Practice Dilemma - Confidentiality issues in childcontraception

A mother finds out that you have given contraception to her under-age daughter. Have you breached confidentiality?

THE DILEMMA

Amy consulted me a few weeks after her 14th birthday to request emergency contraception. She presented as a physically mature and confident girl and told me that she was in a relationship with a slightly older boy who was using condoms. I did not think that there was a child protection issue and I assured her that I would respect her confidentiality, but suggested that she confide in her parents. She later returned to have a contraceptive injection.

Recently, Amy's mother asked me if I could confirm the rumour that her daughter was having a relationship with a married teacher and that she was pregnant. I could say truthfully that I knew nothing of this, but she then asked me if I was providing Amy with contraception. I suggested that she ask Amy herself, but my obvious discomfort answered the question for her.

What should I have done and, as she is still under age, can Amy justifiably complain that I have breached her confidentiality?

A GP'S VIEW

Dr Louise Warburton, a GP in Ironbridge, Shropshire

When Amy first consulted, the GP should have tried to gain more information about her relationship, and could have been more forceful about the involvement of Amy's parents.

If the GP is assuming that she is 'Gillick competent', and therefore entitled to confidentiality, this should have been recorded in the notes.

I would have insisted that Amy discuss the matter with her parents. I would have given her emergency contraception, but I would also have asked her to return with her parents to discuss subsequent contraception.

Of course, this might have meant that she never returned and ended up with an unwanted pregnancy, which would be the worst case scenario. However, with careful counselling, it should be possible to keep both Amy and her parents happy.

Unfortunately, this did not happen, and when faced with an angry parent it is difficult to remain cool. Her mother correctly guessed that the GP has been providing contraception. It is imperative that the GP records that this information was not given directly to the mother, in case a subsequent complaint ensues. I do not think that the GP has betrayed Amy's confidence.

The GP also needs to record that he knew nothing of the nature of the relationship.

It would have been good practice to have carried out a pregnancy test before the contraceptive injection was given. This evidence may prove useful if a complaint is made.

Strictly speaking, the GP did nothing wrong, but the case could have been handled better.

A MEDICO-LEGAL OPINION

Dr Bryony Hooper, medico-legal adviser, Medical Protection Society

When Amy first asked for contraception, you had to make a judgement as to whether she was 'Gil- lick (or Fraser) competent', and whether it was in her best interests to receive contraception even without her parents' involvement.

Having made that decision, you should respect her confidentiality as you would for any of your adult patients, unless you think there is a child protection issue. The Children Act 1989 makes it clear that the welfare of the child is paramount. Therefore, if you feel a child is at risk of harm, you may need to override their request for confidentiality, even if you believe them to be competent.

You are therefore in a difficult position, having been told by Amy that she is in a consensual relationship with a boy of much the same age, and given conflicting information from her mother.

The age gap and position of trust of the teacher clearly suggests such a relationship could be an abusive one, as well as raising concerns about whether an offence is being committed by the teacher under the Sexual Offences Act 2003.

As you do not have any information likely to assist Amy's mother in clarifying whether such a relationship exists, you are right to suggest that she raises these issues with her daughter or the school. You should also try and find out more about the mother's concerns. By doing so you are not breaching Amy's confidentiality, but you are gaining more information that you can discuss with Amy when she next attends in order to make your own assessment.

As for looking uncomfortable when questioned by the mother, no one should read too much into an entirely natural reaction on your part.

A PATIENT'S VIEW

Trevor Seemann, a member of the Patient Partnership Group

Your prime concern appears to be a complaint from Amy but I think you are just as likely to receive one from her mother.

Although Amy is a 'physically mature and confident girl' she is still a 14-year-old child. It is regrettable that you did not take more time to discuss her exact circumstances in respect of her sexual relationship.

It is possible that you may have discovered if there actually was a child protection issue.

I would like to know whether, on subsequent visits, you asked if she had discussed the matter with her parents. My suspicion is that you failed to do so.

I am also at a loss to understand why you were so quick to prescribe the contraceptive injection. My understanding is that this drug should be used with extreme caution when administered to young persons who are still developing their bone structure.

Finally, you gave Amy your personal assurance as to confidentiality.

You may unwittingly be guilty of breaching her confidentiality and I see no reason why she could not complain. However, I do not think anybody would accept you did it deliberately or maliciously. I feel her mother has good grounds to complain too.

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