Focused Reflection on Candour (CPD 2024-2025)

For the 2024/25 CPD year, all registrants will be required to complete a focused reflection on their professional duty of candour. This refers to the requirement for health professionals to be open and honest with patients (i.e. people in their care) when something goes wrong with their treatment or care which causes or has the potential to cause harm or distress (Regulators Joint Statement on Candour (2014)), and directly relates to Principle B and Standard B7 in The Code (2016):

Principle B: You must act with honesty and integrity at all times and uphold high standards of professional conduct and personal behaviour to ensure public confidence in the profession. You must be guided in your behaviour and practise at all times by the principle that the health and well-being of a patient comes first. You must follow procedures set down by the regulator. 

Standard B7: Fulfil the duty of candour by being open and honest with every patient. You must inform the patient if something goes wrong with their care which causes, or has the potential to cause, harm or distress. You must offer an apology, a suitable remedy or support along with an explanation as to what has happened.

Fulfilling the duty of candour helps ensure the development of a professional culture in which safety is paramount, and openness and honesty are shared and acted on. Thus, other standards in The Code are relevant in reinforcing standard B7: 

Standard A3: Take appropriate action if you have concerns about the safety of a patient. 

Standard F1: Explore care options, likely outcomes, risks and benefits with patients, encouraging them to ask questions. You must answer fully and honestly, bearing in mind patients are unlikely to possess clinical knowledge. 

Our expectations for 2024/25

As part of your CPD return for 2024/25, the information you submit to us, by Friday 5 September 2025, must include self-reflection on your familiarity with the principles of candour, and how you integrate them into your practice. We want you to tell us how your own personal knowledge and practices could be strengthened and how you will maintain them in future.

You will be asked to consider:

Candour Guidance

You may find it helpful to refer to our Candour Guidance, which was updated in September 2023 to emphasise the importance of apology as a crucial part of candour and the fact that adverse events can apply to advice or information provided as well as injury arising from hands-on care, and to provide new advice regarding near-miss events. 

Candour Toolkit

Furthermore, the GCC Candour Toolkit includes tips for supporting candour, such as effective communication, active reflection and safety incident reporting. The toolkit includes scenarios to help you reflect on how you apply the principles of candour in your everyday clinical practice, and thereby identify where your knowledge and practices regarding candour may be strengthened.

Scenarios

To help you reflect on Candour and how it could affect your clinical practice, we have prepared the following real-life scenarios for you to consider. A new scenario will be shared in the monthly newsletter and on LinkedIn.

• Scenario 1 - "Why are you treating my left shoulder?"
• Scenario 2 - "Did I cause these bruises?"
• Scenario 3 - "I thought they looked familiar!"
• Scenario 4 - "Did my treatment cause her neck pain?"
• Scenario 5 - "Could I have spotted his cancer sooner?"
• Scenario 6 - "I could have been naked!"
• Scenario 7 - "I'm not even sure this is your hip..."
• Scenario 8 - "Did you know you had a Latex allergy?"
• Scenario 9 - "How much could they hear?"
• Scenario 10 - “I wasn’t sure if it was my place”

The Patient Advisory Panel

Some of these scenarios were also posed to a Patient Advisory Panel in September 2023 as part of a piece of a day-long in person workshop on patient expectations and experience of Candour. The Patient Advisory Panel involves a diverse group of participants to ensure that individuals are exposed to others’ views on the subject and are able to discuss the issues with people from a different background to themselves. Where patients commented on specific scenarios, their comments are also shared below.

Scenario 1 - "Why are you treating my left shoulder?"

The clinic has had a busy few weeks and filing has got a little behind. The chiropractor is running 15 minutes late when his next patient, Mr Smith, is called in for treatment. The chiropractor glances at the notes handed to him by the receptionist and sees that Mr Smith has been having treatment for left shoulder pain for 10 weeks.

The patient is in a hurry so is keen to get on with the treatment. He tells the chiropractor that he’s feeling quite a bit better but is still getting some shoulder pain first thing in the morning. After a brief examination the chiropractor starts massaging Mr Smith’s left shoulder.

The patient looks at the chiropractor a little quizzically and the chiropractor assumes this is because the shoulder is a little stiff. However, while chatting to the patient, the practitioner realises that he has been thinking about the wrong Mr Smith.

He checks the notes and realises that the notes are for Adam Smith, but the patient is Alan Smith - who has a problem with his right shoulder.

Some questions for you to consider:

1. What is important to Alan Smith (the patient being treated) here? Why?
2. What actions should the chiropractor take, if any?
   
   You could also consider:
3. What might the chiropractor say to Mr Smith if they decide to tell him they have made a mistake? Would this be the same if Mr Smith were born and brought up in England or India or Japan?
4. Under what circumstances might they decide not to say anything to Mr Smith and move onto treating his other shoulder?
5. Are there any actions that the chiropractor might take to take to identify whether there are training needs for the receptionist or changes that need to be made with respect to how they manage the keeping and administration of records?

Scenario 2 - "Did I cause these bruises?"

Mrs Ullah is a 78-year-old new patient with lower back pain which comes and goes, and suspected mild osteoarthritis. Her medical history appears unremarkable except for “a terrible memory since her husband died”, which she has a hospital appointment in the coming weeks. She is also unsure of her current medication – but promises to bring the list to the next appointment. The chiropractor advises on possible treatment side effects and, on this basis, Mrs Ullah consents to manipulation of the joints and soft tissue massage to the para spinal muscles.

At the next appointment, Mrs Ullah provides a list of medication – which includes the blood thinner warfarin (which can mean you bruise more easily). She is happy with the progress following her last treatment, but when she undresses for treatment, there is extensive bruising across her back. Mrs Ullah has not had any accidents that may explain the marks, and is unaware of it, so the chiropractor concludes it is likely that they caused this bruising at the last treatment.

Some questions for you to consider:

1. What is important to Mrs Ullah here? Why?
2. What actions should the chiropractor take, if any?
   
   You could also consider:
3. How can the chiropractor ensure that Mrs Ullah is aware of the bruising without alarming her?
4. What additional safeguards might be put in place to avoid this type of incident happening again?

Scenario 3 - "I thought they looked familiar!"

Mr MacDonald is a new patient. While the chiropractor is examining him, Mr Macdonald mentions in passing that he recognised a patient in the waiting room. It then emerges that Mr MacDonald saw the chiropractors schedule on the computer, and it was only then that he remembered the other patient’s name and where he knew them from. Mr MacDonald said: “I thought they looked familiar and now I know why!”

The chiropractor is horrified that he hadn’t locked the computer while he left the room for Mr MacDonald to get changed. He tells Mr MacDonald that the patient records are confidential, and he shouldn’t have seen them. They ask the new patient not to mention the other patient’s name to anyone.

Some questions for you to consider:

1. What is important to each of the patients involved in this scenario?
2. What should the practitioner do in terms of the patient whose name was left visible? Would it make a difference if Mr MacDonald saw his notes as well as his name?

You could also consider:

1. Would it make a difference if both patients knew each other by name?
2. Would it make a difference if Mr MacDonald recognised the patient because of their public profile (sportsperson, politician or celebrity for instance?).
3. Would your views be different if the data breach had happened in a public place (notes left on a train for instance?).

Scenario 4 - "Did my treatment cause her neck pain?"

Rebecca, a new patient with acute low back pain, is seen by a chiropractor who assesses the issue as musculoskeletal and likely to be resolved quickly. As part of their general discussion the chiropractor mentions that treatment can sometimes result in post-treatment soreness or a worsening of symptoms for a while, and Rebecca consents to treatment. As well as treating the low back area, the chiropractor checks the patient’s upper back and neck. Although this area isn’t painful, there are some tender areas in the neck, and the chiropractor suggests some treatment. Rebecca consents to treatment of the neck and the chiropractor uses a combination of deep massage on the muscles around the base of the neck with an attempted manipulation of two vertebral segments between the shoulder blades, which causes Rebecca some discomfort.

Two weeks later Rebeccas’s low back pain has improved significantly, however Rebecca experienced considerable neck pain and headaches shortly after the first session, prompting a GP visit. Both the patient and the GP think that the neck pain is probably a result of the low back problem, with the body trying ‘to sort itself out’. The chiropractor, however, wonders whether the first treatment actually caused the neck problem. The patient doesn’t blame the chiropractor at all. The neck symptoms are now easing somewhat, and they have come for the follow up session hoping now to focus on the neck.

Some questions for you to consider:

1. What is important to Rebecca in this scenario?
2. Should the chiropractor discuss their concerns that the new symptoms may be a result of the treatment?
3. What factors should the chiropractor consider in their decision making?

Scenario 5 - "Could I have spotted his cancer sooner?"

Ade is a 70 year old black man who has been seeing his chiropractor regularly over the last 6 months. He enjoys coming to see the chiropractor, in part because he is rather lonely. He often talks about his working days as a labourer and the chiropractor thinks that he is mildly depressed.

Ade has dull aching pains in his back and ribs, which are worse on movement. He has also complained of being tired and lethargic, which the chiropractor blamed on his low mood and low levels of activity. Ade himself blames his weakness and low energy on the series of minor infections he has been suffering. He is very much hoping to be able to visit family in Nigeria later in the year and he feels sure some “proper” weather and good food will make him feel better.

During a Continuous Professional Development session in which the chiropractor is refreshing their knowledge of blood cancer, they have a sinking feeling as they realise that Ade looks like a “classic case”. When they get back to work, they get out Ade’s notes and read through the initial case history: they find that during the general history, Ade also described being troubled with nose bleeds, feeling sick, as well as constipation and headaches.

Ade’s symptoms fall into place – the chiropractor is now sure Ade has cancer. While they can see why what Ade described might have been interpreted differently, they feel now that they have made a mistake in not referring Ade back to his GP at the initial consultation.

The chiropractor rings Ade and tells him to see his GP for some more tests. Ade is pleased that they have rung and even more pleased that the chiropractor has offered to write to his GP outlining their concerns, as he always feels a bit rushed at the GP’s. After some weeks Ade comes back into the clinic and confirms he has been diagnosed with blood cancer.

Some questions for you to consider:

1. What is important to Ade in this scenario and why?
2. What actions should the practitioner take, if any?

You may also wish to consider:

1. Although there is no indication that Ade is anything other than pleased with the chiropractor's care, the chiropractor feels that the diagnosis could have happened much sooner. What are the arguments for and against contacting Ade to tell him that they think they made a mistake in the management of his care?
2. What factors or principles should inform the chiropractor's course of action?

Scenario 6 - "I could have been naked..."

August is a long-established patient who is very particular about his appointments every month and likes everything to be “just so”. The chiropractor and August have developed a great rapport and joke with each other about “him being very set in his ways”.

At the beginning of each appointment the chiropractor shows August into the treatment room, then leaves to allow him to remove his shirt. August has arthritis in his hands which affects his fine motor skills and so can take a while to unbutton and remove his shirt.

After a minute or so, the chiropractor will knock on the door. If he is ready August will grandly reply “enter” and the chiropractor will come back into the room and start the assessment.

Sam is a new clinic receptionist who is very eager to help, but still learning the ropes and has not yet encountered August.

On the day of August’s appointment, the chiropractor has had back-to-back appointments. While August is removing his shirt in the treatment room, the chiropractor takes the opportunity to go to the toilet.

When they return, August is half undressed, and angrily shouting at Sam in the treatment room.

It transpires that Sam had knocked on the door and then, after not receiving a reply, opened the door to deliver some clinical notes. Sam had not realised that August was alone in the room because ordinarily the chiropractor will wait outside the door when there is a patient changing inside.

Some questions for you to consider:

1. Does the Duty of Candour apply in this scenario?
2. What actions should the chiropractor take, if any?

You may also like to consider:

1. What additional safeguards could be put in place to avoid this type of incident happening again?
2. Would it make a difference if August hadn’t realised Sam had entered the room?
3. What if Sam had admitted his mistake after August had left the building after his appointment?

Scenario 7 - "I'm not even sure this is your hip..."

Mary is a new patient who is reporting a lot of pain in her left hip and upper leg following a fall. She is struggling to bear weight on the leg and the chiropractor suspects that she may have a fractured hip.

After discussing options with Mary, the chiropractor decides that the most appropriate action is to refer her for an X-ray of her hip at a local private hospital. The chiropractor sends the referral, and the X-ray is arranged for a couple of days time.

Later that week, the chiropractor receives an X-ray image from the hospital, but it is very definitely not an image of Mary’s left hip. The X-ray is of a woman’s right hip, and the chiropractor is not convinced that the image is even of Mary. The hospital has very clearly made a mistake.

Some questions for you to consider:

1. What is important to Mary in this scenario and why?
2. What actions should the chiropractor take, if any?
3. Who is responsible for the Duty of Candour in this scenario? Is it the chiropractor, or the hospital?

You may also like to consider:

1. How would the approach be different if the hospital had accidentally sent the wrong image? Or if the hospital had taken an image of the wrong hip?
2. How would the chiropractor's approach change if the hospital argued that a mistake on the referral paperwork had led to the wrong hip being imaged?

Scenario 8 - "Did you know you have a latex allergy?"

Alesha is an active woman in her 30s who regularly receives chiropractic care. At her latest appointment, she shares that she is experiencing some stiffness in the back of her thigh which the chiropractor believes could be treated with dry needling.

Alesha has not had dry needling before, but they discuss the risks and what to expect and Alesha agrees. The chiropractor treats the area and Alesha is initially very pleased with the relief it provides. However, thirty minutes after the end of the appointment Alesha is back in the reception furiously rubbing the back of her thigh. It is swollen, red and itchy.

The chiropractor realises Alesha has had an allergic reaction to the latex gloves they wore while performing the dry-needling. Although Alesha had consented to the dry needling, the chiropractor had not mentioned that they would be wearing latex gloves (they usually treat with bare hands).

The chiropractor checks the case history questionnaire that Alesha completed before her first appointment two years ago and, under allergies, she has written “none”.

Some questions for you to consider:

1. What is important to Alesha here? Why?
2. What actions should the chiropractor take, if any?
3. How can the chiropractor explore with Alesha if she is aware of having a latex allergy, without appearing to blame her for not declaring it?

You may also like to consider:

1. While Alesha’s allergic reaction is mild, in serious cases latex allergy can cause anaphylaxis. If Alesha did not realise she has a latex allergy, how can the chiropractor direct her to further information without causing her further concern?
2. What additional safeguards might be put in place to avoid this type of incident happening again?
3. This incident could be described as a safety incident under standard B4 of the Code of Professional Practice (in effect from 1 January 2026). What extra steps could the chiropractor consider so that the wider profession can learn from it?

Scenario 9 - "How much could they hear?"

On a particularly warm afternoon, a chiropractor opens the treatment room window to let in some fresh air. Just outside the window is the clinic’s small, shared waiting area, where the next patient is seated, waiting for her appointment.

At the start of her consultation, the patient casually mentions that she could hear parts of the previous appointment while waiting. She makes the comment lightly, with no sign of concern, but it catches the chiropractor off guard.

The previous consultation had included sensitive health discussions. While no names were used, some of the details might have made the patient identifiable — especially if the individuals know each other or live locally.

Some questions for you to consider:

1. Does the Duty of Candour apply in this scenario?
2. What actions should the chiropractor take, if any?
3. Should the chiropractor inform the previous patient that their consultation may have been overheard?
4. Would this be different if the patient had only overheard gasps and treatment noises (not words) from the previous patient?

Scenario 10 - "I wasn't sure it was my place"

Aidan, a chiropractor in a shared clinic space, has noticed over several weeks that one of his regular patients, Sam, seems increasingly withdrawn and fatigued. At today's appointment, Sam appears visibly unkempt and mentions he’s been “feeling low and barely eating.” 

During the consultation, Aidan gently asks if everything is okay. Sam shrugs it off, saying, “Just one of those times, I suppose.” Aidan feels concerned, especially as Sam also mentions missing work and losing interest in hobbies, signs Aidan recognises could indicate a decline in mental health. 

He considers whether to raise it more directly or signpost Sam to his GP but hesitates. He worries it may feel intrusive or beyond his remit as a chiropractor. In the end, he says nothing. 

Later, Aidan reflects on the encounter and wonders whether his silence, though well-intended, missed an important opportunity to act in the patient’s best interests. 

Some questions for you to consider:

1. What signs of potential risk did Aidan observe, and what action could he have taken? 
2. Does concern for patient safety extend beyond physical health? How? 
3. How can chiropractors approach sensitive topics like mental health while remaining professional and supportive? 
4. What systems or protocols could support Aidan in knowing when and how to act?