Is an apology an admission of liability?

No. Paragraph 14 of the GMC and NMC professional duty of candour guidance states that apologising to a patient does not mean you are admitting legal liability, and Regulation 20(7) defines an apology simply as an expression of sorrow or regret in respect of a notifiable safety incident.

What counts as a notifiable safety incident under Regulation 20?

For a health service body, Regulation 20(8) defines it as any unintended or unexpected incident during a regulated activity that, in the reasonable opinion of a healthcare professional, could result in, or appears to have resulted in, death directly related to the incident, severe harm, moderate harm or prolonged psychological harm.

Who should hold the candour conversation?

Paragraph 9 of the professional duty of candour guidance says the most appropriate team member will usually be the lead or accountable clinician. An SHO should be present, honest and involved, but a serious complication is disclosed by the consultant responsible for the patient.

What are the six steps of SPIKES?

Setting, perception, invitation, knowledge, emotions, and strategy and summary. Baile and colleagues published the protocol in The Oncologist in 2000 as a six-step method for delivering bad news, and it provides the running order for a candour conversation.

Do you have to tell a patient about a near miss?

Paragraph 20 of the professional duty of candour guidance defines a near miss as an adverse incident that had the potential to cause harm but did not, and says you must use professional judgement about telling the patient, doing so where they need or would want to know. Near misses must still be reported within the organisation.

What must the written notification under Regulation 20 contain?

Regulation 20(4) requires a written notification containing the information given in person, the results of any further enquiries, and an apology. CQC's Regulation 20 guidance, updated 16 May 2025, lists the same requirement together with keeping a written record of all correspondence.

What is the difference between moderate and severe harm in the Regulations?

Regulation 20(7) defines moderate harm as harm that requires a moderate increase in treatment and significant but not permanent harm, and severe harm as a permanent lessening of bodily, sensory, motor, physiologic or intellectual functions directly related to the incident and not to the natural course of the illness.

Duty of Candour: CST Interview Management Station Answer

Disclosing a complication means telling the patient what happened, apologising, putting right what can be put right, and explaining the effects, and doing it promptly and in person. That is the professional duty of candour in the joint GMC and NMC guidance. Above it sits the statutory duty on the organisation, Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, enforced by the CQC. The CST management station tests whether you can hold the conversation and whether you know which duty is whose.

Key takeaways

The GMC and NMC professional duty of candour guidance, paragraph 1, requires every healthcare professional to tell the patient when something has gone wrong, apologise, offer an appropriate remedy or support, and explain fully the short and long term effects.
Paragraph 14 of the same guidance states that apologising to a patient does not mean you are admitting legal liability.
Regulation 20(1) of the 2014 Regulations requires registered persons to act in an open and transparent way, and 20(2) and 20(3) require notification in person, as soon as reasonably practicable, with a true account and an apology, followed by a written notification.
Regulation 20(8) defines a notifiable safety incident for a health service body as an unintended or unexpected incident that could result in, or appears to have resulted in, death, severe harm, moderate harm or prolonged psychological harm.
Regulation 20(7) defines an apology as an expression of sorrow or regret, and prolonged psychological harm as harm experienced, or likely to be experienced, for a continuous period of at least 28 days.
SPIKES, published by Baile and colleagues in The Oncologist in 2000, is a six-step protocol for the conversation itself: setting, perception, invitation, knowledge, emotions, strategy and summary.

What is the principle behind the duty of candour?

The principle is that patients are owed the truth about their own care, quickly and without being asked, and that saying sorry is part of care rather than a legal risk.

The GMC and NMC guidance on the professional duty of candour, paragraph 2, states that as a doctor, nurse or midwife you must be open and honest with patients, colleagues and your employers.

RCS Good Surgical Practice, section 2.5, states that surgeons must inform patients promptly and openly of any significant harm that occurs during their care, whether or not the information has been requested.

That last clause matters at the CST interview: candour is proactive. Waiting to be asked is a failure of the duty, not a neutral choice.

What is the difference between the professional and the statutory duty?

The professional duty of candour binds you as an individual registrant; the statutory duty in Regulation 20 binds the organisation registered with the CQC, and it has defined harm thresholds and a written-notification step.

Regulation 20(1) states that registered persons must act in an open and transparent way with relevant persons in relation to care and treatment. Regulation 20(2) requires action as soon as reasonably practicable after becoming aware of a notifiable safety incident.

Regulation 20(3) requires the notification to be given in person, to include a true account of all the facts as known, advice on what further enquiries are appropriate, and an apology, and to be recorded in writing.

Regulation 20(4) requires a written notification afterwards containing the same information and the results of further enquiries. CQC's guidance page on Regulation 20, updated 16 May 2025, lists the same steps.

Regulation 20(7) defines the terms. Moderate harm is harm requiring a moderate increase in treatment and significant but not permanent harm. Severe harm is a permanent lessening of bodily, sensory, motor, physiologic or intellectual functions related directly to the incident.

What does the professional duty require you to do, step by step?

The professional duty of candour guidance sets out four actions in paragraph 1 and then explains how to apologise well in paragraphs 13 to 16.

Tell the patient, or where appropriate their advocate, carer or family, when something has gone wrong
Apologise to the patient
Offer an appropriate remedy or support to put matters right, if possible
Explain fully the short and long term effects of what has happened

Paragraph 9 states that once you realise something has gone wrong, and after doing what you can to put it right, you or someone from the team must speak to the patient, usually the lead or accountable clinician.

Paragraph 13 states that patients expect three things from an apology: what happened, what can be done to deal with any harm, and what will be done to prevent someone else being harmed.

Paragraph 15 states that you are not expected to take personal responsibility for a system failure or a colleague's mistake, but the patient still has the right to an apology from the most appropriate team member. Paragraph 16 asks you to record the apology in the clinical record.

What is SPIKES and how does it fit the conversation?

SPIKES is the six-step protocol for breaking bad news published by Baile and colleagues in The Oncologist in 2000, and it gives the candour conversation its running order.

Setting: a private room, sitting down, the right people present, bleep handed over
Perception: find out what the patient already understands about what happened
Invitation: ask how much detail they want now; paragraph 12 of the candour guidance says patients may choose not to hear every detail
Knowledge: give a warning shot, then the facts in plain words, in small pieces
Emotions: name and respond to the reaction before giving more information
Strategy and summary: what happens next, who they can contact, and a written follow-up

In practice, the apology sits inside the knowledge step and again at the end. Baile's paper reports that clinicians taught the protocol felt more confident disclosing unfavourable information, which is the point of rehearsing it.

How would a worked scenario run in the station?

A typical CST scenario: a swab count was recorded as correct, but a day-three X-ray for pyrexia shows a retained swab and the patient needs a second operation. The consultant asks you to be present when she tells the patient.

Step one: make the patient safe and gather the facts

Treat the sepsis, book the theatre, and get the facts straight before the conversation: what the X-ray shows, what the count said, what will happen next. Do not speculate about whose fault it was.

Step two: hold the conversation with SPIKES

The consultant leads because paragraph 9 of the candour guidance points to the accountable clinician. You sit in, take notes, and help with the follow-up. The apology is personal: I am sorry this has happened to you.

Step three: report and record

A retained foreign object after a procedure is a Never Event on the NHS England list, so it is also a notifiable safety incident under Regulation 20 and triggers the organisation's written notification. Complete the incident report and record the conversation and apology in the notes.

Step four: follow up

Tell the patient who their contact is, when they will hear the results of the investigation, and where independent support such as the patient advice service is. Reflect on the case for your own portfolio.

What is the interviewer listening for?

The CST panel listens for the four professional duties said as a list, the statutory thresholds said as definitions, and an apology given without hedging.

Patient safety first, then the conversation, then the paperwork
The professional duty of candour named as GMC and NMC guidance, with its four actions
Regulation 20 named, with the notifiable safety incident thresholds of death, severe harm, moderate harm and prolonged psychological harm
The sentence that an apology is not an admission of legal liability, from paragraph 14
A structured conversation: SPIKES named and used
Documentation, incident reporting and a named contact for the patient

What is the trap in this question?

The trap is refusing to apologise for fear of liability, or apologising for something you have not yet understood.

Paragraph 14 of the candour guidance answers the first fear directly: apologising does not mean admitting legal liability, and a fitness to practise panel may view an apology as evidence of insight.

The second failure is speculation. Paragraph 3 of the same guidance frames candour as sharing what you know and believe to be true; guessing at causes before the investigation misleads the patient and may be wrong.

A third trap is holding the conversation alone as an SHO when the accountable clinician should lead. Being present and honest is right; being the sole voice on a serious complication is usually not.

What is the escalation route?

Escalate to the consultant responsible for the patient, who owns the candour conversation for a serious incident, and to the trust's incident-reporting and governance process, which owns the Regulation 20 written notification.

Paragraphs 22 to 33 of the candour guidance cover the organisational duty: report adverse incidents that lead to harm and near misses, so the organisation can learn. Paragraph 20 states that you must use professional judgement about telling patients of near misses that caused no harm.

For a Never Event, the NHS England policy also requires a full investigation under the national incident framework, so the escalation route runs beyond the ward to the patient safety team.

How does candour link to the portfolio domain?

Candour links to the CST portfolio through the Quality Improvement and Clinical Audit domain, because an incident you were involved in disclosing is the strongest possible reason for the audit or QI project that follows it.

NHS England's 2025/26 CST portfolio guidance grades level A as leading all aspects of a surgically themed audit or QI project that demonstrated change, and a count-compliance or consent-documentation project born from a real incident tells that story with evidence.

It is also a truthful answer to the reflective question about a time something went wrong.

How this comes up at the CST interview

The candour scenario appears at the CST interview either as a role-play of the conversation or as a management question about what the duty requires, and often as both in one station.

Practise the four professional actions and the Regulation 20 thresholds until they are automatic, and practise saying sorry aloud without qualifiers. coresurgeryinterview has a scored candour scenario in its 299-question bank with AI-marked spoken practice: /Question-Bank/Sample-Questions.

Breaking Bad News and Disclosing Complications: Duty of Candour