Duty of candour procedure checklist

Source anchors

How to use this checklist

Use this checklist to audit whether the service can show a clear duty of candour trail after incidents: threshold decision, verbal notification, apology, written follow-up, support, linked records and learning. It can be used after a serious incident, quarterly, before governance review, or before an inspection-readiness review.

Regulation 20 uses a specific notifiable safety incident threshold, and that threshold differs by provider type. Check the current Regulation 20 wording and apply the correct threshold for the service.

For each row, record:

Met: evidence is current and complete.
Part met: evidence exists but has a gap or needs follow-up.
Not met: evidence is absent or the control is not working.
Not applicable: the service does not carry out this activity.

Every Part met or Not met item should create an action with an owner and due date.

The PDF is designed for printing, or for completing on screen with a PDF viewer's Fill & Sign, Markup or comment tools. Use those tools to tick boxes and type into the lines.

Service details

Field	Local entry
Service name
Location
Date completed
Completed by
Registered Manager
Candour Lead
Provider type threshold used
Period reviewed

1. Local threshold and roles

Check	Evidence to review	Status	Action owner	Due date
The service has identified the Regulation 20 threshold that applies to its provider type.	Procedure, legal source check, governance record.
Registered Manager sign-off route is clear.	Procedure, role list.
Candour Lead or Governance Lead is named.	Role list, procedure.
Clinical or care harm-review route is clear.	Incident procedure, clinical lead role.
Staff know which incidents to escalate for threshold review.	Staff interview, induction record.
Written follow-up template and review route exist.	Template, procedure, reviewer list.

2. Incident screening and threshold decision

Check	Evidence to review	Status	Action owner	Due date
Incidents involving harm or possible harm are screened for duty of candour.	Incident sample, candour decision.
Threshold decision records provider type and source checked.	Decision note, source reference.
Harm known at the time is recorded clearly.	Incident record, clinical review.
Borderline or serious cases have senior review.	Registered Manager review, clinical lead note.
Threshold decisions are reviewed if new harm information emerges.	Update note, supplementary decision.
Not-opened decisions explain why the threshold was not met.	Not-opened sample, incident closure.

3. Relevant person and support

Check	Evidence to review	Status	Action owner	Due date
Relevant person is identified and authority is recorded where needed.	Candour record, consent or representative note.
Capacity, consent or bereavement considerations are recorded where relevant.	Capacity note, family contact note.
Communication needs and reasonable adjustments are recorded.	Accessible-information record, support note.
Support is offered to the person or representative.	Conversation note, support referral.
Preferred route for written follow-up is recorded.	Candour record, contact preference.

4. Verbal notification

Check	Evidence to review	Status	Action owner	Due date
Verbal notification happened as soon as reasonably practicable.	Candour timeline, conversation note.
Conversation included what is known and what is still being investigated.	Conversation note.
Apology was given and recorded.	Conversation note, wording.
Immediate action and next steps were explained.	Conversation note, action plan.
Questions or response from the relevant person were recorded.	Conversation note, follow-up record.
Reason is recorded if verbal notification could not be completed.	Exception note, senior review.

5. Written follow-up

Check	Evidence to review	Status	Action owner	Due date
Written follow-up was sent as soon as reasonably practicable after the verbal notification.	Letter copy, send date, timeline.
Written follow-up reflects the conversation and includes an apology.	Letter copy, review note.
Further enquiries, findings or next update plan are explained.	Letter copy, investigation update.
Written follow-up was reviewed before sending where risk was serious or complex.	Reviewer note, sign-off.
Evidence of sending is stored.	Email confirmation, postal record, handover signature.
Supplementary written updates are sent if material information changes.	Update letter, supplementary note.

6. Linked records and learning

Check	Evidence to review	Status	Action owner	Due date
CQC statutory notification is opened or ruled out separately.	Notification record, decision note.
Complaint, safeguarding, coroner, police or commissioner routes are considered where relevant.	Linked records, decision note.
Improvement actions have owners and due dates.	Action log, improvement record.
Incident investigation learning is linked to the candour record.	Investigation report, governance action.
Closure states what was done and what remains open elsewhere.	Closure note, cross-links.

7. Governance and training

Check	Evidence to review	Status	Action owner	Due date
Duty of candour records are reviewed at governance.	Governance minutes, candour report.
Review includes threshold decisions, verbal timing, written timing and apology quality.	Audit report, sample review.
Staff awareness training is current.	Training matrix, induction record.
People delivering conversations have deeper communication training.	Training record, role profile.
Repeated incident themes are escalated to risk, audit or improvement action.	Risk register, audit plan, action log.

8. Summary judgement

Question	Answer
Does the service know which Regulation 20 threshold applies?
Which incident in the last 12 months had the strongest candour trail?
Which threshold decision would be hardest to defend?
Which written follow-up still lacks evidence of sending?
What would a CQC inspector see if they asked for candour evidence today?

9. Action log

Action	Source check	Owner	Due date	Completion evidence

10. Completion

Sign-off	Name	Date
Completed by
Reviewed by Registered Manager

This checklist is a working tool. It does not replace live regulator guidance, the service's own incident procedure, professional advice, legal advice or clinical judgement.