Care Quality Commission prosecutes University Hospitals Plymouth NHS Trust for breaching duty of candour regulation following patient death

Published: 23 September 2020 Page last updated: 23 September 2020

University Hospitals Plymouth NHS Trust has been ordered to pay a total of £12,565 after admitting it failed to disclose details relating to a surgical procedure or apologise, following the death of a 91-year-old woman.

The trust was fined £1,600, a £120 victim surcharge and ordered to pay £10,845.43 court costs at Plymouth Magistrates’ Court today (Wednesday, 23 September), in the first prosecution of its kind.

The Care Quality Commission (CQC) brought the prosecution after it emerged that the trust failed to share details of what happened to Elsie Woodfield prior to her death at Derriford Hospital, in Plymouth, following an unsuccessful endoscopy procedure. The trust also failed to apologise to Mrs Woodfield’s family within a reasonable timeframe.

Under the Health and Social Care Act, duty of candour (Regulation 20), care providers must act with openness and transparency, and provide a timely apology to people receiving care, or their relatives, in the event of a serious incident.

Mrs Woodfield suffered a perforated oesophagus during an endoscopy in December 2017. As a result, the procedure was abandoned, and Mrs Woodfield was transferred to the hospital’s Marlborough Ward for observations. While there she collapsed and later died.

Following the operation, it was found that the trust had not communicated what had happened with the pensioner’s family in an open and transparent way, nor had it apologised for what had happened to her in a timely way.

Nigel Acheson, Deputy Chief Inspector of Hospitals, said:

“All care providers have a duty to be open and transparent with patients and their loved ones, particularly when something goes wrong, and this case sends a clear message that we will not hesitate to take action when that does not happen.

“Sadly, Mrs Woodfield’s family received neither a prompt apology nor full explanation regarding the tragic events that took place prior to her death. University Hospitals Plymouth NHS Trust was not transparent or open with regards to what happened and it did not apologise to Mrs Woodfield’s family in a timely way.

“Patients and their families are entitled to the truth and a formal written apology as soon as is practical after a serious incident, and the University Hospitals Plymouth NHS Trust’s failure to fulfil this duty is why CQC took this action.

“This is the first time CQC has prosecuted an NHS trust for failure to comply with the regulation concerning duty of candour, and we welcome the outcome of today’s hearing.”


For media enquiries, contact Louise Grifferty, Regional Engagement Manager, on 07717 422917 or call the press office on 020 7448 9401 during office hours. Journalists wishing to speak to the press office outside of office hours can find out how to contact the team here. (Please note: the duty press officer is unable to advise members of the public on health or social care matters).

For general enquiries, please call 03000 61 61 61.

About the Care Quality Commission

The Care Quality Commission (CQC) is the independent regulator of health and social care in England.

We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve.

We monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and we publish what we find to help people choose care.