Clinician perspective

This clinician perspective is written by an infection control doctor who was the chair of the Incident Management Team (IMT).

Hospital-acquired infections are more often than not sporadic cases and typically communicated by the patient’s clinical team. For the most common hospital-acquired infections, for example, Methicillin-resistant Staphylococcus aureus, Clostridium difficile infection, there are well-established patient information leaflets available. In many NHS boards, a single case of preventable S. aureus bacteraemia will initiate a serious clinical incident review. Single episodes of hospital-acquired infections might also be classified as a duty of candour event if related to a preventable source and harm ensued, for example, bloodstream infection secondary to a contaminated infusate. Postoperative surgical site infections are highlighted as a risk during the consent procedure but might constitute a duty of candour event if there was clear organisational failing such as failure to sterilise equipment or suboptimal operating theatre ventilation, leading to harm.

Outbreak situations can be more complex and may involve multiple patients and families requiring an apology if harm has ensued. No one outbreak or incident is the same and bespoke decisions about duty of candour will be required for each circumstance. Often outbreaks in the hospital setting are short lived, however occasionally they can become protracted lasting >28 days.

Following the issue of the Scottish guidance in 2018, the lead author, an infection control doctor, introduced duty of candour as an agenda item for all infection control incidents/outbreaks within the organisation. This was first tested during the aforementioned prolonged incident related to a contaminated water system involving paediatric haemato-oncology patients who developed hospital-acquired infections. Where patients met the outbreak case definition, the infection control doctor accompanied the patient’s clinician to apologise to families, answer questions and provide assurances.

Cause and effect may be clearly identifiable for most duty of candour situations, however infection control incidents are characterised by less certainty. Some outbreaks, such as the aforementioned, require multiple hypotheses to be investigated with a subsequent need to evaluate the control measures. Incidents may be multifactorial requiring a multimodal strategy to prevent further cases. Duty of candour in such a situation becomes more complex due to an evolving situation, a lack of definitive cause and effect early on and an inability to determine the weight of any particular intervention. As a result, the initial conversation with families can be a source of frustration for both parties, with patients and families seeking definitive answers which clinicians are unable to commit to.

As the outbreak in this haemato-oncology unit evolved, duty of candour and effective communication became more challenging. While families whose children met the outbreak case definition were spoken to, others, whose children did not develop infections, received communication in the form of written statements. As part of the outbreak communication strategy, press statements were issued to the public and on occasion were released before parents had been communicated with, causing considerable distress.

The psychological harm associated with such a prolonged incident was underestimated. Haemato-oncology patients are more susceptible to hospital-acquired infections due to both the underlying disease itself and also the treatment and presence of central lines. As such, patients and families are very aware of infection risk and will practice infection control in the home environment. They require assurances that the hospital environment is safe and that all measures have been taken to mitigate risk. Parents of children who had infections were concerned regarding repeat episodes, those whose children had not developed infections were concerned regarding the ongoing risk to their child and those of children who were outpatients were concerned about the safety of day care and clinic attendance. The need for duty of candour and effective communication becomes more crucial in such a situation. Various strategies were employed; written information continued to be provided with all inpatients being spoken to by the infection control doctor, the patients’ clinicians and a hospital manager. Outpatients were spoken to in groups and some were contacted by telephone. Later in the incident social media was used establishing a closed Facebook group. Adequate assurances regarding the environment were not sufficient and information was not considered to be open, transparent and timely. The situation was compounded with the closure of the paediatric ward and the relocation of patients into a ward within the adult hospital, one not designed with a paediatric patient and their families in mind. Further anxiety and mistrust developed following the development of further infections in this new ward setting in June 2019. Subsequently, oversight was provided by the Scottish Government and the closed Facebook site was used, with answers to parent questions publicised.

The significant learning from this incident is that patients and families should be communicated to in a timely, open, transparent fashion, with frequent updates. Information should be released ahead of and containing the media lines to avoid the anxiety of finding out via this route. Every effort should be made to provide families with assurances that control measures have been implemented and that the risk has been mitigated. Where risk remains, it must be explained along with the proposed strategy to mitigate. Duty of candour remains an underdeveloped area with respect to hospital-acquired infection incidents and further thought is required with future policy development. With respect to duty of candour, consideration must be given to what constitutes harm for the particular patient group and this should be continually reassessed during an evolving situation. Psychological harm should not be underestimated. While there may be reticence by an organisation to discuss ongoing investigations and unconfirmed hypotheses, from the experience of the lead author and IMT chair, families valued honesty and assurances that everything was being done that could be done, over any withholding of information. IMTs must develop clear communications and duty of candour strategy particularly where an incident is likely to be of a prolonged nature. Significant resource may be required and consideration should be given to a communications subgroup of the IMT.

Discretion

An important aspect within duty of candour should be the continual evaluation by those discharging their duty of the impact and implications for the patient and those acting on behalf of the patient while having an ability to apply discretion in making decisions through the use of reasoning and professional judgement. However, discretion, when applied, should be recorded to reflect such decision-making, ensuring that the risks of doing against the risks of not doing, are clearly documented with due regard to likely harm, then and in the future.

It is the case that during complex cases, the aggregated impact of physical, emotional and psychological harm may result in the patient and or family being considered too vulnerable for further information or that their emotional state renders them temporarily vulnerable. In such circumstances, it is considered prudent to consider discretionary decision-making within their statutory duty as this may alleviate further harm. This is in essence a reciprocal duty of candour, proactively protecting the patient and family until such times as they have suitably recovered, to receive the information.

If discretion has been exercised by the statutory body, with proper recording of such decision-making, including rationale for doing so, there should be further written acknowledgement of the fact that patient care was not adversely impacted and that as soon as is reasonably practicable the patient and/or their family should be advised accordingly. This will have the further safeguard of ensuring corporate knowledge among clinicians resulting in the development of corporate memory and resultant corporate approach to duty of candour, with due regard to the respect for their patient and their rights.