Chaperoning of Patients During Examination, Investigation or Clinical Recording - Policy on the

Publication: 01/11/2006  
Next review: 18/10/2023  
Clinical Policy
CURRENT 
ID: 890 
Approved By: Executive Team Meeting 
Copyright© Leeds Teaching Hospitals NHS Trust 2021  

 

This Clinical Policy is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Policy for the chaperoning of patients during examination, investigation or clinical recording

  1. Staff Summary
  2. Purpose
  3. Background/Context
  4. Definitions
  5. Policy Effect: Processes under the Policy
  6. Roles and Responsibilities
  7. Communication and Documentation
  8. Equality and Diversity Statement
  9. Consultation and Review Process
  10. References

Staff Summary

The Trust is committed to providing a safe, comfortable environment where patients and staff can be confident that best practice is being followed at all times and the safety of everyone is of paramount importance.

The purpose of this policy is to describe the process and responsibilities relating to chaperoning patients within Leeds Teaching Hospitals Trust.

It applies to all healthcare professionals who perform examinations, investigations or clinical recordings and staff members who will perform the role of a chaperone.

The remit of the policy is to ensure, that patients’ privacy and dignity are maintained at all times, through using chaperones as required. It also aims to ensure processes are in place to safeguard the interests of all parties that are involved.

This policy will be implemented within each Clinical Service Unit (CSU) through an agreed communication and implementation plan led by CSU Triumvirates. The ratified policy will be made available to all staff via the LTHT intranet and the Leeds Health Pathways, and will be reviewed two years after publication.

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Purpose

The purpose of this policy is to produce a co-ordinated approach to the use of chaperones during consultations, examinations and procedures carried out within the Trust.

The policy provides guidance for the suitable use of chaperones and the procedures that should be in place to enable access to appropriate, competent chaperones.

This policy is intended to safeguard patients/service users and ensure that privacy and dignity is given high regard when treatment involves intimate or other examinations. The policy also serves to reduce the likelihood of service users misinterpreting actions taken by staff as part of consultation, examination, treatment and care; however the focus of the procedure remains with the service user.

This policy applies to all employees Trust-wide, including locum, bank and agency staff working on behalf of the Trust and involved in the direct care of patients, and any others who may be asked to chaperone patients. This policy applies to the use of chaperones with infant, child or adult patients.

It sets out guidance on the use of chaperones within the Trust and is based on recommendations from the General Medical Council, Royal College of Nursing, NHS Guidance and the findings of the Ayling Inquiry (2004) and recommendations of the Verita Report (2015). All healthcare professionals have a responsibility to ensure they work in line with their own professional code of conduct.

This policy will be available via the Trust internet and stored on the Leeds Health Pathways web pages.

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Background/Context

Patients can find some consultations, examinations, investigations or procedures distressing and may prefer to have a chaperone present in order to support them. It is good practice to offer all patients a chaperone for any consultation, examination or procedure, or where the patient feels one is required.

Examples of consultations or procedures which may make the patient feel particularly vulnerable include the need to undress, the use of dimmed light or intimate examinations involving the breasts, genitalia or rectum.

The intimate nature of many nursing, midwifery and medical interventions, if not practised in a sensitive and respectful manner, can lead to misinterpretation and the potential for allegations of sexual assault or inappropriate examinations. This policy is intended to safeguard patients/service users and ensure that privacy and dignity is given high regard when treatment involves intimate or other examinations. The policy also serves to reduce the likelihood of service users misinterpreting actions taken by staff as part of consultation, examination, treatment and care; however the focus of the procedure remains with the service user.

In these circumstances a chaperone will act as a safeguard for both patient and clinician.

All patients have the right, if they wish, to have a chaperone present during an examination, procedure, or treatment. Staff should be sensitive to differing expectations with regard to race, culture, ethnicity, age, gender and sexual orientation, and wherever possible, the chaperone should be of the same gender as the patient.

The Ayling Inquiry (2004) stated that there was a need for each NHS Trust to determine its chaperoning policy, make this explicit to patients and to resource it accordingly.

Guidance from the Nursing and Midwifery Council (2015) and the Royal College of Nursing (RCN) (2016) states that all patients should have the right, if they wish, to have a chaperone present during an examination or procedure, treatment or care irrespective of organisational constraints or settings in which they are carried out.

The General Medical Council (GMC) (2003) recommends that whenever possible medical practitioners should offer the patient the security of having an impartial observer (a “chaperone”) present during an intimate examination even if you are the same gender as the patient.

This policy has been developed with the aim of producing a co-ordinated approach to the use of chaperones during consultations, examinations or procedures carried out within Leeds Teaching Hospitals NHS Trust. It should be used in conjunction with existing guidance from Professional Bodies and with reference to:

  • Heath Records Management Policy
  • Freedom to Speak Up Policy
  • Mental Capacity Act 2005
  • Adult/Children Safeguarding Polices
  • Consent to Examination or Treatment Policy
  • Equality and Diversity Policy

This policy applies to all staff working in the Trust who may be involved in examining or undertaking clinical procedures as well as those who may be asked to chaperone patients.

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Definitions

Chaperone: There is no common definition of a ‘chaperone’ and the role varies according to the needs of the patient, the healthcare professional, and the examination or procedure being carried out. It is acceptable for a friend, relative or carer to be present during a procedure if that is the wish of the patient; this should be documented.

For this policy, the following definitions are used:

A formal chaperone: This implies a healthcare professional, such as a Registered Nurse, or a specifically skilled unregistered staff member e.g. health care assistant (HCA). Where appropriate they may assist in the procedure being carried out and/or hand instruments to the examiner during the procedure. Assistance may also include clinical interventions and support provided to the patient when attending to personal hygiene, toileting and undressing/dressing requirements.

A chaperone will be able to identify any unusual or unacceptable behaviour on the part of the health care professional, and should immediately report any incidence of inappropriate behaviour, which includes inappropriate sexual behaviour to their line manager or another senior manager.

A chaperone will provide protection to healthcare professionals against unfounded allegations of improper behaviour made by the patient.

In all cases the presence of the chaperone should be confined to the physical examination part of the consultation or procedure unless the patient requests otherwise.

Confidential clinician–patient communication should take place on a one to one basis after the examination / procedures unless the patient requests otherwise It is the responsibility of the health care professional to ensure that any concerns they have regarding the examination or procedure are reported immediately to their line manager or senior manager

It is the responsibility of the Health Care Professional to ensure that accurate records are kept of the clinical contact, which also includes records regarding the acceptance or refusal of a chaperone.

It is the responsibility of the Health Care Professional to access any information and training required to support their role as a chaperone.

  • Medical and registered staff and healthcare support workers, who are up to date with all LTHT Mandatory training requirements and have familiarised themselves with this policy can undertake the role as formal chaperone.
  • Medical, nursing and midwifery students, and Allied Health Professional students, who are in their final year, and where there are no practice concerns from their learning institution or the Trust, may volunteer to undertake the formal chaperone role provided that they are aware of the role and responsibilities chaperoning entails, and they are aware of the mechanisms for raising concerns during or after the examination in which they are participating.
  • It is mandatory within the Trust that a formal chaperone is present for all intimate examinations.

A relative or friend of the patient is not usually an impartial observer and would not be a suitable formal chaperone, but you should comply with any request to have such a person present during intimate examinations, as well as a formal chaperone.

Intimate examinations: these include examinations of breasts, genitalia and rectum. Cultural and diversity influences may affect what is deemed ‘intimate’ to a patient and particular regard should be taken of social, ethnic and cultural perspectives.

An informal chaperone: family member, friend, legal guardian, non-clinical staff member, medical or junior healthcare student.

An informal chaperone can be used to support the patient during any non-intimate consultation, examination or procedure.

Clinical recording is an umbrella term that includes photography, video and audio recording.

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Policy Effect: Processes under the Policy

CHAPERONING OF PATIENTS

 

Good practice. It is good practice to offer all patients a chaperone for any consultation, examination or procedure where the patient feels one is required. 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 a chaperone should be made clear to the patient prior to any procedure.  

 

If a patient prefers to undergo an examination/ procedure without the presence of a chaperone this should be respected and their decision documented in their clinical record, unless the examination is an intimate examination or procedure, when a chaperone is mandatory.

 

Details of any examinations/procedures should be recorded in the patient’s

health record and the presence or absence of a chaperone recorded, including

the name of the chaperone.

 

An intimate examination is defined as an examination of the breast, genitalia or rectum and applies to both female and male patients. (An exception to this may be made for the examination of male breast tissue, decided on a case-by-case basis).

In order for patients to exercise their right to request the presence of a chaperone, a full explanation of the examination, procedure or treatment to be carried out should be given to the patient. This should be followed by a check to ensure that the patient has understood the information and gives consent.

 

To protect the patient from vulnerability and embarrassment, consideration should be given to the chaperone being of the same sex as the patient wherever possible.

 

Facilities should be available for patients to undress in a private, undisturbed area. There should be no undue delay prior to examination once the patient has removed any clothing.

 

Examinations should take place in a closed room or well screened bay that cannot be entered without consent while the examination is in progress. ‘Do not enter’ or ‘examination in progress’ signs must be used when possible, and the chaperone must be present.

 

During the examination the examiner should:

 

  • be courteous at all times
  • offer reassurance
  • keep all discussion relevant to the examination and avoid personal comments
  • remain alert to any verbal and non-verbal signs of distress from the patient
  • respect any requests for the examination to be discontinued
  • document the name and presence of the chaperone in the patient’s notes or electronic record

 

4.1 Documentation and Record Keeping

The name and role of the chaperone present, and whether ‘formal’ or ‘informal’, must be documented in the patient’s notes or electronic record. If the patient is offered a chaperone and declines the offer, this must also be documented.

 

4.2 Consent

Consent is a patient’s agreement for a health professional to provide care. Before health care professional’s (HCP) examine, treat or care for any person they must obtain their valid consent.

 

There is a basic assumption that every adult has the capacity to decide whether to consent to, or refuse, proposed medical intervention, unless it is shown that they cannot understand information presented in a clear way. Staff must refer to the Trust consent and mental capacity policy in relation to this.

 

Staff need to be mindful that by attending a consultation it may be assumed that a patient is seeking treatment. However, before proceeding with an examination it is vital that the patient’s valid consent is obtained. This means that the patient must have capacity/ be Gillick competent to make the decision. They must have received sufficient information to take it and not be acting under duress.

 

When patients do not have the ability to consent for themselves the healthcare professional (HCP) should undertake an assessment of mental capacity and make the decision in the patient’s best interests in line with the Mental Capacity Act 2005 and Trust Policies. This must be documented in the patient’s notes.

 

For any procedure where consent is required prior to intimate examinations or procedures staff should refer to the Trusts Consent Policy.

 

In the case of any victim of an alleged sexual attack, valid written consent must be obtained for the examination and collection of forensic evidence. In situations where abuse is suspected, great care and sensitivity must be used to allay fears of repeat abuse. Healthcare professionals should refer to the LTHT Safeguarding Children Policy/Safeguarding Adults at Risk Policy or advice can be sought from the Safeguarding Children team on 23937 or the Adults Safeguarding team 66964. http://lthweb/sites/safeguarding

 

4.3 Where a chaperone is declined by the patient.

If a patient prefers to undergo an examination / procedure without the presence of a chaperone this should be respected and their decision documented in their clinical record.

 

If the patient has declined a chaperone for an intimate examination, the practitioner must explain clearly to the patient why a chaperone is necessary. The examination should not proceed without a chaperone. Exceptions to this are specified within this policy.

Any discussion about chaperones and the outcome should be recorded in the patient’s notes or electronic record. That the offer of a chaperone was made and declined should always be recorded.

 

4.4 Where a suitable chaperone is not available or cannot be provided.

Every effort should be made to provide a chaperone. If either the practitioner or the patient does not want the examination to go ahead without a chaperone present, or if either is uncomfortable with the choice of chaperone, the examination may be delayed to a later date when a suitable chaperone will be available, as long as the delay would not adversely affect the patient’s health.

 

Where a suitable formal Chaperone cannot be provided, a Trust incident Datix should be completed outlining the reasons and action taken. The immediate line manager must be notified and any adverse implications this will have on the patient’s care and or treatment discussed with them. In all circumstances the patient must be notified that a chaperone is not available and noted in their notes.

 

Should the HCP proceed to undertake the intimate examination without the formal chaperone present they will be held accountable for answering any allegations made against them.

 

In a legal situation the ability of the Trust to defend a false accusation may be jeopardised if a formal chaperone is not present when required. Where an examination is inappropriate or not consented it may constitute a criminal or civil offence.

 

4.5 Patients with individual needs

Patients with communication needs or learning disabilities must have formal chaperone support from healthcare professionals.

 

Family, friends  and carers who understand their communications needs and are able to minimise any distress caused by the procedure could also be invited to be present throughout any examination.

 

Staff must be aware of the implications of the Mental Capacity Act (2005) (‘MCA’) and cognitive impairment. If a patient’s capacity to understand the implications of consent to a procedure, with or without the presence of a chaperone, is in doubt, the procedure to assess mental capacity must be undertaken. This should be fully documented in the patient’s notes or electronic record, along with the rationale for the decision.

 

4.6 Where the patient’s first language is not English

An interpreter should be used when a service user does not understand any English; or

 

  • When a service user may be able to speak some English but whilst under distress, their understanding becomes impaired; or

 

  • When a service user has an impairment which requires specialist support; or

 

  • When important clinical information is to be given or consent obtained and the service user would not be able to understand this in English.

 

Clinical information, medical terminology or decision making about clinical care should always be through the authorised interpreting services except in an emergency situation when staff may have to act in a patient’s best interest and not have time to arrange an interpreter.

 

Relatives, carers and friends should not interpret for service users

 

Consideration will be given within reason on gender of the interpreter and permission from the service user will be sought.

 

4.7 Issues specific to children and young people under the age of 18 years

 

It is mandatory at LTHT for all children and young people under the legal age of consent (16 years) to be seen in the presence of another adult.

 

A chaperone would normally be a parent or carer, or someone trusted and chosen by the child. However, good practice would indicate a staff member should act as chaperone in all settings, where intimate or complicated examinations are being undertaken, as parents do not always have an understanding of procedures. The age of consent is 16 years, but for a minor who is assessed as competent to make the decision, the guidance relating to adults applies. This may be a parent, acting as an informal chaperone. A parent or informal or formal chaperone must be present for any physical examination; the child should not be examined unaccompanied. Any intimate examination must be carried out in the presence of a formal chaperone.

 

Parents or guardians must receive an appropriate explanation of the procedure in order to obtain their informed consent to examination.

 

A parent or carer or someone already known and trusted by the child may also be present for reassurance.

 

For young adults, who are deemed to have mental capacity, the guidance that relates to adults is applicable.

 

Children and young adults being prepared for ‘transition’ to adult services may be seen for consultation or assessment without their parents/ carer at their request and with parental consent. That they are undertaking transition, as per Trust policy, should be recorded in the patient record. However, any physical examination requires a chaperone.

If they specifically request review without a chaperone, this must be discussed with them and their carer, and documented in the notes or electronic record., Intimate physical examination must not proceed without a chaperone.

 

Please see the LCSP ‘Intimate Care Policy’ for further information https://www.leedsscp.org.uk/Practitioners/Local-protocols/Intimate-Care-Policy-(1)

 

 

4.8 Maternity

Midwifery practice, by definition, involves intimate contact with women throughout pregnancy, in labour and postnatally. The Nursing and Midwifery Council (NMC) (2013), in its position statement, acknowledges the right of patients in the care of nurses and midwives to request a chaperone.

 

Consent should be obtained, and documented, for all intimate examinations on pregnant or post-partum women by midwives (eg vaginal examinations, induction of labour, examination of the perineum, perineal suturing, assisting with breastfeeding). In gaining consent there should be acknowledgment of the intimate nature of the procedure and the choice for women to request a chaperone. In most cases an informal chaperone (eg partner) is present. Equally, some women may not want their partner present for such an examination and this request should also be respected.

 

Where women request a formal chaperone for an examination by a midwife, this should be provided, with an explanation that the need to provide appropriate clinical care in an emergency may require intimate procedures to be performed in the absence of a chaperone. However, midwives should not proceed with an intimate examination if consent is withheld (but see emergency care below).

 

4.9 Issues for Specialist Services, Departments and compliance.

If a department or service believes they cannot meet full compliance with the policy due to the speciality or care they provide, then the service should ensure they have a Standard Operating Procedure (SOP) in place that demonstrates steps taken towards achieving compliance and a risk mitigation approach to any incidence of non-compliance. Any specialist service, department and CSU who identified the need to have a SOP will be required to have ensured the SOP has been ratified after following Trust governance process.

 

Mammography services:

The Ionising Radiation Medical Exposure (IRME) safety guidance states that the number of people present, including staff, should be at a minimum wherever possible. Society and College of Radiographers (SCoR) guidance also notes that mobile mammography units may not be roomy enough to accommodate extra staff, although two members of staff will always be present in the unit. For these reasons, while women undergoing mammography screening should be offered the opportunity to have a chaperone if they wish, it is not mandatory. Practitioners need to document a discussion with women about chaperoning, and ensure they operate within the (SCoR) protocols 

 

4.10       Remote or video consultation.

A remote or video consultation does not negate the need to offer a chaperone and the same principles would apply. The likelihood is however that the chaperone will be remote and as such all parties need to agree and be assured that the links and remote connections are working appropriately.

Information described in the Key Principles for intimate clinical assessments undertaken remotely in response to COVID-19 (NHS England & NHSI, 2020)

https://www.leedsth.nhs.uk/assets/905b5ba081/Key_principles_for_intimate_clinical_assessments_undertaken_remotely_in_response_to_COVID19_v1-1-1.pdf   gives further guidance to support clinicians provide care in a way that is in the best interests of their patients, whilst protecting both patients and clinicians from the risks associated with remote intimate assessments.

The guide is applicable across all health care settings. Focusing on how to safely manage the receipt, storage and use of intimate images taken by patients for clinical purposes, it reiterates the principles that remote consulting should be approached in the same way that it would be for face-to-face interactions.

 

4.11       Cultural and religious issues

The cultural values and religious beliefs of patients can make intimate examinations and procedures difficult and stressful for themselves and healthcare professionals. Clinicians must be sensitive to the needs of patients and their specific requirements understood (through the use of interpreters if appropriate) and whenever possible complied with.

 

4.12       Anaesthetised patients

Prior to intimate examination, or supervised examination by a student, on an anaesthetised patient, the patient should be appropriately consulted and a written, signed consent obtained in advance.

 

4.13       Emergency care

It is acceptable for clinicians to perform intimate examinations without a chaperone if the situation is an emergency or life threatening and speed is essential in the care or treatment of the patient, and the patient’s condition means they are unable to be consulted for consent. This should be recorded in the patient’s notes or electronic record.

 

4.14       Intimate personal care

‘Intimate personal care’ is defined as the care associated with bodily functions and personal hygiene, which require direct or indirect contact with, or exposure of, the sexual parts of the body. It is recognised that much medical and nursing day-to-day care is delivered without a chaperone, as part of the unique and trusting relationship between patients and practitioners.

 

However, staff must consider the need for a chaperone on a case-by-case basis, mindful of the special circumstances outlined in this policy, and patients should always be offered the opportunity to have a chaperone if they wish. Staff must be aware that patients of diverse cultures may interpret other parts of the body as intimate.

It is not necessary to request a chaperone for assisting infants and young children with care, such as nappy changing, unless there are special circumstances as outlined in this policy.

 

4.15       Other circumstances

Whilst exercising clinical judgment, clinicians are advised that they should consider being accompanied by a formal chaperone when examining or treating  patients:

  • Who are semiconscious or unconscious.
  • Who are intoxicated with alcohol, or have  taken anxiolytics, hypnotics or any drug or substances known to have hallucinogenic effects.
  • Who are confused / disorientated.
  • Who have  hearing, visual or speech difficulties
  • Who has  a history of abuse, or where abuse is suspected. Great care and sensitivity must be used to allay fears.
  • Who are vulnerable for other reasons not specified in this policy.

 

For some people who use our services, consultations, examinations and procedures may be threatening or confusing. A chaperone, particularly one trusted by the patient, may help the patient through the process with the minimum of distress.

 

For most patients respect, explanation, consent and privacy take precedence over the need for a chaperone.

 

Staff are still expected to portray the presence of a chaperone as a positive presence in assuring patients of safe care.

  • The role of the staff chaperone is to protect the interests of the patient and the professional by providing impartial observation of procedures, examinations, investigations or care, see Appendix A. Where two members of staff are involved in a procedure, for example in the anaesthetic room, one of them could fulfil the role of a chaperone; this may help to maintain the patient's privacy and dignity.
  • In order to maintain the confidentiality of the relationship between health care professional and patient, the need for a chaperone will normally end once the physical examination or procedure has been completed. Confidential doctor or healthcare professional communication with the patient should then take place on a one to one basis after the examination or procedure has taken place.

 

4.16       Preparation for the role and Training requirements

It is advisable that members of staff who undertake a formal chaperone role should have undergone local training so that they develop the relevant competencies and skills required for this role.

 

All staff should have an understanding of the role of the chaperone and the procedures for raising concerns. Staff chaperones need to be appropriately prepared for the role; this can be achieved locally within clinical teams with reference to this policy. A staff chaperone does not need to be a registered health care professional, but the use of administrative or clerical staff should be avoided.

 

This training should form part of the local ward/departmental induction programme and be facilitated by their respective line manager. Induction of new clinical staff who would act as formal chaperones must include the key principles listed below:

 

Training should 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 e.g. advocate, and the appropriate conduct during intimate examinations.
  • Policy and mechanism for raising concerns and accurate recording.
  • Staff undertaking the role of chaperone must understand what is expected / involved in the examination that is taking place. They must be able to identify appropriate examination techniques in relation to the examination they are acting as chaperone for.

 

Additional training may be necessary in specialist areas and this should be identified by the appropriate multidisciplinary team.

 

4.17       Mental Capacity

There is a legal presumption that every adult has the capacity to decide whether to consent to or refuse a proposed medical intervention, before proceeding with an examination it is vital that the patient’s valid consent is gained. This means that the patient must: 

  • Have capacity to make the decision.
  • Have received sufficient information and
  • Not be acting under duress

 

Staff should refer to all the relevant Trust Consent and Mental Capacity Act policy and guidance in all situations relating to any adult who does not have capacity. If in doubt contact the safeguarding team for advice.

 

4.18       Lone Working

Where a healthcare professional is working in a situation away from other colleague’s e.g. home visit, out-of-hours activity, the same principles for offering and use of chaperones should apply. Where it is appropriate family members/friends may take on the role of an informal chaperone only. In cases where a staff 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. If after consultation with the patient the decision is made to go ahead with an examination/procedure without the presence of a staff chaperone this decision should be documented in the patient’s clinical or investigation record.

 

Healthcare 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.

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Roles and Responsibilities

5.1 Role of the Chief Executive

        The Chief Executive is has overall accountability for ensuring that the Trust meets its obligations in respect of delivering care to our patients that is of a high quality with an emphasis on ensuring privacy, dignity and safety. The Chief Executive devolves the responsibility for monitoring and compliance to the Chief Nurse and Chief Medical Officer.

5.2 Role of the Chief Nurse

The Chief Nurse and Medical Director are responsible for ensuring that Trust staff uphold the principles of chaperoning and that appropriate policies and procedures are developed maintained and communicated throughout the organisation in co-ordination with other relevant organisations and stakeholders.

5.3 Role of Medical Director and Director of Nursing (Operations)

The Medical Director and Nurse Director (Operations) are responsible for ensuring implementation of this policy in Clinical Service Units (CSUs).

 

5.4 Clinical Director, Head of Nursing (or Head of Profession) and General Manager

The Clinical Director, Head of Nursing (or Profession) and General Manager are responsible for ensuring that the requirements of this policy for the chaperoning of patients during examination are managed within their CSU and that staff are aware of, and implement, those requirements.

 

5.5 Lead Clinician, Matron and Business Manager

The Lead Clinician, Matron and Business Manager are responsible for ensuring that chaperoning principles are communicated and implemented within their areas of responsibility.

Lead Clinicians and Matrons will take a leading role in the implementation of this policy and any associated training within their clinical areas. Lead Clinicians and Matrons will also take a leading role in the investigation of incidents arising from chaperoning of patients.

 

5.6 Role of Senior Sister, Charge Nurse, Lead for Medical Illustration, Lead AHP

It is the role of the Senior Sister, Charge Nurse, Lead for Medical Illustrations or the Lead for Allied Healthcare Professions to locally implement this policy. They should make provision for mechanisms to be in place to ensure that their staff have read and understood this policy, publicise the chaperone check list, and to ensure that strategies are in place to ensure that training is available to assist with the implementation of this policy. Any incidents relating to the chaperoning of patients must be reported via the Trust’s incident reporting system.

 

5.7 All Trust healthcare professionals

All Trust healthcare professionals have a responsibility to act in the patient’s best interests and are accountable for their actions. They should provide safe and effective care, while working within the law and respecting the human rights of individuals. All healthcare professionals should be prepared to make arrangements for patients to have a chaperone during intimate examinations. All Trust healthcare staff should be aware of  and comply with  the chaperone policy. Staff are also responsible for reporting any incidents or complaints relating to the use of chaperones, via the Datix system.

 

5.8 Students

Students can undertake the role of Chaperone if the activity is deemed within their level of competence, commensurate with their stage of training and has a specific learning and development opportunity associated with the task. An assessment would be undertaken by their mentor / practice educator in discussion with the student to determine this. The student has the right to engage or refuse to undertake the role as a Chaperone in accordance with their code of professional conduct.

 

5.9 Medical Students

In line with GMC guidance, medical students should only:

  • Act as a chaperone for patients examined by the relevant clinical supervisor
  • Conduct non-intimate examinations on patients with their clinical partner

 

Medical student should not:

  • Conduct intimate examinations on a patient without a clinically qualified chaperone being present (i.e. doctor or nurse).
  • Act as chaperone to their clinical partner for intimate examinations.
  • Conduct any intimate examination unsupervised even if the patient is happy for them to proceed with the examination.

 

5.10       Role of staff who undertake the procedure or who are taking the chaperone role

The role of the chaperone may vary according to the clinical situation and can include:

·       Providing the patient with physical and emotional support and reassurance

·       Ensuring the environment supports privacy and dignity

·       Providing practical assistance with the examination

·       Safeguarding patients from humiliation, pain, distress or abuse

·       Providing protection to healthcare professionals against unfounded

allegations of improper behaviour

·       Identifying unusual or unacceptable behaviour on the part of the healthcare professional

·       Providing protection for the healthcare professional from potentially abusive patients

 

Chaperones should:

  • be sensitive and respectful of the patient’s dignity and confidentiality
  • be familiar with the procedures involved in routine intimate examinations be prepared to ask the examiner to abandon the procedure if the patient expresses a wish for the examination to end
  • ensure their presence at the examination is documented by the examining professional in the patient’s notes or electronic record
  • be prepared to raise concerns if misconduct occurs and immediately report any concerns to a senior colleague, and also report this via the Datix system.

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Communication and Documentation

Poor communication between a health professional and a patient is often the root of complaints and incidents.

Details of the examination/event requiring presence of chaperone (including the presence or absence of a chaperone and their details which includes full name and contact number) must be documented in the patient’s medical/nursing record.

The notes should also record if a chaperone has been offered, but declined by the patient.

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Equality and Diversity Statement

This policy has been assessed for its impact upon equality. The equality analysis can be seen Annex 1.

The Leeds Teaching Hospitals NHS Trust is committed to ensuring that the way we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group.

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Consultation and Review Process

This policy was circulated for review to:

  • Chief Nurse Team
  • Heads of Nursing and Professions
  • Matrons
  • Nurse Consultants
  • Clinical Directors
  • Lead for Medical Illustration
  • AHP Leads
  • Patient Experience Team
  • Safeguarding Team
  • Learning Disability and Autism Team
  • Mental Health Legislation Team.

 

This policy will be reviewed two years after its publication date, by the Head of Nursing for Professional Practice, Clinical Standards & Patient Safety

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Provenance

Record: 890
Objective:
Clinical condition:
Target patient group:
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Allied Health Professionals
Midwives
Adapted from:

Evidence base

References

Dimond, B (2006) Legal aspects of midwifery. London: Elsevier

General Medical Council (2013) Good medical practice: intimate examinations and chaperones (2013). London: GMC. [online] www.gmc-uk.org [accessed 10/07/2020]

General Medical Council (2013) Maintaining a professional boundary between you and your patient. London: GMC [online] https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/maintaining-a-professional-boundary-between-you-and-your-patient [accessed 03/08/2020]

General Medical Council (2018) Sexual behaviour and your duty to report colleague. London: GMC [online] https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/sexual-behaviour-and-your-duty-to-report-colleagues [accessed 03/08/2020]

General Medical Council (2013) Good medical practice London, GMC.

General Medical Council (2012) Protecting children and young people: the responsibilities of all doctors. London, GMC

 

GMC: Intimate examinations. London: GMC [online] http://www.gmc-uk.org/standards/intimate.htm [accessed 10/7/2020]

 

NHS England and NHS Improvement (2020)Key principles for intimate clinical assessments undertaken remotely in response to COVID-19 Version 1 – July 2020. https://www.leedsth.nhs.uk/assets/905b5ba081/Key_principles_for_intimate_clinical_assessments_undertaken_remotely_in_response_to_COVID19_v1-1-1.pdf [accessed 31/07/2020]

 

 

Royal College of Nursing (2016) Genital Examination in Women. London RCN

(Publication code 005 480) Available at: www.rcn.org.uk/publications

[accessed 3/8/2020]

 

Mental Capacity Act (2005)

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Document history

LHP version 1.0

Related information

Appendix A - The Role of the Staff Chaperone

The Role of the Staff Chaperone

The role of the staff chaperone is to protect the interests of the patient and the professional by providing impartial observation of intimate procedures, examinations, investigations or care.

A staff chaperone is a health care worker that is specifically trained for the role, for example a registered or unregistered member of the Nursing, Midwifery, Allied Health Professional or Medical team. A friend or family member can be present during the procedure or examination to act as a source of comfort and support for the patient.

Staff Chaperones will:

  • maintain patient’s privacy and dignity
  • where possible, be the same sex as the patient
  • provide comfort and reassurance to patients
  • assist patients with dressing and undressing if required
  • ensure that there is no undue delay prior to examination once the patient has removed any clothing
  • help to prevent vulnerable patients from being abused
  • help to protect health care professionals against false allegations of misconduct or sexual abuse
  • assist the health care professional to complete the procedure, examination, clinical recording or delivery of care, when appropriate
  • assist the healthcare professional to position the patient for the procedure, using appropriate moving and handling techniques
  • be experienced in the specialty and aware of the normal procedures for examination, treatment and care
  • have the ability to take appropriate action and highlight  concern, either during or immediately after the event
  • have an understanding of cultural, ethical and religious diversity
  • ensure that the full name and job title of the chaperone as well as a record of the procedure is documented in the patients notes by the practitioner undertaking the examination/procedure.

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Appendix 2 - Suggested Wording for Patient Letters and Signage

Suggested Wording for Patient Letters and Signage.

Suggested wording to be included in patients letters and any signage to inform patients and carers with regards to the Leeds Teaching Hospitals approach to chaperoning of patients

CHAPERONE POLICY

The Leeds Teaching Hospitals NHS is committed to providing a safe, comfortable environment where patients and staff can be confident that best practice is being followed at all times and the privacy, dignity and safety of everyone is of paramount importance.

All patients are entitled to be accompanied during a consultation, examination, investigation or clinical recording where they wish. This person may be a family member or friend. There may be times when you are asked to leave an area (during X Rays or other treatments for example) but staff will explain this to you.  On occasions you may prefer a chaperone to be present, i.e. a member of staff.

Wherever possible we would ask you to make this request at the time of booking appointment so that arrangements can be made and your appointment is not delayed in any way. Where this is not possible we will endeavour to provide a chaperone at the time of request. However occasionally it may be necessary to reschedule your appointment.

Your healthcare professional may also require a staff chaperone to be present for certain consultations or procedures in accordance with our chaperone policy.

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Equity and Diversity

The Leeds Teaching Hospitals NHS Trust is committed to ensuring that the way that we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group.