Dr Richard Stacey and Sara Williams tackle some of the typical questions asked by practices about chaperones
Can receptionists be chaperones? What training is required? Where does a chaperone stand? There is a certain ambiguity surrounding chaperones and what exactly their purpose is.
"It is very rare for a doctor to receive an allegation of assault if they have a chaperone present"
In 2004, the Committee of Inquiry published its independent report into how the NHS handled the concerns in relation to the conduct of Dr Clifford Ayling. In 2000, Dr Ayling was convicted of 12 charges of indecent assault relating to ten female patients, and was sentenced to four years’ imprisonment. The Inquiry specifically looked at the use and role of chaperones and provided some pragmatic recommendations in this regard (2.58-2.6 – page 26, see useful links), which can be summarised as follows:
- Each trust should have its own chaperone policy and this should be made available to patients.
- An identified managerial lead (with appropriate training) should be responsible for the initiation of the policy.
- Family members or friends should not undertake the chaperoning role.
- The presence of a chaperone must be the clear expressed choice of the patient; patients also have the right to decline a chaperone.
- Chaperones should receive training.
Why use chaperones?
MPS’s experience is that it is very rare for a doctor to receive an allegation of assault if they have a chaperone present. The challenge for today’s doctors is to show their human face while maintaining clear professional boundaries. Using a chaperone is not only an effective safeguard against unfounded accusations; it will help put a patient at ease.
Respect for a patient’s autonomy is expressed in many different ways. On an overt level, it is conveyed by seeking consent, conducting open discussions and working in partnership with patients. On a more subtle level, it requires a sensitive recognition of the power differentials that exist between doctors and their patients, and the vulnerability patients may feel. Using a chaperone is both an added layer of protection and an acknowledgement of a patient’s vulnerability.
Other roles of a chaperone may include:
- Providing emotional comfort and reassurance
- Assisting in the examination
- Assisting with undressing patients
- Acting as aninterpreter.
What is an intimate examination?
Defining an intimate examination can be trickier than it would first appear and it is easy for a patient to misconstrue a legitimate clinical examination. Obvious examples include examinations of the breasts, genitalia and the rectum, but it also extends to any examination where it is necessary to touch or be close to the patient; for example, conducting eye examinations in dimmed lighting.
"You should be aware of grey areas, or areas of vulnerability, where an inadvertent brush or touch may occur"
This is important, as most allegations of sexual assault are down to inadvertent touching. You should be aware of grey areas, or areas of vulnerability, where an inadvertent brush or touch may occur. Examples include listening to the chest, taking the blood pressure cuff and palpitating the apex beat – all could involve touching the breast area.
Why is it risky?
MPS has experience of practices that do not have a chaperone policy or have an inconsistent approach to chaperones and training. In addition, some GPs do not record the presence and identity of the chaperone in the medical records; they continue to use untrained receptionists as chaperones and ask them to stand outside the curtain.
How to develop a chaperone policy
Drawing up a chaperone policy for a practice is the first step to effective chaperone management; however, it is estimated that only about a third of practices actually have one.
When creating a policy the purpose of it should be at the forefront of your mind – chaperones are necessary to assist during intimate examinations, to comfort patients, and protect doctors and nurses from allegations of impropriety. GMC and NMC advice on intimate examinations should be considered (see useful links).
Written information detailing the policy should be provided for patients, either on the practice website or in the form of a leaflet.
Here is a useful checklist for the management of a consultation.
- Establish there is a need for an intimate examination and discuss this with the patient.
- Explain why an examination is necessary and give the opportunity to ask questions; obtain and record the patient’s consent.
- Offer a chaperone to all patients for intimate examinations (or examinations which may be construed as such). If the patient does not want a chaperone, record this in the notes.
- If the patient declines a chaperone and as a doctor you would prefer to have one, explain to the patient that you would prefer to have a chaperone present and, with the patient’s agreement, arrange for a chaperone.
- Be aware and respect cultural differences. Religious beliefs may also have a bearing on the patient’s decision over whether to have a chaperone present.
- Give the patient privacy to undress and dress.
- Use paper drapes where possible to maintain dignity.
- Explain what you are doing at each stage of the examination, the outcome when it is complete and what you propose to do next. Keep the discussion relevant and avoid personal comments.
- Record the identity of the chaperone in the patient’s notes.
- Record any other relevant issues or concerns immediately after the consultation.
- In addition, keep the presence of the chaperone to the minimum necessary period. There is no need for them to be present for any subsequent discussion of the patient’s condition or treatment.
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Dr Richard Stacey answers the most common FAQs about chaperones
1) Should chaperones be trained?
Practices should no longer use untrained practice staff to fulfil the role of a chaperone. Chaperones need to be trained so that they understand what a legitimate clinical examination entails and at what stage it becomes inappropriate.
Although a chaperone does not have to be medically qualified they must be:
- Sensitive to the patient’s confidentiality.
- Prepared to reassure the patient.
- Familiar with the procedures involved in an intimate examination.
- Prepared to raise concerns about a doctor if misconduct occurs. The local commissioning body may be able to help in terms of identifying locally available training courses for chaperones.
2) What if a chaperone is not available?
There may be occasions when a chaperone is unavailable... in such circumstances, the doctor should first consider whether or not on a clinical basis the examination is urgent
There may be occasions when a chaperone is unavailable (for example, on a home visit or in the out-of-hours setting). In such circumstances, the doctor should first consider whether or not on a clinical basis the examination is urgent.
- If the examination is not urgent, then it might be possible to simply rearrange the appointment for a time when a chaperone will be available.
- If the examination is clinically indicated on an urgent basis, but the doctor has enough information from the history to indicate that the patient would require an admission to hospital in any event, then it may be appropriate to admit them.
- If the examination is urgent, but hospital admission is not indicated on the history alone, there may be occasions when a doctor goes ahead in the absence of a chaperone. In such circumstances, the patient’s consent should be obtained and recorded. In addition, the fact that the patient was examined in the absence of a chaperone should be recorded, together with the rationale for the same.
3) What if a patient declines a chaperone?
Even if a patient declines the offer of a chaperone, the doctor/nurse may feel that in certain circumstances (for example, an intimate examination on a young adult of the opposite gender), it would be wise to have a chaperone present for their own protection.
- The doctor should explain that they would prefer to have a chaperone, explain that the role of the chaperone is in part to assist with the procedure and provide reassurance. It is important to explore the reasons why the patient does not wish to have a chaperone and to address any concerns they may have.
- If the patient still declines, the doctor will need to decide whether or not they are happy to proceed in the absence of a chaperone. This will be a decision based on both clinical need and the requirement for protection against any potential allegations of improper conduct.
- Another option to consider is whether or not it would be appropriate to ask a colleague to undertake the examination (although the chaperone issue may still prevail).
- The doctor should always document that a chaperone was offered and declined, together with the rationale for proceeding in the absence of a chaperone. If a chaperone is present then it is important to record their identity.
"MPS advises that a chaperone be offered for any intimate examination regardless of the patient’s gender"
4) Do same-gender examinations require a chaperone?
In the context of allegations of improper conduct, the most common scenario is that a female patient makes allegations against a male doctor. In MPS’s experience, it is unusual for doctors to be the subject of allegations of improper conduct from patients of the same gender.
However, there have been such cases, and MPS advises that a chaperone be offered for any intimate examination regardless of the patient’s gender. The GMC guidance Maintaining Boundaries reinforces this advice, by stating that a chaperone should be offered “whether or not you are the same gender as the patient” (paragraph 10).
Scenario A
Husband and wife Mr and Mrs C attend their GP surgery and are seen by a GP. He assumes that consent to disclosure of the clinical findings is implied by Mr C’s presence. Mrs C has been experiencing vaginal discharge and is worried it could be cervical cancer. The GP conducts an internal examination and removes a retained condom. Mr C erupts. He had a vasectomy three years ago and has not used a condom since.
Advice
This scenario raises two issues: firstly, doctors should not rely solely on family members to always fulfill the role of a chaperone and, secondly, doctors should not assume that because a patient attends with a third party that this necessarily amounts to consent to the disclosure and discussion of confidential information.
Always explain the procedure and ensure that the patient understands what you are planning to do and why, ie, ensuring that the patient is fully informed about the procedure. In this case, Dr D should have asked Mrs C directly whether her husband could act as chaperone, giving her the chance to object. However, it might have been hard for her to refuse if she was asked in front of her husband.
"Doctors should not assume that because a patient attends with a third party that this necessarily amounts to consent to the disclosure"
Ideally the GP should have asked the husband to wait in the waiting room and asked the nurse to attend the consulting room to act as chaperone. As an alternative, Dr D could ask both husband and wife to take a seat in the waiting room, until the practice nurse was free.
The examination could then have taken place in the nurse’s consulting room. It would be up to the wife to decide what information to tell her husband about the cause of the discharge.
Scenario B
Locum GP Dr A is seeing a patient, Miss F, who is complaining of a problem in her right eye. Dr A explains that “he will need to look at the back of the eye”. He promptly turns out the light in the consulting room and proceeds to perform a fundoscopy. Whilst Dr A is leaning forward, his tie inadvertently (and unbeknown to Dr A) comes into contact with Miss F’s blouse. She leaves the consultation thinking that Dr A has touched her inappropriately and makes a complaint.
Advice
Dr A should have given a clear explanation as to what the examination entailed and confirmed the patient was content for him to proceed before going ahead. Inadvertent contact of this nature can easily be misconstrued, especially in this particular context. Dr A should have been alive to this possibility and taken Here is a useful checklist for the management of a consultation.
Visit MPS Educational Services for more.
Key points to remember:
GPs do not have to undertake an examination if a chaperone is declined
- Inform your patients of the practice’s chaperone policy.
- Record the use, offer of and declining of a chaperone in the patient’s notes.
- Ensure training for all chaperones.
- GPs do not have to undertake an examination if a chaperone is declined.
- Be sensitive to a patient’s ethnic/religious and cultural background. The patient may have a cultural dislike to being touched by a man or undressing.
- Do not proceed with an examination if you feel the patient has not understood due to a language barrier.
Conclusion
Regardless of the patient’s role, the guidelines from medical regulatory bodies are clear: it is always the doctor’s responsibility to manage and maintain professional boundaries – utilising chaperones effectively is a way of managing relations with patients, where the ultimate responsibility for ensuring that relations remain on professional footing rests with you.
Useful links
Last updated: October 2009
Please note: Medical Protection does not maintain this article and therefore the advice given may be incorrect or out of date, and may not constitute a definitive or complete statement of the legal, regulatory and/or clinical environment. MPS accepts no responsibility for the accuracy or completeness of the advice given, in particular where the legal, regulatory and/or clinical environment has changed. Articles are not intended to constitute advice in any specific situation, and if you are a member you should contact Medical Protection for tailored advice. All implied warranties and conditions are excluded, to the maximum extent permitted by law.