- Doctor: Drs. Liz Hamblin & Jas Dhillon
- Nurse: Chantelle Kerin
- Admin: Vicky O’Shea
20th June 2019
DATE OF NEXT REVIEW:
This webpage provides information for patients, staff and other health professionals. A chaperone is a third party who oversees what is happening in a medical consultation/examination/investigation inorder to protect the patient from improper behaviour and to protect the health professional from allegations of improper behaviour or an attack. Often, a chaperone will help out with other things like helping the patient undress, assisting with the examination or investigation, attending to the patient’s comfort, explaining or interpreting and providing emotional support.
Doctors examine patients every day but an individual patient gets examined rarely. So, be caring, sensitive and empathic. Cover up patients – don’t leave them naked. Don’t leave them waiting too long for an examination (for example, whilst your finishing off the notes).
All staff at the surgery will have training with respect to the chaperone role. As a result they will have an understanding of the role of the chaperone and the procedures for raising concerns. Our training covers the following…
- What is meant by the term chaperone
- What is an “intimate examination”
- Why chaperones need to be present
- The rights of the patient
- Their role and responsibility
- Policy and mechanism for raising concerns
Any new staff will also recieve similar training during their induction period.
Chaperones protect everyone...
- All medical consultations, examinations and investigations are potentially distressing. Those involving the breasts, genitalia or rectum particularly intrusive (these examinations are collectively referred to as “intimate examinations”). Also consultations involving dimmed lights, the need for patients to undress or for intensive periods of being touched may make a patient feel vulnerable. A chaperone can help put the patient at ease and help explain what is happening or going to happen through to them.
- Also, chaperones help protect the patient by ensure the health professional does not go beyond what is clinically necessary. GP Clifford Ayling spent 20 years indecently assaulting female patients. The use of chaperones helps stop this sort of thing from happening.
PROTECTING HEALTH PROFESSIONALS
- A chaperone oversees what the health professional is doing. In so doing, the chaperone helps protect the health professional from false claims of abuse.
- A chaperone can help the health professional with their examination by helping prepare the patient and attending to their comfort.
A chaperone is present as a safeguard for all parties (patient and practitioners) and is a witness to continuing consent of the procedure.
This organisation 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. 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 a patient may prefer a formal chaperone to be present, i.e. a trained member of staff. Wherever possible the patient should make this request at the time of booking appointment so that arrangements can be made and that the 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 the appointment. The healthcare professional may also require a chaperone to be present for certain consultations in accordance with our chaperone policy. The Chaperone Policy is detailed on this page.
Just because a patient attends surgery for their problem, it does not imply automatic consent to examination
One might assume that a patient seeking treatment and attending the surgery appointment is a sort of implied consent to any subsequent necessary examinations. This is not necessarily the case! Before proceeding with an examination, healthcare professionals should always seek to obtain, by word or gesture, some explicit indication that the patient understands the need for examination and agrees to it being carried out. Consent should always be appropriate to the treatment or investigation being carried out.
Frequently Asked Questions (FAQs)
- Providing emotional comfort and reassurance to patients
- To assist in the examination, for example handing instruments during IUCD insertion
- To assist with undressing patients
- To act as an interpreter
- To provide protection to healthcare professionals against unfounded allegations of improper behaviour.
- In very rare circumstances to protect the clinician against an attack
- An experienced chaperone will identify unusual or unacceptable behaviour on the part of the health care professional
PLEASE NOTE: In order to determine whether a health professional is ‘doing the right thing’, the chaperone needs to be able to see what they are doing. There is no point in having a chaperone who stands outside of the curtain whilst the patient is being examined. Similarly, if you’re acting as a chaperone there’s also no point in standing inside of the curtain and looking at the floor throughout the examination. The chaperone needs to be inside the curtain AND watching both the health professional and the patient and what is being done.
- It is good practice to offer all patients a chaperone for any consultation, examination or procedure where the patient feels one is required.
- The offer of chaperone should be made clear to the patient prior to any procedure, ideally at the time of booking the appointment. 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.
- When offering a chaperone, explain what a chaperone is (many will not know or even heard of the word) and explain the purpose of a chaperone is to keep them comfortable and safe.
- When an intimate examination is clinically necessary, offer the patient the choice of a male of female health professional to carry out this investigation.
- In the first instance, a nurse or doctor will be asked to act as a chaperone. Where this is difficult, a trained member of reception staff will asssist. You can only be a chaperone if you have recieved chaperone training. Formal chaperones need to understand their role and responsibilities so that they are competent to perform that role.
- Doctor/Nurse – please make sure you ask the patient if they are comfortable with the specific person offered to be the chaperone.
- Chaperone – if you know the patient on a personal level or if the patient feels uncomfortable because they know you too well – please inform the doctor and get someone other suitably trained person to chaperone.
Protecting the patient from vulnerability and embarrassment means that the chaperone would usually be of the same sex as the patient. Therefore the use of a male chaperone for the examination of a female patient or of a female chaperone when a male patient was being examined could be considered inappropriate. However, one also needs to take into account who is available at the time and the patient should always have the opportunity to decline a particular person as chaperone if that person is not acceptable to them for any reason.
- 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.
- Where the patient declines but the doctor or other health professional feels uneasy about this (e.g. because there is a real risk of false allegation, unpredicatable behaviour from the patient), a chaperone should still be sought – explain to the patient why you would like one present and see if the patient will (without any coercion) agree. Otherwise, book the patient in with another health professional (of the same sex) – this situation is very rare.
- Health professional – document in Systm1: Whether chaperone offered, whether accepted or not, Name of the chaperone and their role.
- Chaperone – again document in Systm1 that you were present: record your name, position and time present.
- The first thing to remember is that whilst doctors and nurses examine patients several times a day, being examined is a relatively infrequent experience for a patient and can unsurprisingly lead to anxiety and apprehension.
- Therefore, when examining a patient, please give attention to the environment ensuring adequate privacy is afforded in order to maintain the patient’s dignity. This is BOTH the health care professional’s and chaperone’s responsibility. For example, after they have undressed, make sure they are not kept waiting too long before the examination or procedure. Also, make sure their dignity is maintained by covering up exposed areas until the examination or procedure is due (use the large paper rolls or the patient’s own clothing or even both). Make sure the curtain is drawn around them and the window blinds are drawn closed.
- The chaperone must be INSIDE the curtain otherwise they cannot observe what is being done. DO NOT STAND OUTSIDE THE CURTAIN. Where the chaperone postiions themself within the curtain space depends on what is being examined. They need to be able to see what is being done. If the chaperone is unsure where to stand, ask the health professional to advise them.
- The chaperones role is as an impartial observer. Also attend to the patient’s comfort.
- Refrain from personal comments like ‘you smell nice’. This is a clinical procedure.
- The chaperone leaves the room ONLY when the patient is dressed and ready to resume the consultation.
Some Key Things to Remember:
- For most patients respect, explanation, consent and privacy take precedence over the need for a chaperone. The presence of a third party does not negate the need for adequate explanation and courtesy and cannot provide full assurance that the procedure or examination is conducted appropriately. Adequate information and explanation as to why the examination or procedure is required should be provided and where necessary, easily understood literature and diagrams can support this verbal information. For example, as doctors it makes sense to do a rectal examination in a male patient complaining of prostatic urinary symptoms. However, a patient may not understand why a doctor needs to put a finger up their bottom for something that they are complaining of from their front end.
- In a similar vein, it is unwise to assume that the patient understands why certain examinations are being conducted or why they are done in a certain manner. For example, patients need to be told why both breasts are examined when they may complain of a lump in only one, or why a vaginal examination maybe necessary if a women complains of abdominal pain or why the testes may be examined in a child with abdominal pain. There was a case where a female patient complained against her male doctor for conducting an inappropriate breast examination. She complained that she was asked to strip off and display her naked torso and that the doctor spent some time looking at her breasts. He then asked her to raise her arms and examined the ‘normal’ breast. The case was dismissed from the GMC but illustrates how a simple explanation of what the examination entails could prevent problems.
- Most patients would value a chaperone… a study looking at attitudes of patients towards the use of chaperones carried out in Tyneside found that 90% of female patients and 78% of male patients thought that a chaperone should be offered for ‘intimate’ examinations. However, most patients decline the offer of a chaperone for a number of reasons: because they trust the clinician, think it unnecessary, require privacy, or are too embarrassed.
- Complaints involving allegations of improper examination by a doctor are very rare. Where allegations of indecent assault during a clinical examination do occur almost all are against a male doctor and a small but significant minority of cases involve a male doctor and a male patient.
- In all cases where the presence of a chaperone may intrude in a confiding clinician-patient relationship their presence should be confined to the physical examination. One-to-one communication should take place after the examination, once the chaperone has left.
- The use of the feminine gender equally implies the male and similarly the use of the male gender equally implies the female.
- The offer of a chaperone and their presence should be recorded in medical note.
- Establish there is a genuine need for an intimate examination and discuss this with the patient. Explain to the patient why an examination is necessary and give the patient an opportunity to ask questions.
- Offer a chaperone or invite the patient to have a family member/friend present. If the patient does not want a chaperone, record that the offer was made and declined in the patients notes.
- Obtain the patient’s consent before the examination and be prepared to discontinue the examination at any stage at the patient’s request. Record that permission has been obtained in the patients notes.
- Once the chaperone has entered the room give the patient privacy to undress and dress. Use drapes where possible to maintain dignity. Facilities should be available for patients to undress in a private, undisturbed area. Intimate examination should take place in a closed room or well-screened bay that cannot be entered while the examination is in progress. Examination should not be interrupted by phone calls or messages. If you plan to lock your door, please ask the patient first if it is okay. Some patients (especially those with a history of sexual abuse) may find the click of a door being locked very distressing. So – seek permission and ask ‘is it okay if i lock the door so that your privacy is maintained?’.
- There should be no undue delay prior to examination once the patient has removed any clothing – a delay just increases a patient’s anxiety and can be undignifying.
- During the intimate examination
- Offer reassurance and be courteous
- Explain what you are doing at each stage of the examination.
- Keep discussions relevant and avoid unnecessary personal comments like ‘you smell nice’, ‘that’s a very nice skirt’, ‘very cute piercing/tattoo’
- Encourage questions and discussion
- Remain alert to verbal and non-verbal indications of distress from the patient Any requests that the examination be discontinued should be respected.
- At the end of the examination and once the patient is dressed the findings must be communicated to the patient – explain what you found, and what you propose to do next. If appropriate this can be used as an educational opportunity for the patient. The professional must consider (asking the patient as necessary) if it is appropriate for the chaperone to remain at this stage.
- If a chaperone has been present record that fact and the identity of the chaperone in the patients notes.
- Record any other relevant issues or concerns immediately following the consultation.
NB Where appropriate a choice of position for the examination should be offered for example left lateral, dorsal, recumbent and semi-recumbent positions for speculum and bimanual examinations. This may reduce the sense of vulnerability and powerlessness complained of by some patients.
Explanation is the key to ensuring patients understand what is being asked of them or done to them. In this way, it gives them truly informed choice. Explanation is therefore also the key to minimising complaints. Remember, patients are not doctors or nurses and so cannot second guess why you might be doing something. For sure, there are some things that you will do that will be obvious to them as to why you are doing them (like listening to the heart for chest pain). But there are other things that might appear illogical to them and some of these are listed below. You should explain more explicitly in these situations and ensure the patient understands.
- Intimate examinations cause anxiety for both male and female patients.
- A male patient might be puzzled as to why you are checking their back passage (i.e. a PR) when they came in with front passage (urinary) complaints.
- A female patient might be wondering why your hand is holding up her breast even though you know you are feeling for the apex beat.
- Some patients may feel uncomfortable at how close you will get to them when examining the eye with an ophthalmoscope – tell them beforehand.
- A patient may wonder why you are feeling their groin (inguinal area)
- in an abdominal examination(even though you know you are checking for hernia)
- when all they came in for was pain in the calf and cold legs (even though you are checking the peripheral vascular system)
- when all they complained of was sore neck and axillary lymph nodes (even though you know you are checking for inguinal lymph nodes)
Try not to examine the genitalia of men by asking them to stand and drop their trousers. It is embarassing and undignifying for them. Perform the examination on the examination couch. This will help the examination ‘feel’ clinical, help them feel more dignified and reassure them that you are taking their matter seriously.
During an intimate internal examination it is strongly recommended that surgical gloves be worn. The glove acts as a physical barrier, keeping the examination on a clinical basis, limiting the possibility of sexual connotations. Situations where a healthcare professional may reasonably not wear gloves would be in a life-saving situation where gloves are not available. Healthcare professionals should always seek to carry gloves when on call.
If the patient has requested a chaperone and none is available at that time the patient must be given the opportunity to reschedule their appointment within a reasonable timeframe. 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 health care 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.
Where a health care professional is working in a situation away from other colleagues e.g. home visit, out-of-hours centre, 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 would be advised 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 practitioner is community based, then procedures should be in place to ensure that communication and record keeping are treated as paramount.
Health care professionals should note that they are at an increased risk of their actions being misconstrued or misrepresented if they conduct intimate examinations where no other person is present.
- Many patients feel reassured by the presence of a familiar person and this request in almost all cases should be accepted.
- A situation where this may not be appropriate is where a child is asked to act as a chaperone for a parent undergoing an intimate examination. They may not necessarily be relied upon to act as a witness to the conduct or continuing consent of the procedure. However if the child is providing comfort to the parent and will not be exposed to unpleasant experiences it may be acceptable for them to be present.
- HOWEVER – it is inappropriate to expect an informal chaperone to take an active part in the examination or to witness the procedure directly. In such cases, a formal chaperone (nurse, trained reception staff member) should be sought.
In any situation where concerns are raised or an incident has occurred you have a duty to inform the complaints lead at your practice. If you don’t know who this ease, ask the Practice Manager or one of the GP partners. You may need to write a report about what happened. This should be completed immediately after the consultation
The relationship between a patient and their practitioner is based on trust. A practitioner may have no doubts about a patient they have known for a long time and feel it is not necessary to offer a formal chaperone. This is fine, providing you have asked the patient if they would like a chaperone or not. This should not detract from the fact that any patient is entitled to a chaperone if they feel one is required. Studies have shown that many patients are not concerned whether a chaperone is present or not but you should ask out of courtesy and respect. You can’t always second guess what your patient is thinking – no matter how well you think you know them.
- In the case of children a chaperone would normally be a parent or carer or alternatively someone known and trusted or chosen by the child. Patients may be accompanied by another minor of the same age.
- For competent young adults the chaperone guidance relating to adults is applicable.
- If a minor presents in the absence of a parent or guardian the healthcare professional must ascertain if they are capable of understanding the need for examination. In these cases it would be advisable for consent to be secured and a formal chaperone to be present for any intimate examinations.
- Children and their parents or guardians must receive an appropriate explanation of the procedure in order to obtain their co-operation and understanding.
- The age of Consent is 16 years, but young people have the right to confidential advice on contraception, pregnancy and abortion and it has been made clear that the law is not intended to prosecute mutually agreed sexual activity between young people of a similar age, unless it involves abuse or exploitation. However, the younger the person, the greater the concern about abuse or exploitation. Children under 13 years old are considered of insufficient age to consent to sexual activity, and the Sexual Offences Act 2003 makes clear that sexual activity with a child under 13 is always an offence.
- In situations where abuse is suspected great care and sensitivity must be used to allay fears of repeat abuse. Healthcare professionals should refer to their local Child Protection policies for any specific issues.
- Further information about confidentiality, data protection and consent can be found at www.doh.gov.uk/safeguardingchildren/index.htm and Working Together to Safeguard Children (Department of Health 1999).
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. A careful simple and sensitive explanation of the technique is vital. This patient group is a vulnerable one and issues may arise in initial physical examination, “touch” as part of therapy, verbal and other “boundary-breaking” in one to one “confidential” settings and indeed home visits.
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 should be abandoned and an assessment should be made of whether the patient can be considered competent or not. If the patient is competent, despite learning difficulties or mental health problems, the investigation or treatment cannot proceed. If on the other hand, the patient is incompetent, the patient should be treated according to his or her own best interests. Assessing best interests must take into account the potential for physical and psychological harm but in some situations it may be necessary (to secure the patients best interests) to proceed in an appropriate manner which, in some cases, may mean examination under anaesthetic. In life-saving situations the healthcare professional should use professional judgement and wherever possible discuss with a member of the Mental Health Care Team.
The series Books Beyond Words (Gaskell Publications), especially “Looking After My Breasts” and “Keeping Healthy Down Below” may be helpful.
The ethnic, religious and cultural background of some women can make intimate examinations particularly difficult, for example, Muslim and Hindu women have a strong cultural aversion to being touched by men other than their husbands. Patients undergoing examinations should be allowed the opportunity to limit the degree of nudity by, for example, uncovering only that part of the anatomy that requires investigation or imaging. Wherever possible, particularly in these circumstances, a female healthcare practitioner should perform the procedure. It would be unwise to proceed with any examination if the healthcare professional is unsure that the patient understands due to a language barrier. If an interpreter is available, they may be able to double as an informal chaperone. In life saving situations every effort should be made to communicate with the patient by whatever means available before proceeding with the examination.
There may be special situations where more explicit consent is required prior to intimate examinations or procedures, such as where the individual concerned is a minor or has special educational needs. In these circumstances individuals should refer to their local policy on Consent for specific details relevant to their working environment. For example, in the case of a woman who is a victim of an alleged sexual attack valid written consent must be obtained for the examination and collection of forensic evidence.
Adapted from guidance written by Dr Clare Gerada and Lucy Warner.