The dilemma: The parents of my patient, a 15-year-old girl with Down’s syndrome, are going through divorce proceedings. Her father has sent an email to the practice explaining that he does not agree with childhood immunisation – specifically the COVID-19 vaccine – and has indicated that he does not consent to any childhood vaccination being administered to his daughter.
On the other hand, the patient’s mother has voiced her strong support for childhood immunisation including for COVID-19. She plans to take her daughter for her COVID-19 vaccination when called, regardless of her estranged husband’s objections.
The child’s capacity has been assessed and she does not have capacity to consent to the immunisation herself. What should we do?
Public Health England and the DHSC publish the ‘Green Book’ which has the latest information on vaccines, including vaccination procedures for all preventable infectious diseases that may occur in the UK.
This has been updated to reflect the inclusion of children and young people in the COVID-19 vaccination programme following recent recommendations from the Joint Committee on Vaccinations and Immunisation (JCVI).
Risks from COVID-19
The guidance explains that 'a small number of children and young people with underlying chronic conditions are at increased risk of serious COVID-19 disease'. The JCVI has therefore advised that chidren and young people aged 12 years and over with specific underlying health, as well as those aged over 12 who are household contacts of anyone who is immunosuppressed, should be offered the COVID-19 vaccine.
Down’s syndrome is listed in the Green Book as one of the conditions associated with increased risk of serious COVID-19 disease.
Chapter 2 of the Green Book addresses the issue of consent and states that although the consent of one person with parental responsibility for a child is usually sufficient, if one parent agrees to immunisation but the other disagrees, the immunisation should not be carried out unless both parents can agree, or there is a specific court approval that the immunisation is in the best interests of the child.
In this case, the practice should advise the parents that they have a responsibility to discuss the matter and reach agreement between themselves as quickly as possible.
Until the dispute is resolved, the child’s vaccination should generally not be provided unless the GP has considered it to be necessary to safeguard the child’s best interests. In this instance, medicolegal advice from your medical defence organisation should be sought as to whether an application to the court is required.
The practice also may wish to consider inviting the child’s father to meet with the clinical team, allowing him to share his concerns about childhood immunisation. This would be a good time to assess whether his views are based on accurate and up-to-date information, discuss the potential risks and side effects, and help him fully understand the risks and benefits of the COVID-19 vaccination.
If the discussion proceeds well and the patient’s father has agreed for the child to be vaccinated, it is important to revisit this in future to ensure that consent is obtained for each vaccine. This is because one of the parents, or both, may change their minds and withdraw consent at any time.
It would be prudent, in this instance, to record in the patient’s notes if and when consent has been discussed and obtained, even though it is not a legal requirement for immunisation consent to be in writing through a signed consent form. It is also particularly important to document the disagreement between those with parental responsibility for the child, and the date when the disagreement is resolved.
Vaccinating the patient
On the day of the vaccination, the person with parental responsibility does not necessarily need to be present at the practice. The patient may be presented to the practice for immunisation by a person without parental responsibility, such as a grandparent or child-minder.
According to the Green Book, the clinician who administers the vaccination must be satisfied that:
- The person with parental responsibility has consented in advance to the immunisation (i.e. they received all the relevant information in advance and arranged for the other person to bring the child to the appointment); or
- The person with parental responsibility has arranged for this other person to provide the necessary consent (i.e. they asked the other person to take the child to the appointment, to consider any further information given by the health professional, and then to agree to immunisation if appropriate).
This scenario and the advice is based on guidance available at the time of publishing. It is important to remember that clinical guidance regarding COVID-19 vaccination is evolving and may be subject to change, potentially at short notice. Clinicians should always ensure that they are acting in accordance with the current clinical recommendations and best practice.
- Dr Andrew Power is medicolegal consultant at Medical Protection