The human rights commissioner said there had to be a criminal sanction when something significant had gone wrong that could lead to death or serious harm.

“Up until now a duty of candour has been a moral obligation and there’s been no sanction attached to it,” said Alyson Kilpatrick.

“I know there are disciplinary codes that require you (staff) to be open and honest with the patient, but who knows what that means. This is turning what is the right thing to do into the legal thing to do.

“We have numerous inquiries, but nothing has changed in practice or in the law that’s made a difference. So if it keeps happening, if these things keep happening over decades, you’ve got to change something, something has got to give.

“I do wonder why there seems to be something emotive about attaching the word criminal to it (duty of candour).

“It is unlikely people are going to end up in prison – but if somebody has deliberately failed to notify a serious adverse incident resulting in death, maybe that has to be a sanction that is available – it is a very, very serious failure.”

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