Duty of Candour

About Penumbra Mental Health 

Penumbra Mental Health is a charity that in 2023-24 supported 17,755 people, and currently employs around 600 staff across Scotland. 

Penumbra Mental Health has a comprehensive policy framework that guides our work to ensure we work safely, effectively and with transparency.

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 an assurance the organisation will learn from the situation.

We are committed to activating 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 of services by Penumbra Mental Health;
  • And that, 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.

Penumbra has a statutory duty to report if we have had any incidents which met the Duty of Candour reporting requirements under the Health (Tobacco, Nicotine etc and Care) (Scotland) Act 2016.  These ensure all organisations providing care services are open and transparent if a serious situation occurs which causes harm.  The report below covers the period of 1st April 2023 to 31st March 2024. We are encouraged to note that no situations occurred in this timeframe which met these criteria.  More detail of this is provided below.


All health and social care services in Scotland must provide an annual Duty of Candour report for their organisation.  The information contained in our report is also shared with the Care Inspectorate, who are the regulator for many of our services.


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 0
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 01/04/23 - 31/03/24 zero (0) incidents triggered Duty of Candour

Our Policy and Procedure

If an incident occurs that would meet the criteria above, our staff report this this using our dedicated incident reporting database, which includes a section to identify duty of candour events.  In the case of a Duty of Candour triggering incident, this would generally be investigated by a senior manager not directly associated with the service.  All our incidents are reviewed by our Director of Services who ensures all appropriate actions have been completed before closing the incident process.  If such an incident occurs within a Care Inspectorate registered services, the relevant registered manager shall report it immediately to the Care Inspectorate. 

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 may arise from staff misconduct or negligence, appropriate actions under our disciplinary policy are immediately instigated. 

What have we learned?

We are encouraged that we have not had any incidents which met the threshold of Duty of Candour reporting in 2023-24.  However, we emphasise a learning culture and both our quality systems, and our boards People, Quality and Improvement sub-committee regularly review data and learning from incidents in order to ensure we are constantly striving to reduce the risk of unintended negative consequences from our work.

If you would like more information about this report, please contact our Head of Innovation and Improvement, Stephen Finlayson.


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