Chaperones are most often required or requested where a male examiner is carrying out an intimate examination or procedure on a female patient. 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. However, it is good practice for a health organisation to offer all patients a chaperone for any consultation, examination or procedure where the patient feels one is

required. This offer can be made through a number of routes including prominently placed posters, practice leaflets and verbal information prior to the actual consultation. It is not always clear ahead of the consultation that an intimate examination or procedure is required. It may be wise, especially where a male clinician examines a female patient to repeat the offer of a chaperone at the time of the examination.

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. In addition, careful and sympathetic explanation of the examination technique to be used should be given throughout the procedure being carried out. 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.

           Attention must be given to the environment ensuring adequate privacy is afforded to maintain dignity.

Staff should be aware that intimate examinations might cause anxiety for both male and female patients and whether or not the examiner is of the same gender as the patient.

There is no common definition of a chaperone and their role varies considerably depending on the needs of the patient, the healthcare professional and the examination or procedure being carried out. Broadly speaking their role can be considered in any of the following areas:

• 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

       A chaperone is present as a safeguard for all parties (patient and practitioners) and is a witness to continuing   consent of the procedure.

The designation of the chaperone will depend on the role expected of them and on the wishes of the patient. It is useful to consider whether the chaperone is required to carry out an active role – such as participation in the examination or procedure or have a passive role such as providing support to the patient during the procedure.

Informal chaperone

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. It is inappropriate to expect an informal chaperone to take an active part in the examination or to witness the procedure directly.

Formal chaperone

A formal chaperone implies a clinical health professional, such as a nurse, or a specifically trained non-clinical staff member, such as a receptionist. This individual will have a specific role to play in terms of the consultation and this

role should be made clear to both the patient and the person undertaking the chaperone role. This may include assisting with undressing or assisting in the procedure being carried out. In these situations staff should have had sufficient training to understand the role expected of them. Common sense would dictate that, in most cases, it is not appropriate for a non-clinical member of staff to comment on the appropriateness of the procedure or examination, nor would they feel able to do so. 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. 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.

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.

It is advisable that members of staff who undertake a formal chaperone role have undergone training such that they develop the competencies required for this role. These include an understanding of:

• 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

Induction of new clinical staff should include training on the appropriate conduct of intimate examination. Trainees should be observed and given feedback on their technique and communication skills in this aspect of care.

All staff should have an understanding of the role of the chaperone and the procedures for raising concerns.

All patients should be routinely offered a chaperone during any consultation or procedure. This does not mean that every consultation needs to be interrupted in order to ask if the patient wants a third party present. 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.

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. 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.

However, there are some cases where the (usually male) doctor may feel unhappy to proceed. This may be where a male doctor is carrying out an intimate examination, such as cervical smear or breast examination. Other situations are where there is a history of violent or unpredictable behaviour on behalf of the patient or their family member/friend. In these situations it may be possible to arrange for the patient to see another doctor or health professional.

For some patients, the level of embarrassment increases in proportion to the number of individuals present.

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 time frame. 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.

Implicit in attending a consultation it is assumed that that a patient is seeking treatment and therefore consenting to necessary examinations. However 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.

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.

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 guidance relating to adults is applicable. 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.

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.

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 lifesaving

situations the healthcare professional should use professional judgement and wherever possible discuss with a member of the Mental Health Care Team.

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.

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. 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. Once the patient is dressed following an examination or investigation the findings must be communicated to the patient. 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.

Any requests that the examination be discontinued should be respected.

Any requests that the examination be discontinued should be respected.

The most common cause of patient complaints is a failure on the patient’s part to understand what the practitioner was doing in the process of treating them It is essential that the healthcare professional explains the nature of the examination to the patient and offers them a choice whether to proceed with that examination at that time. The patient will then be able to give an informed consent to continue with the consultation.

Recording in Patients’ notes

Details of the examination including presence/absence of chaperone and

information given must be documented in the patient’s medical records. This

could include formal GP records, nursing notes, Patient Medication Records

for pharmacists or therapists record cards.

For GP records appropriate READ coding is available, either in 4 or 5 byte mode:

4byte                                                                    5 byte (include full stop)

9NP0             Chaperone Offered                    9NP0.

9NP1             Chaperone Present                   9NP1.

9NP2             Chaperone Refused                  9NP2.

9NP3             Nurse Chaperone                      9NP3.

If the patient expresses any doubts or reservations about the procedure and the healthcare professional feels the need to reassure them before continuing then it would be good practice to record this in the patient’s notes. The records should make clear from the history that an examination was necessary.

In any situation where concerns are raised or an incident has occurred and a report is required 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. Similarly studies have shown that many patients are not concerned whether a chaperone is present or not. However this should not detract from the fact that any patient is entitled to a chaperone if they feel one is required. Chaperone guidance is for the protection of both patients and staff and this guidance should always be followed. The key principles of communication and record keeping will ensure that the practitioner/patient relationship is maintained and act as a safeguard against formal complaints, or in extreme cases, legal action.