Healthcare delivers a range of complex interactions between people, skills, technologies and drugs.
Sometimes things can go wrong and they do go wrong. Based on available information and research it is estimated at about 10 per cent of patients admitted to hospitals in this country and more in countries in the developing world will be unintentionally the victim of an error.
There is huge human and financial cost to the NHS from such incidents in financial terms. Mid Yorkshire Hospitals Trust pays out about £10m in compensation alone through the NHS Litigation Authrotiy.
Besides this there is the cost of increased bed occupancy, cost of treatment and there is a cost in terms of human life.
Most of these unintentional errors do not cause any harm to the patient (70 per cent or so), but some cause low (30 per cent), moderate (7.5 per cent), severe harm (0.1 per cent) or death (0.1 per cent).
Sometimes when an error happens the provider of services fails to inform the patient if their safety has been compromised and try to cover up their mistakes.
To prevent this cover-up new rules to toughen up transparency in NHS organisations and increase public confidence were introduced in early 2013 following a public consultation by the department of health. This resulted in regulations that required NHS England to include a contractual duty of candour in all commissioning contracts from April 2013.
This means NHS organisations will be required to tell patients if their safety has been compromised, apologise and ensure that lessons are learned to prevent them from being repeated.
For the sake of clarity, further guidance has now been published, and annexe four of the 2013-14 NHS Standard Contract Technical Contract Guidance in implementing the contractual requirement relating to duty of candour states that the contractual duty applies to incidents which result in moderate harm, severe harm and death.