.  Empowered with the “hindsight” provided by the lessons from the Bristol enquiry and many others that followed, the Mid Staffs disaster should not have happened. Yet we let it happen.

The Francis report is yet another wake up call to professionals like us. As Robert Francis QC pointed out- the system cannot make the change for the better, it is the individuals in the system that can. Is there are a hospital near you or perhaps even yours who may be declared as the next “Mid Staffs”? We need to be courageous to speak up and stand up for the patients that we serve. The big question is ...will we?

 Robert Francis asks for a culture change in a climate fraught with tensions between management and clinicians. Consultant morale is the lowest it has been in years and not enough nurses can even be recruited into the posts. Further nursing profession regulation, could potentially make the nursing profession unattractive for new entrants. Talk of criminalising failure to deliver care may only drive the offenders deeper into the woodwork. People will be less likely to open up to their faults if they are afraid of being prosecuted. The report talk about routing out the blaming culture but till that is really done not much can be done about being open about mistakes.  As the management would like to put it, it is no longer a “no blame” culture but a “fair blame” culture-fair by whose standards, one wonders.

We have a government that has set targets for financial savings for healthcare organisations. The management unprepared for these challenges will make changes such as cutting manpower because that is the easiest way to save. Unless the government has a rethink of its financial strategy for the NHS, no real change can be made in the thinking or actions of the management. On the other hand, one could argue that a well qualified management team could identify cost cutting measures which do not sacrifice quality. The report’s recommendation to provide accreditation for management post holders and holding them more accountable for their performance may encourage individuals with the correct credentials to apply for these posts. Too often, managers in such posts are not specifically trained for them and tend learn more on the job rather than come prepared to deliver an effective role.

The Deaneries have been given a chance to influence the environment in which training takes place and must grab this opportunity to make an impact. It can only be a good thing for trainee doctors to be made aware of their responsibility to report deficiencies in care as a cultural change started amongst trainees is more likely to produce a next generation of doctors with a conscience-a conscience that will ensure that they act on behalf of their patients. 

Far too many organisations exist and each adds further bureaucratic   barriers to the transfer of information. The Francis report is welcomed as step in the right direction in highlighting this issue. Particularly welcome was the suggestion to not embark on another re-organisation but one wonders as to whether this will be followed.

While all this make for gloomy reading, one does need to make the change that Robert Francis has asked for in his report-patients are being treated poorly and as doctors we  have let it happen – we need  to overcome our squabbles and professional divides and  fight this together.

The Francis Report is a compelling read and I would advise every one of you to read it, if you have not done so already.

Dr MAKANI PURVA

Consultant Anaesthetist

Director of Medical Education

Hull and East Yorkshire Hospitals NHS Trust

Hull

UK

Notes:
1) This article was originally written for and published by a BAPIO publication
2) This article was first blogged on the Success At Medical Interactions blog site which is part of Success At Medical Interactions interview skills course providers for doctors
3) Dr M Purva can be reached via twitter
 

The Pretence of Better Communication

This blog was first published at doc2doc http://doc2doc.bmj.com/blogs/doctorsblog/_pretence-of-better-communication It has been modified, extended and re-posted here.

Discharge Summaries in NHS
10 years ago in the NHS most consultants used to do discharge summary letters for their in-patients. Quite rightly so. The discharge summary was and is the only communication that the hospital provides to primary care on what happened to the patient in the hospital. It is one of the most important pieces communication that the specialist sends to the generalist. It was the knowledge of the expert given as an opinion. It was also an opportunity for the consultant to review and reflect on the care provided, identify errors and recognise the capability/limitations of the team members.

5 years ago the consultants mostly devolved this responsibility to some experienced staff working with them such as Staff Grades or Registrars. The discharge letter became a task that had to be done. Information was passed to the general practitioners.

Now, the discharge letters are electronic and are primarily if not exclusively done by FY1s or FY2s who are the least experienced doctors in the system. Discharge letters are a part of the contractual requirement to be sent within a set time. There is enormous data within those discharge letters which is sent to the GP more or less contemporaneously. The junior doctors do a very good job; of transmitting data; they cannot with their level or training, expertise and experience do anything more.

Anyone who knows a little about this things will recognise that to derive any meaning or learning from what we do on a day to day basis, data has to be processed and assembled to generate information; information has to be analysed and contextualised to create knowledge. In the case of the NHS discharge summaries, knowledge transmission has now deteriorated into data transmission. Transparency and detail which are important have taken the place of trust and succinct senior opinion which are equally important.

The most crucial and often the only piece of communication from hospitals to general practices is now generated by a combination of off the shelf software programmes filled in by the junior most medical staff and usually has no oversight from anyone senior. Of course there are reasons for this, the letters can be generated quicker, can reach general practitioners on time and the current economic climate a consultant who is an expensive human resource is better used doing actual clinical work. Fully understandable. But let us not make the mistake of assuming that this is superior communication.

A friend who works on analysing and reporting risks in financial industry wrote in to say 'in my area of work if I do not provide the final oversight on what gets published on the credit opinions..which can sway bond markets...an error means I can be banned from working in financial services...if related to sovereigns...maybe jailed as well'. Now that's how seriously communication should be taken.

The Abuse of Communication Skills

Now that this blog has a growing readership; friends and acquaintances are writing in with examples from their own places of work. There seems an increasing cultural tendency where people think its okay to abuse communication skills. Righting a wrong not by action but by words. Not fair but read on.....................

Car Parking Vs Patients

Clinician running late, found a parking place and noticed that the parking permit was missing. Dilemma. Go to work and ring security to inform - risk of clamping and £60 fine. Go to security first and late to work - patients waiting.

Decision. Go to security first. Cannot afford £60 fine.

Explanation: 'Oh we can apologise to patients, show them empathy, sympathy, tell them our story, sit by their side rather than opposite them, perhaps even hold their hand and build a better relationship. They will forget the waiting. But security will clamp and will fine £60; my work place will not be supportive'

'We can handle complaints'

Bed manager rings on-call doctor: 'Try and send patients home from A&E, there are no beds in the hospital and we don't want patients to breach in A & E'

On-call doc: 'Well, apart from clinical reasons, there is also patient expectation. We could have serious complaints'

Bed manager: 'Oh don't worry about that. Complaints come only later. We can handle that. We are really good at handling complaints. We can provide them a detailed explanation and an apology if necessary'


Those are classic examples of abuse of a good skill. I have a problem with people using great tools and doing wrong things with it.

Let us get real. Let us not delude ourselves in the NHS by harping on about the primacy of communication.

©M HEMADRI 

Follow me on twitter @HemadriTweets

Duty of candour: Voluntary or statutory?

Duty of candour: Voluntary or statutory?

Candour is the quality of being honest and telling the truth, especially about a difficult or embarrassing subject[1]. When things go wrong and especially when patients are harmed whether it is due to natural circumstances or due to error by individuals or systems candour becomes very important. One of the components of such candour is to offer an apology to the patients and their families. It is important to understand that as clinicians we may not be apologise for in a ‘conventional’ sense when there is no individual error is involved; what we would be apologising for in all cases is for the fact that the patients’ expectations were unable to be fulfilled on that occasion.

Compensation Act 2006 states: ‘An apology, offer of treatment or other redress shall not of itself amount to an omission of negligence or breach of statutory duty. The medical indemnity providers have always held a similar view that apologising does not put a clinician at risk of being accused of anything in the future – it is not an admission of liability.

In the document ‘The Coalition: our programme for government’[2] it says "We will enable patients to rate hospitals and doctors according to the quality of care they received, and we will require hospitals to be open about mistakes and always tell patients if something has gone wrong".  The words ‘will’, ‘require’ and ‘always’ seems to indicate that the government is inclined towards introducing  statutory candour or some version of it.

The CMO has been recommending a statutory duty of candour for a good few years and there are currently deliberations including the GMC on this subject. There has been parliamentary health select committee recommendation to consider this subject.

Understandably patient groups especially the AvMA are in full support of a legal duty of candour; understandable because of the powerful case studies[3] they use where a statutory duty could have either avoided prolonged and vexatious interactions with authorities involved in those case studies or would have helped to bring events to a closure quickly. 

The MDU does not support the consideration of a statutory duty of candour based on the argument that there is already an ethical duty backed up by adequate GMC sanctions.[4] The MPS also seems to take a similar view. The NPSA’s new ‘being open’ policy (as opposed to its ‘open disclosure’ policy) is based on the premise that doctors apologising would prevent many unnecessary complaints and possibly some of the litigation that follows. There is international evidence that litigation occurs less often when an apology is offered and accepted upfront.

The GMC guidance on good medical practice[5] states ‘‘if a patient under your care has suffered harm or distress, you must act immediately to put matters right, if that is possible. You should offer an apology and explain fully and promptly to the patient what has happened and the likely short-term and long-term effects’’. However, a 2008 survey by the MPS[6] showed that while more than 90% of professionals believed that patients are less likely to litigate after errors if they received an explanation and an apology but only 68% were willing to be open when something went wrong. Clearly the issue of liability and blame still plays in the minds of doctors.

This raises the question whether the duty of candour should be statutory or mandatory.

Clinicians especially doctors really would not want statutory duty of candour as they would like to think that they are doing the right thing because it is the right thing and not because it is simply required by law. The GMC and other bodies, regulatory or not, take a very poor view of lack of transparency. Actioning after an event of low transparency is like many other triggers may turn out to be subjective, discretionary and inconsistent. However, in practice once the issue reaches the 'authorities' there are significant consequences which inevitably follow. Therefore a culture change route is preferable for clinicians.

The next issue to consider is how we design a response to the call of ‘duty of candour’. What the profession needs to understand is whether there was a rising trend that doctors and other clinicians are getting less transparent, if there is no such trend whether there are frequent examples of lack of candour. There seems to be no general trend that doctors are getting less transparent. Hence, a culture change approach using the voluntary duty supported by a strong view from the GMC and other bodies would certainly make a difference from the perspective of clinical professionals; with aberrant doctors dealt with strongly by using the full force of current systems. 

There are however, very frequent examples of outliers. This is when we have to recognise that institutional candour is a different situation. While individuals are all for openness, the current system of risk, clinical governance, complaints and legal actions inevitably raises doubts on the relevance of the extent of candour and its impact on future action against organisations. Further, often in inefficient and overspent circumstances or in situations of poor organisational vision, what is not required by the force of law or the force of higher authority is actively prevented from happening. This is understandable from an organisation's perspective but would be unacceptable to patients. There are examples of individual clinical candour followed by organisational resistance that happen in sequence. This is obviously unsatisfactory.

On balance, it seems that under current moral mores of our society a statutory duty of candour is probably going to be inevitable.  The question is of course is whether individual clinicians or the organisation would be legally responsible for the statutory duty of candour. It would make sense for the organisation to be responsible for such a statutory duty. The issue of candour after serious untoward incidents has extremely personal and wide ramifications at the same time, that it becomes clearly outside the remit of individual personal clinical responsibility. Further, organisations and organisational responsibility is likely to cover everyone in the organisation which would include doctors - any aberrations on the grounds of candour by doctors would therefore be dealt with by their organisation and by the GMC.

There might be a case for parallel dual responsibility (which has the risk of diluting responsibility) or for purely individual responsibility (where it could become 'fault', 'witch-hunt'  and 'scape goating' usual suspects). In a broad sense since the responsibility for quality moved from consultants to chief executives in the mid 80s, candour as such should therefore be an organisational responsibility delivered by individuals rather than individual responsibility enforced by personally applicable law.


© HEMADRI

Follow me on twitter @HemadriTweets

The department of health has launched a consultation on duty of candour: http://www.dh.gov.uk/health/2011/10/candour-consultation/ Please respond to it.

 

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[1] Cambridge Advanced Learner’s Dictionary

[2] The Coalition: Our programme for government: http://www.direct.gov.uk/prod_consum_dg/groups/dg_digitalassets/@dg/@en/documents/digitalasset/dg_187876.pdf

[3] http://www.avma.org.uk/pages/legal_duty_of_candour_-_robbies_law.html 

[4] http://www.the-mdu.com/section_medical_students/topnav_News_3/hidden_Article.asp?articleID=2011&contentType=Media+release&articleTitle=MDU+supports+apologies+to+patients+but+says+no+need+for+duty+of+candour

[5] http://www.gmc-uk.org/guidance/good_medical_practice/relationships_with_patients_open_and_honest.asp

[6] http://www.medicalnewstoday.com/articles/127194.php