Duty of Candour

About Penumbra Mental Health 

This report describes how Penumbra Mental Health has implemented Duty of Candour throughout the period of 1 st April 2022 to 31st March 2023. 

Penumbra Mental Health is a charity that supports around 6000 adults and young people every week and employ around 500 staff across Scotland. 

Penumbra Mental Health has a comprehensive policy framework that provides guidance to our staff linked
to the following areas: 

• Organisational
• Services and Supported People
• Human Resources

Our Duty of Candour policy is contained within this framework and is available to all staff. Our staff members also receive training in Duty of Candour, its purpose and responsibilities.

Duty of Candour

Duty of Candour is a legal requirement to ensure that if something goes wrong in health or social care services the people affected are offered an explanation, an apology and an assurance that staff will learn from the error. The learning is shared with the people affected and throughout Scotland.

We must activate the duty of candour procedure as soon as reasonably practicable after becoming aware that:

• an unintended or unexpected incident occurred in the provision of the health, care or social work service provided by the organisation as the responsible person;

• in the reasonable opinion of a registered health professional (means a member of a profession to which section 60(2) of the Health Act 1999 applies) not involved in the incident:

(a) that incident appears to have resulted in or could result in any of the outcomes outlined in the table below; and

(b) that outcome relates directly to the incident rather than to the natural course of the person’s illness or underlying condition.


All health and social care services in Scotland must provide an annual Duty of Candour report for their service. Our report is outlined below. The information contained in this report is also shared with our regulator (Care Inspectorate).


Type of unexpected or unintended event Number of times this happened
Someone has died 0
Someone has permanently less bodily, sensory, motor, physiological or intellectual functions 0
Someone's treatment has increased because of harm 1
The structure of someone's body changes because of harm 0
Someone's life expectancy becomes shorter because of harm 0
Someone's sensory, motor or intellectual functions is impaired for 28 days or more 0
Someone experiences pain or psychological harm for 28 days or more 0
A person needed health treatment in order to prevent them dying 0
A person needing health treatment in order to prevent other injuries 0
During the period 01/04/22 - 31/03/23 one (1) incidents triggered Duty of Candour

Our Policy and Procedure

When an incident occurs that necessitates the implementation of Duty of Candour, our staff report this to their line manager and to the Director of Services & Innovation who oversees the service we provide. The incident is recorded and the Registered Manager completes the Care Inspectorate reporting e-form.

Penumbra’s Accident & Incident Monitoring Form and Practice Reflection Tool from our Supervision Toolkit highlights the learning needed as a result of the incident and any specific staff team learning necessary.

Our external confidential, Employee Assistance Programme is available to all staff at any time but if Duty of Candour is triggered it is emphasised to staff that this is available. Senior management meet with staff to provide support and emphasise this is about learning and improving not blame.

Where the incident arises from staff wrong doing our disciplinary process is immediately put in place. 

What have we learned?

Although our actions in the incident recorded above did not directly cause harm to a person, they contributed to the circumstances in which harm occurred. We therefore applied the Duty of Candour process and have reviewed our processes in accordance with our policies and procedures.

If you would like more information about this report, please contact our Director of Programmes


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