Medicolegal - The function of a chaperone

A chaperone can act as a safeguard for both GP and patient, says MDU adviser Dr Emma Cuzner.

In Victorian times, chaperones accompanied young unmarried women to social outings to protect them from unwanted or inappropriate attention.

However chaperones continue to have a place in the modern medical setting.

Reassurance
Guidance published by the NHS Clinical Governance Support Team in 2005 recommends that every primary care organisation should have a chaperone policy.

It suggests that 'a chaperone is present as a safeguard for all parties (patients and practitioners) and is a witness to the continuing consent of the procedure'.

The specific function of a chaperone will vary according to the situation but their main role is to provide the patient with reassurance and emotional support when undergoing an examination that they may find embarrassing or uncomfortable.

A chaperone can also help the doctor with the examination, act as an interpreter, discourage unfounded allegations of improper behaviour and protect the doctor from physical attack.

In a healthcare setting, the role of a chaperone can be filled by a number of people, such as a relative or a practice nurse.

This is reiterated in the latest GMC guidance on chaperones, which states that they do not have to be medically qualified and can be a relative or friend of the patient.

When to use a chaperone
The GMC has recently updated its guidance, Maintaining Boundaries, on chaperones. It says that doctors should usually offer one for intimate physical examinations. If either the doctor or the patient wishes a chaperone to be present but none is available, the consultation should be rearranged for a later date, if possible.

Doctors should make a detailed note in the records and ensure it includes details of whether a chaperone was offered and was present (and their identity), or if a chaperone was refused.

Poor clinical records, particularly if there is no entry that an intimate physical examination was carried out, can leave a doctor vulnerable to a serious allegation of improper behaviour.

The chaperone's role only extends as far as the physical examination. Once it is completed, the chaperone should leave the consulting room to allow one-to-one communication to take place, unless the patient wishes them to stay.

Communication
Effective communication is the key to preparing patients for intimate physical examinations.

Doctors need to give a full explanation of the nature and the purpose of the examination so that the patient understands exactly what is entailed, to ensure that consent is obtained and prevent misunderstanding that can lead to allegations of indecency.

You should give the patient privacy to undress and keep discussion relevant, avoiding personal comments.

The MDU advises that during the examination, the GP may need to further explain what they are doing.

It is unwise to assume that a patient understands why certain examinations are carried out in a certain manner, such as why both breasts are examined when a patient complains of a lump in only one, or why the testes may be examined in a child with abdominal pain.

Allegations
Each year the MDU receives enquiries from members about the use or lack of availability of chaperones. It assists with a handful of allegations of improper examination. These cases are investigated by the police or GMC.

Complaints of indecent assault are made by patients of both sexes against doctors of both sexes, but most are from female patients against male doctors. The presence of a chaperone does not guarantee protection against a complaint There have been cases dealt with by the MDU where allegations have been made in spite of the presence of a chaperone.

In one case, a patient accused a doctor of indecency during the taking of a cervical smear, in the presence of a chaperone. The case was eventually dismissed by the GMC but the doctor endured a public hearing that was widely reported in the media.

These cases are unusual but it is more common to face an accusation of indecency when a chaperone has not been present.

Dr Cuzner is a medicolegal adviser at the MDU

This topic falls under section 10.1 of the GP curriculum 'Women's Health' www.rcgp-curriculum.org.uk

Contact Sharon Pickett at GP Education on (020) 8267 4512 or email GPclinical@haymarket.com

 Learning points
 Using a chaperone

1. Always offer a chaperone for intimate examinations.

2. If a chaperone is not available, rearrange the appointment for another time.

3. Record the patient's decision about whether or not to have a chaperone, and the identity of any chaperone used.

4. Explain the examination fully to both patient and chaperone.

5. Once the examination is finished the chaperone should leave the room, allowing one-to-one discussion between doctor and patient, unless the patient wants them to stay.

References
- Guidance on the Role and Effective Use of Chaperones in Primary and Community Care Settings: Model Chaperone Framework, NHS Clinical Governance Support Team, June 2005

- Maintaining Boundaries, GMC, 2006, www.gmc-uk.org

 CHAPERONE CHECKLIST
  • Obtain the consent of the patient for a chaperone to be present and record this in the patient's notes.
  • Record if the patient has declined a chaperone.
  • If possible, use a chaperone of the same gender as the patient.
  • Record the identity of the chaperone in the patient's notes.
  • Allow the chaperone to hear the explanation of the examination and the patient's consent.
  • Position the chaperone where they can see the patient and how the examination is being conducted.
  • Don't continue the examination if the chaperone leaves the room unless the patient agrees.
  • Explain clearly beforehand what you will be doing during the examination and at each stage of the procedure.
  • Encourage questions and discussions.
  • Ensure the patient's privacy.
  • Be alert to verbal and non-verbal indications of distress from the patient.
  • Avoid personal remarks.

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