The General Medical Council (GMC) regularly receives complaints from patients who feel that doctors have behaved inappropriately during an intimate examination. Intimate examinations, that is examination of the breasts, genitalia or rectum can be stressful and embarrassing for patients. However, as the Medical Defence Union (MDU) suggests, some patients may regard any examination in which the doctor needs to touch or be very close to them as intimate, particularly vulnerable patients or those who have suffered abuse in the past. In these circumstances, the healthcare professional should use their professional judgement about whether to offer a chaperone, depending on the patient’s views and level of anxiety. Cultural factors should also be considered. This is important when examinations are performed by members of the opposite sex.
For most patients and procedures, respect, explanation, consent, and privacy are all they need. These take precedence over the need for a chaperone. A chaperone does not remove the need for adequate explanation and courtesy, and neither can it provide full assurance that the procedure or examination is conducted appropriately.
The GMC advises that a health professional should:
Before the examination
- Explain to the patient why an examination is necessary and give the patient an opportunity to ask questions, so they can give informed consent.
- Explain what the examination will involve, in a way the patient can understand, so that the patient has a clear idea of what to expect, including any potential pain or discomfort.
- If for justifiable practical reasons you cannot offer a chaperone you should explain that to the patient and, if possible, offer to delay the examination to a later date. You should record the discussion and its outcome in the patient’s record.
- Offer a chaperone who will be a member of the St Luke’s nursing team and on occasion another doctor. This applies whether or not the health professional is the same gender as the patient.
- Allow the chaperone to hear the explanation of the examination and the patient’s consent.
During the examination
- Give the patient privacy to undress and dress and use drapes and curtain to maintain the patient’s dignity. Do not assist the patient in removing clothing unless you have clarified with them that your assistance is required
- Position the chaperone where they can see both the patient and how the examination is being conducted
- Explain again what examination is about to be started gaining further consent if this will differ from what has previously been explained
- Discontinue the examination/procedure if the patient asks for this, clearly documenting if this is the case.
- Keep discussion relevant and avoid unnecessary personal comments
- It can be helpful to invite the patient to tell you if the examination becomes uncomfortable. While performing the examination, watch for any signs of pain or discomfort and check that the patient agrees for you to continue.
After the examination
- The Chaperone should leave the room following the examination and once the patient is dressed so the consultation can continue in private.
The Role of the Chaperone
A chaperone is an impartial observer present during an intimate examination of a patient, they are present as a safeguard for everyone concerned (patient and health care practitioner) and are a witness to the continuing consent of the procedure/examination.
All Chaperones at St Luke’s surgery are members of the Nursing team, both Practice Nurses (PNs) and health care assistants (HCAs) and on rare occasion may be a doctor. All of these clinical staff are DBS checked and have been trained regarding the role of being a chaperone. The Royal College of Nursing (RCN) in 2020 suggested that if the chaperone is from within the nursing team, in such situations as assisting with a coil insertion, they can also act as an advocate for the patient. The chaperone’s role includes the following:
- Explain what will happen during the examination or procedure, and the reasons why if appropriate to do so.
- Assess a patient’s understanding of what they have been told, particularly if English is not their first language.
- Provide a reassuring presence and protecting the patient’s dignity during the examination or procedure.
- Safeguard against any pain, humiliation, intimidation, or unnecessary discomfort.
- Observe the patient, offering emotional support, to ensure they feel safe and are comfortable.
- Always be sensitive to cultural and religious issues, as well as the context of the patient’s circumstances and specific needs.
- Be prepared to raise concerns if they are concerned about the Doctor’s behaviour or actions.
The MDU recommends the following documention in the Patient’s record
- The Doctor is to document not only the presence of a chaperone but their identity (name and full job title). If no chaperone is present, the doctor should document that one was offered and then declined.
- If an accusation of improper behaviour is made several years later and there is no record of who acted as chaperone, it would be difficult to recall who witnessed the examination
At St Luke’s Surgery the chaperone will also document in the Patient’s record
- A completed ‘chaperone template’. This will provide some protection for the chaperone who may in the future be asked to complete information relating to the consultation, should a complaint be made in the future against the medical practitioner performing the examination/procedure.
A Chaperone template example:
Either tick to add the text if it reflects your views of the consultation, or use the free text box to add any further comments.
If you have any concerns whatsoever about any aspect of the examination conducted please raise this with your line manager or with the safeguarding lead in the practice
ð Chaperone present
ð I acted as a Chaperone for the examination conducted today. I have no concerns regarding the manner or the extent of the examination conducted. During the examination, the patient expressed no verbal or nonverbal concerns about the examination and I was present until the patient had replaced their clothing.
Any further comments?
It is important that it is well known by all patients of the availability of Chaperones with in the surgery and so Posters are displayed on notice boards around the surgery, within each consulting room and on the patient TV screens in both of the waiting rooms.
Can the chaperone be a relative of friend of the patient?
A relative or friend of the patient is not an impartial observer and so would not usually be a suitable chaperone, but an agreeable response regarding this request, would be to have such a person present as well as a chaperone.
Do children/teenagers need a Chaperone?
Remember it may be appropriate on some occasions to offer a Chaperone to a child or teenager for as the GMC guidance states, a relative or friend of a patient is not an impartial observer and therefore they would not usually be a suitable chaperone. There may be circumstances when a young person does not wish to have a chaperone. The reasons for this should be clear and recorded.
Can a patient refuse a chaperone?
Patients have a right to refuse a chaperone. If a health professional is unwilling to conduct an intimate examination without a chaperone, they should explain to the patient why they would prefer to have one present. They may need to offer an alternative appointment, or an alternative health professional, but only if the patient’s clinical needs allow this.
“In conclusion Chaperones should not be involved solely to protect doctors, nor should they be passive onlookers. They need to be impartial, have objective reasons to be present, have expertise in clinical practice they are observing, be able to purposefully observe the examination and have the authority to halt it if they suspect malpractice or witness wrongdoing” (Nursing Times Contributor, Nurses as Chaperones 7 June 2019)
S Green July 2022