Chaperones and Consent

We are committed to providing a safe, comfortable environment where patients and staff can be confident that best practice is being followed at all times and the safety of everyone is of paramount importance.

All patients are entitled to have a chaperone present for any consultation, examination or procedure where they feel one is required. This chaperone may be a family member or friend. On occasions you may prefer a formal chaperone to be present, i.e. a trained member of staff.

Wherever possible we would ask you to make this request at the time of booking an appointment so that arrangements can be made and your appointment is not delayed in any way.

Where this is not possible we will endeavour to provide a formal chaperone at the time of request. However occasionally it may be necessary to reschedule your appointment.

Your healthcare professional may also require a chaperone to be present for certain consultations in accordance with our Chaperone Policy.

If you would like to see a copy of our Chaperone Policy or have any questions or comments regarding this please contact the manager.

Chaperone Policy

Introduction

This policy sets out guidance for the use of chaperones and procedures that should be in place for consultations, examinations and investigations.

Willow Group is committed to providing a safe, comfortable environment where patients and staff can be confident that best practice is being followed at all times and the safety of everyone is of paramount importance

Recommendations

No family member or friend of a patient should be routinely expected to undertake any formal chaperoning role in normal circumstances. The presence of a chaperone during a clinical examination and treatment must be the clearly expressed choice of a patient

Chaperoning should not be undertaken by any other than chaperone-trained staff. Ideally the chaperone should be of the same sex as the patient. If the patient requests a male chaperone, either one of the male GPs in the practice should be asked if they are able to assist, or the patient may be asked to book with a male GP at another time if clinically appropriate.

The patient must have the right to decline any chaperone offered if they so wish.

It is recognised that developing and resourcing a chaperoning policy will have to take into account issues such as one to one consultations in the patient’s home.

Role of the Chaperone

There is no common definition of a chaperone and their role varies considerably depending on the needs of the patient, the healthcare professional and the examination or procedure being carried out. Broadly speaking their role can be considered in any of the following areas:

• Providing emotional comfort and reassurance to patients

• Assisting in the examination

• Assisting with undressing the patients

• Acting as an interpreter

• Providing protection to healthcare professionals against unfounded allegations of improper behaviour.

All staff should have an understanding of the role of the chaperone and the procedures for raising concerns.

Offering a Chaperone

All patients should be routinely offered a chaperone during any consultation or procedure. This does not mean that every consultation needs to be interrupted in order to ask if the patient wants a third party present.

Most patients will not take up the offer of a chaperone, especially where a relationship of trust has been built up or where the examiner is the same gender as them.

If the patient is offered and does not want a chaperone it is important to record that the offer was made and declined. If a chaperone is refused a healthcare professional cannot usually insist that one is present and many will examine the patient without one. However, there may be occasions where a healthcare professional feels that a chaperone needs to be present during an examination or consultation for their own security as much as for that of the patient and on these occasions they may feel unable to proceed unless one is agreed.

A chaperone should be placed within the examination area in such a position that they are able to see the patient and how the examination is being conducted.

Where a Chaperone is needed and not available

If the patient has requested a chaperone and none are available at that time the patient must be given the opportunity to reschedule their appointment within a reasonable time-frame. If the seriousness of the condition would dictate that a delay is inappropriate then this should be explained to the patient and recorded in their notes. A decision to continue or otherwise should be jointly reached. In cases where the patient is not competent to make an informed decision then the healthcare professional must use their own clinical judgement and record and be able to justify this course of action.

It is acceptable for a doctor (or other appropriate member of the healthcare team) to perform an intimate examination without a chaperone if the situation is life threatening or speed is essential in the care or treatment of the patient. This should be recorded in the patients’ medical records.

Consent is a patient’s agreement for a health professional to provide care. There is a basic assumption that every adult has the capacity to decide whether to consent to, or refuse, proposed medical intervention, unless it is shown that they cannot understand information presented in a clear way.

By attending a consultation it is assumed by implied consent that a patient is seeking treatment. When patients are not able to consent for themselves they should be treated in their best interests.

Children over 16 can consent for themselves without their decision being referred to their parents or guardians, however it is good practice to involve the parents, but this must be decided by the young person. A person with parental responsibility can consent for a child under 16 unless the child is deemed to be ‘Gillick competent’.

Issues Specific to Learning Difficulties / Mental Health Problems

For patients with learning difficulties or mental health problems that affect capacity, a familiar individual such as a family member or carer may be the best chaperone.

Adult patients with learning difficulties or mental health problems who resist any intimate examination or procedure must be interpreted as refusing to give consent and the procedure must be abandoned. In life threatening situations the healthcare professional should use professional judgement and where possible discuss with a member of the Mental Health Care Team.

Issues Specific to Children

Parents will not be automatically used as chaperones for their children. However, in the event a child does not wish for a nurse to be present a parent can be present as a chaperone for their child. In this event the role should be clearly examined to the parent and their consent sought.

Lone Working

Where a healthcare professional is working in a situation away from other colleagues such as a home visit, the same principles for offering and use of chaperones should apply.

Where it is appropriate family members/friends may take on the role of informal chaperone. In cases where a formal chaperone would be appropriate, i.e. intimate examinations, the healthcare professional may decide to reschedule the examination to a more convenient location. However, in cases where this is not an option, for example due to the urgency of the situation or because the patient is housebound, then procedures should be in place to ensure that communication and record keeping are treated as paramount.

Communication and Record Keeping

It is essential that the healthcare professional explains the nature of the examination to the patient and offers them a choice whether to proceed with that examination at that time. The patient will then be able to give informed consent to continue with the consultation.

Confidentiality Policy

Importance of confidentiality

Confidentiality is a fundamental part of health care and crucial to the trust between doctors and patients. Patients entrust their practice with sensitive information relating to their health and other matters in order to receive the treatment and services they require. They should be able to expect that this information will remain confidential unless there is a compelling reason why it should not. All staff in the NHS have legal, ethical and contractual obligations of confidentiality and must ensure they act appropriately to protect patient information against improper disclosure.

Some patients may lack the capacity to give or withhold their consent to disclosure of confidential information but this does not diminish the duty of confidence. The duty of confidentiality applies to all patients regardless of race, gender, social class, age, religion, sexual orientation, appearance, disability or medical condition.

Information that can identify individual patients must not be used or disclosed for purposes other than healthcare unless the patient (or appointed representative) has given explicit consent, except where the law requires disclosure or there is an overriding public interest to disclose. All patient identifiable health information must be treated as confidential information, regardless of the format in which it is held.

Obligations for all staff

All staff must:

• always endeavour to maintain patient confidentiality;

• not discuss confidential information with colleagues without patient consent (unless it is part of the provision of care);

• not discuss confidential information in a location or manner that allows it to be overheard;

• handle patient information received from another provider sensitively and confidentially;

• not allow confidential information to be visible in public places;

• store and dispose of confidential information in accordance with the Data Protection Act 1998 and the Department of Health’s Records Management Code of Practice (Part 2);

• not access confidential information about a patient unless it is necessary as part of their work;

• not remove confidential information from the premises unless it is necessary to do so to provide treatment to a patient

• contact the information governance lead (Practice Manager) or Caldicott Guardian (Deputy Practice Manager) if there are barriers to maintaining confidentiality;

• report any loss, inappropriate storage or incorrect disclosure of confidential information to the information governance lead or Caldicott Guardian;

• if applicable, document, copy, store and transfer information in the ways agreed with other providers;

It is expected that members of staff will comply with the law and guidance/codes of conduct laid down by their respective regulatory and professional bodies.

Information disclosures:

When a decision is taken to disclose information about a patient to a third party due to safeguarding concerns/public interest, the patient should always be told and asked for consent before the disclosure unless it would be unsafe or not practical to do so.

In the circumstances that consent cannot be sought, then there must be clear reasons and necessity for sharing the information.

Disclosures of confidential information about patients to a third party must be made to the appropriate person or organisation and in accordance with the principles of the Data Protection Act 1998, the NHS Confidentiality Code of Practice (see below) and the GMC’s Good Medical Practice.

Obligations for employers

The employers at the practice must:

• ensure that confidential information can be stored securely on the premises and that there are processes in place to guarantee confidentiality;

• make sure that all individuals to whom this protocol is relevant have read, understood and signed this protocol;

• review and update this policy on a regular basis.

This protocol is subject to the provisions set out in the legislation and guidance listed below:

• Data Protection Act 1998; The Information Commissioners’ Office guide to data protection

• The Department’s Code of Practice for Records Management (Part 2)

• Human Rights Act 1998

• The Common Law Duty of Confidence

• Access to Health Records Act 1990

• Confidentiality: NHS Code of Practice 2003

• NHS Care Record Guarantee 2009

Scope and Principles

It is a general legal and ethical principal that valid consent must be obtained before starting a treatment or performing an examination. The person giving consent must have mental capacity, must give the consent voluntarily, and have had sufficient information to be able to make the decision. There are some differences for children and young people set out below.

Implied – assume the patient is happy unless they tell you otherwise.

Suitable for day-to-day non-invasive interactions with patients

• Taking blood pressure

• Checking temperature

• Examining eyes and ears

• Performing dressings

Verbal – ask if the patient is happy for you to continue and explain the procedure.

Suitable for more specialised examinations

• Physical examination including rectal examination and proctoscopy

• Cervical smears

• Vaccinations

Written – use the form (to be scanned into the notes) and record information given in the medical notes

Suitable for invasive procedures that carry a risk of wound infection or organ perforation

• Minor surgery including contraceptive implants and joint injections

• Insertion of IUS and IUCDs

• Research

• Recording or videoing consultations

There is no legal requirement for written consent, but it can provide evidence that consent was obtained. Medical notes should record that information was given, including options and the possible consequences of taking no action if applicable.

The doctor or nurse undertaking a treatment or procedure at the time it is being done.

Does the person have capacity?

For adults, a person lacks capacity if

• they have an impairment or disturbance (for example a disability or condition or trauma or the effect of drugs or alcohol) that affects the way their mind or brain works, and

• that impairment or disturbance means that they are unable to make a specific decision at the time it needs to be made.

The assessment of capacity is based on a person’s ability to make a specific decision at the time it needs to be made and not their ability to make decisions in general (so their capacity may vary over time and may be different for different decisions). A person is unable to make a decision if they cannot do one or more of the following things

• understand the information that is given to them that is relevant to the decision

• retain that information long enough to make the decision

• use or weigh-up the information as part of the decision-making process

• communicate their decision – this could be by talking or using sign language and includes simple muscle movements such as blinking and eye or squeezing a hand

Consent should be free of coercion and a patient may need to be seen on their own to ensure a decision is not influenced by partners or family members. Doctors and Nurses can provide appropriate reassurance about a treatment or procedure and explain its potential benefits and the possible consequences of not proceeding, but need to be alert to the possibility of overstepping the boundary into exerting undue pressure.

Has the person received sufficient information?

The patient needs to be told about any ‘material’ or ‘significant’ risks or unavoidable risks, even if small, in the proposed treatment or procedure; any alternatives to it; and the risks incurred by doing nothing. For written consent or where there is doubt – these should be recorded in the notes.

A person over the age of 18, if they have capacity, can refuse treatment, even if this may result in their death.

A person may withdraw consent at any time. If this happens, the procedure should be stopped, the person’s concerns established, and the consequences of not completing the procedure explained. If the problem is pain, this may be able to be corrected and the procedure completed. If, however, the person confirms that they no longer consent – the procedure should be abandoned.

Children and young people

A child is someone under the age of 16
A young person is someone aged 16-17

A young person can give or withhold consent, though it can be over-ridden on occasions by a person with parental responsibility or a court (usually this is in situations that might result in death or severe harm). Capacity criteria are as for an adult. Legally, parental consent does not have to be obtained though it is good practice to try and include a parent in the discussion if the young person agrees to allow their medical information to be shared.

Gillick Competence

“Children who have sufficient understanding and intelligence to enable them to understand fully what is involved in a proposed intervention will also have the capacity to consent to that intervention”

Where advice or treatment relates to contraception or the child’s sexual or reproductive health, the doctor or nurse should try to persuade the child to inform his or her parent(s), or allow the healthcare professional to do so. If, however, the child cannot be persuaded, advice and/or treatment should still be given if the healthcare professional considers that the child is very likely to begin or continue to have sexual intercourse with or without the advice or treatment and that unless they receive the advice or treatment then the child’s physical or mental health is likely to suffer.

Child lacking capacity

In this circumstance a parent can give consent, so long as the principles of the child’s best interests and welfare are paramount. Parental refusal of treatment can only be over-ridden in an emergency or where there is the suspicion of abuse or neglect.

the child’s mother
the child’s father if he was married to the mother at the time of the child’s birth
unmarried fathers if the practice understands them to have a parental responsibility order
a legally appointed guardian
the person who has a residence order concerning the child
a local authority designated in a care order in respect of the child

For the purposes of vaccination, the practice will accept consent if a relative brings the child with a letter signed by one of the above. Foster parents do not automatically have parental responsibility – so this will be checked with them.