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Chaperones and Informed Consent

Case Study:

Mrs M is a woman with a history of gynaecological problems. She makes a call to her local GP Clinic asking for a doctor to make a house call. She is experiencing severe nausea, fatigue, fever and abdominal pain and has noticed some menstrual spotting. Dr O, a new GP at the Clinic, agrees to attend. Mrs M advises that she is bed-bound and leaves instructions where Dr O can find the spare key to enter the house.

Dr O arrives and lets himself into the house, as directed by Mrs M. He finds her upstairs in her bedroom. Mrs M explains her symptoms and Dr O explains that he wishes to examine for abdominal tenderness. Mrs M lifts her night gown only exposing her abdomen and Dr O proceeds to examine her. Dr O then removes her underwear and conducts an internal examination for what Mrs M considers to be a prolonged period. On finishing the examination, Dr O informs Mrs M that he is not too concerned, but recommends further tests at the hospital. He calls an ambulance, waits for it to arrive and explains the situation to the paramedics before returning to the clinic.

Following the tests, Mrs M is diagnosed with acute gastroenteritis and is treated accordingly.

When she recounts the events of the day and the ultimate diagnosis to her husband, Mrs M begins to feel very uncomfortable and upset, as Dr O didn’t inform her that he was going to perform an intimate examination, nor did he explain why he needed to do so. Having thought about it, Mrs M decides to make a complaint to the Medical Council on foot of the inappropriate examination.

NOTE: This case study does not form part of the Guide to Ethics and Professionalism for Registered Medical Practitioners, nor does it constitute clinical or legal advice. It is intended as a helpful illustration of a potential scenario.


What guidance does the Medical Council provide to doctors that could have helped Dr O in this situation?

In this case study, Mrs M complained to the Medical Council, despite Dr O having the best intentions and conducting a thorough examination. If we consult the Ethical Guide, we can find guidance that would help Dr O to reassure his patient by acting more professionally.

With regard to physical and intimate examinations, paragraph 35 of the Guide to Professional Conduct and Ethics for Registered Medical Practitioners (8th edition) states:

35.1 Clinical assessments of patients often involve a physical examination as well as relevant history-taking. Before undertaking any physical examination, including an intimate examination, you should explain to patients why it is needed and what will be involved, and get their consent.

Did Dr O give his patient enough information before getting consent to examine her?

35.2 You should respect patients’ dignity by giving them privacy to undress and dress, and keeping them covered as much as possible. You should not help the patient to remove clothing unless they have asked you to do so, or you have checked with them that they want your help.

35.3 Where an intimate examination is necessary, you must explain to the patient why it is needed and what it will entail. You must ask the patient if they would like a chaperone to be present – for example, a nurse or family member - and note in the patient’s record that a chaperone was offered. You should also record if a chaperone was present, had been refused, or was not available but the patient was happy to proceed.

Mrs M was at home alone and notified Dr O of this before he left his clinic, yet he did not attempt to find a chaperone for the visit to her home.

The guidance on consent in paragraph 11 is also relevant in this situation:

11.1 You must give patients enough information, in a way that they can understand, to enable them to exercise their right to make informed decisions about their care. Consent is not valid if the patient has not been given enough information to make a decision.

11.2 The amount of information patients need before making a decision will vary according to a number of factors, including:

  •  the nature of the condition;
  •  the type of investigation;
  •  the complexity of the treatment;
  •  the risks associated with the treatment or procedure (and the risks of non-treatment)
  •  the patient’s own wishes.

Dr O did not explain to Mrs M what he thought the probable causes were and that he could not provide clinical care for her.

Let’s look at this from Dr O’s perspective:

  • I responded to my patient very quickly and suspended my clinic to make a house call to her, as she was bed-bound and unable to attend;
  • I was aware of my patient’s previous medical history;
  • I examined my patient thoroughly and recommended further tests as a precaution; 
  • I called an ambulance and completed an effective clinical handover; 
  • I thought I had acted appropriately and in the best interests of my patient.

Now, let’s consider Mrs M’s perspective:

  • Dr O knew I was alone in my home and very unwell. He also knew that I may need an intimate examination, but he didn’t take a chaperone with him, nor did he ask me if I wanted one;
  • Dr O did not fully explain why he needed to examine me;
  • When Dr O realised that he couldn’t offer me clinical care, he didn’t explain this to me; 
  • I wasn’t offered any privacy to remove my clothing;
  • I felt vulnerable and was unable to make an informed decision about my care.

How could Dr O have avoided a complaint to the Medical Council?

In this scenario, Mrs M is a particularly vulnerable patient. She is in distress and home alone. Although Dr O attended to her in a timely and efficient manner, he neglected to provide a chaperone and his examination of Mrs M made her feel uncomfortable. If Dr O explained to Mrs M that he could not, in this situation, provide any clinical care for Mrs M, she may not have given consent to the examination.

*Doctors should be aware that complaints have been made to the Medical Council from patients who were not offered a chaperone and who were denied a chaperone, as well as related issues.

In such a case, Medisec Ireland advise members to determine if an intimate examination is urgent on a clinical basis and if not, to reschedule or make other arrangements.

Further Resources:

Best Practice in the Use of Chaperones (Medical Defence Union Journal)
www.themdu.com/guidance-and-advice/journals/mdu-journal-april-2014/best-practice-in-the-use-of-chaperones

Chaperones (Medical Protection Society)
https://www.medicalprotection.org/uk/resources/factsheets/england/england-factsheets/uk-chaperones

Chaperones (Medisec)
http://www.medisec.ie/a-z/chaperones-for-examinations

Acknowledgement:

The Medical Council is grateful to Medisec Ireland for contributing the above case study. In such a case, Medisec Ireland advise members to determine if an intimate examination is urgent on a clinical basis and if not, to reschedule or make other arrangements.