The medical consultation is a challenge to both doctor and patient, whether in the community or in hospital. The need for more detailed discussions with patients, along with their increasing autonomy and right to make choices in relation to their clinical care and treatment, has affected the traditional role of the doctor-patient relationship. This has made maintaining appropriate professional boundaries in the doctor-patient consultation more challenging, however, the guidance from national and regulatory bodies is clear that it is always the health professional’s responsibility to do so.
Chaperones and the role of an accompanying person in the consultation and in the clinical examination is a part of this responsibility to achieve a good standard of medical practice.
In 2004 the Committee of Inquiry looked at the role and use of chaperones, following its report into the conduct of Dr Clifford Ayling (see further information). It made the following recommendations:
- Each Trust/Practice should have its own chaperone policy and this should be made available to patients.
- An identified managerial lead (with appropriate training).
- The presence of a chaperone must be the clear expressed choice of the patient; patients also have the right to decline a chaperone when offered.
- Chaperones must receive appropriate training.
- Family members or friends should not undertake the chaperoning role.
Definition of a Chaperone
A chaperone is an independent person, appropriately trained, whose role is to independently observe the examination/procedure undertaken by the doctor/health professional to assist the appropriate doctor-patient relationship.
The GMC guidance in Good Medical Practice 2013 indicates:
9. A chaperone should usually be a health professional and you must be satisfied that the chaperone will:
The name of the chaperone should be recorded in the clinical records and the patient should be informed of this.
a. be sensitive and respect the patient’s dignity and confidentiality
b. reassure the patient if they show signs of distress or discomfort
c. be familiar with the procedures involved in a routine intimate examination
d. stay for the whole examination and be able to see what the doctor is doing, if practical
e. be prepared to raise concerns if they are concerned about the doctor’s behaviour or actions.
In what circumstances should a chaperone be offered?
The most obvious example is with intimate examinations, and in these situations a chaperone must be offered. However, it is important to remember that what can be classed as an intimate examination may depend on the individual patient (see below for more detail on this point). Guidance on this has been given by a number of national and regulatory bodies/organisations (see further information).
It may also be appropriate to offer a chaperone in other circumstances – for the whole of a consultation, or for other specific sections of the consultation, and not just the physical examination.
Some examples of situations where a chaperone may be beneficial include:
- Vulnerable or anxious patients.
- Allocated patients or who are being rotated through practices by the Clinical Commissioning Group.
- Patients with whom there may have been a difficulty, misunderstanding or difference of recollection in the past.
- Patients who are being seen by trainee doctors or students.
- Patients where religious/cultural approach to a physical examination is different.
Why use a chaperone?
- Their presence adds a layer of protection for a doctor as well as for the patient; it is very rare for an allegation of assault to be made if a chaperone is present.
- To acknowledge a patient’s vulnerability and to ensure a patient's dignity is preserved at all times.
- May assist the health professional in the examination (for example – may assist with undressing/dressing patients as required
- Provides emotional comfort and reassurance.
What is an intimate examination?
Intimate examinations may be embarrassing or distressing for patients and such examinations should be carried out with sensitivity to the patient’s perception as to what they may think of as embarrassing/intimate. This is likely to include examinations of breasts, genitalia and 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, applying the blood pressure cuff, palpating the apexbeat. It will be an important part of this type of examination to explain clearly to the patient beforehand the purpose and method of the examination and during the examination what is being done, as well as to explain the finding after the examination is complete. This detailed communication is likely to avert misunderstanding by the patient.
Consult GMC, NMC, RCOG and RCP advice on intimate examinations (see further information).
What if a chaperone is not available?
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 would be appropriate, after explaining to the patient, to rearrange the appointment for a mutually convenient time when a chaperone and the patient will be available.
- If the examination is clinically indicated on an urgent basis, and 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 defer this examination until after admission to hospital, again explaining this to the patient and in the referral letter.
- If the examination is urgent, and hospital admission is not indicated on the history alone, any delay must not adversely affect the patient’s health, so there may be occasions when a doctor goes ahead in the absence of a chaperone. In such circumstances, the patient’s written consent should be obtained (see RCOG guidance in further information). In addition, the fact that the patient was examined in the absence of a chaperone should be recorded, together with the rationale for this.
Should chaperones be trained?
Yes – 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 may become inappropriate. Your Local Area team (LAT) may be able to help in terms of identifying locally available training courses for chaperones.
Although a chaperone does not have to be medically qualified they must be:
- A health professional.
- Sensitive to the patient's confidentiality
- Prepared to reassure the patient.
- Familiar with the procedures involved in the relevant examination.
- Prepared to raise concerns about a doctor if misconduct occurs.
It is important to note that family members cannot fulfil the role of chaperone.
Approaching the topic of chaperones with a patient
Written information detailing the chaperone policy should be freely available to patients – for example the policy might be displayed in waiting rooms, consultation rooms, and on the Practice/Trust website. This empowers patients to address the topic themselves if they would feel more comfortable with a chaperone present.
As a general starting point, the following list sets out the most important points to address when offering a chaperone to a patient:
- Establish where there is a need for an examination, and explain and discuss this with the patient.
- Explain why an examination is necessary and how it will be carried out, and give the patient an opportunity to ask questions.
- Obtain and record the patient’s consent for the examination.
- If the examination will be intimate, or if otherwise appropriate, explain to the patient that you would like a chaperone to be present.
- 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.
- If the patient still refuses, you will need to decide whether to proceed with the examination in the absence of a chaperone (see below for more information). Guidance for intimate examinations is that a chaperone must be present. It may be possible to arrange the examination by a health professional of the same sex as the patient if that is an issue.
- Be aware and respect cultural differences. Religious beliefs may also have a bearing on the patient’s decision as to whether to have a chaperone present.
- Give the patient privacy to undress and dress. Use paper drapes/sheet where possible to maintain the patient’s dignity before during and after the examination.
- In line with usual expected practice, ensure that you 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, or the period agreed with the patient at the outset.
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 comfort/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 an unconsented examination/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).
- A further option would be to consider referring the patient to secondary care for the examination (although the chaperone issue may, again, still prevail).
- The doctor/health professional 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 and to inform the patient of this.
Where should the chaperone stand?
A chaperone must be in a position to be able to properly observe the procedure so as to be an independent witness as to how the examination procedure was carried out and, where necessary, to any variations in the examination which should also be recorded. They should therefore be present for the whole of that examination.
Key points to remember
- Inform your patients of the Practice/Trust or organisation's chaperone policy.
- Record the use, offer 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 person of another sex or undressing.
- Do not proceed with an examination if you feel the patient has not understood due to a language barrier or any other reason.
- GMC (2013), Intimate Examinations and Chaperones
- GMC (2013), Maintaining a Professional Boundary Between You and Your Patient
- NHS Clinical Governance Support Team (2015), Guidance on the Role and Effective Use of Chaperones in Primary Continuity Care
- CQC (2016), Nigel's surgery 15: Chaperones
- Medical Protection factsheet, Chaperones FAQs
- RCN (2006), Chaperoning:The Role of the Nurse and the Rights of Patients
- RCOG (2002), Clinical Standards, Advice on Planning the Service in Obstetrics and Gynaecology
- RCR (2015), Intimate Examinations and the Use of Chaperones
- Department of Heath Committee of Inquiry report (2004), Independent Investigation into how the NHS handled allegations about the conduct of Clifford Ayling