38.2 Breaking Bad News, Complaints and the Duty of Candour

Difficult Conversations Are Examinable

Preparing for Practice outcome 3.1 specifically names "difficult circumstances, such as breaking bad news, or discussing issues such as alcohol consumption, smoking, or diet". GDC Standards Principle 5 requires a clear and effective complaints procedure, and Principle 1.9 embeds the duty of candour.

Breaking Bad News

The most widely taught structure is SPIKES:

In dentistry this framework applies to a suspected malignancy referral, a poor prognosis for a heavily restored dentition, informing a patient of a permanent nerve injury, and telling a parent that extraction under general anaesthesia is needed.

A specific trap is the suspected cancer referral. The patient must be told honestly why they are being referred urgently. Saying only "it is probably nothing" removes the patient's ability to make an informed decision about attending, and it destroys trust if the diagnosis is confirmed. The proportionate wording acknowledges that most such lesions are not cancer while explaining that the possibility must be excluded quickly.

The Duty of Candour

The professional duty of candour, set out jointly by the GDC and the other healthcare regulators, requires registrants who become aware that something has gone wrong to:

1. Tell the patient or their advocate promptly when something has gone wrong.
2. Apologise — an apology is an expression of regret, not an admission of legal liability, and is expressly protected.
3. Offer an appropriate remedy or support to put matters right where possible.
4. Explain fully the short-term and long-term effects of what has happened.

There is also a statutory duty of candour applying to registered providers in England under CQC regulation, which is triggered by notifiable safety incidents and requires written follow-up.

The candour duty applies to near misses and to errors made by others that the registrant becomes aware of. Concealment is treated far more seriously by the GDC than the original error, and dishonesty in relation to a clinical mistake is one of the most reliable routes to erasure.

Handling Complaints

GDC Standards Principle 5 requires that every practice has a written complaints procedure, that patients are told how to complain, and that complaints are handled promptly and courteously.

A workable structure:

1. Acknowledge in writing, normally within three working days.
2. Investigate — review the records, speak to the staff involved, and establish the facts.
3. Respond substantively within the timescale published in the practice policy, explaining what happened, what has been learned and what will change.
4. Signpost to the next stage if the patient remains dissatisfied — the NHS complaints procedure and the Parliamentary and Health Service Ombudsman for NHS treatment in England, or the Dental Complaints Service for private treatment.
5. Learn — complaints are a governance data source and should feed into significant event analysis and audit.

A defensive, legalistic first response is the most reliable way to escalate a complaint into a GDC referral or a civil claim. Most patients who complain want an explanation, an apology and assurance that the same thing will not happen to someone else.

Exam link. A stem describing a clinician who instruments beyond the apex and does not tell the patient is testing the duty of candour. The expected answer is prompt disclosure, an apology, an explanation of the consequences and an offer of remedy, together with a record of the conversation — not silent monitoring.

The Statutory and Professional Framework

The duty of candour exists in two forms that candidates must distinguish. The professional duty of candour applies to every individual registrant under the GDC's standards and the joint statement of the UK healthcare regulators: when something goes wrong, you must tell the patient, apologise, offer an appropriate remedy and explain fully and promptly what happened and the likely effects. The statutory duty of candour applies to registered providers — the practice, not the individual — under the relevant regulations, and is triggered by a notifiable safety incident, requiring a written notification and record in addition to the verbal apology.

Two points are reliably examined. First, an apology is not an admission of legal liability, and both the regulators and the indemnity organisations encourage prompt apology; withholding one for fear of litigation is wrong. Second, candour applies whether or not the patient has noticed the error — the trigger is the harm or potential harm, not the complaint.

Handling Complaints Properly

Practices must have a written complaints procedure that is accessible and publicised, that acknowledges a complaint promptly, investigates it fairly, responds within the stated timescale, explains the outcome, and tells the complainant how to escalate — to NHS England or the relevant commissioner for NHS treatment, to the Dental Complaints Service for private treatment, and ultimately to the Parliamentary and Health Service Ombudsman. Complaints are a source of learning: they should be recorded, reviewed and fed into significant event analysis and audit, and the GDC expects registrants to reflect on them.