Business Dilemmas

Dr Sally Old discusses what to do if you believe a patient or colleague poses a risk to themselves or others.

 

 

 

 

Dilemma 1

How can I keep confidentiality?

QI am a private GP and recently saw a patient who I believe, based on comments they made during the appointment, may have been radicalised.

Obviously, this is a very serious allegation and, as such, any advice on how I should go about raising my concerns while maintaining patient confidentiality would be appreciated. 

AUnder the Terrorism Act 2000 it is a criminal offence not to tell the police ‘as soon as is reasonably practicable’ if you become aware of information that you know or believe ‘might be of material assistance’ in preventing an act of terrorism and/or securing the arrest, prosecution or conviction of someone involved in ‘the commission, preparation or instigation of an act of terrorism’.

The GMC’s Confidentiality guidance states: ‘Some laws require disclosure of patient information’ for purposes including ‘the prevention of terrorism’. 

‘You must disclose information if it is required by law.’ If you’re satisfied that disclosure is legally required, you should promptly disclose relevant information to the police. 

Identify the signs

According to the UK Govern­ment’s Prevent strategy, there are clearly many opportunities for doctors, nurses and other staff to help to protect people from radicalisation. The key challenge is to ensure that healthcare workers can identify the signs that someone is vulnerable to radicalisation. 

As part of this strategy, the Government has also produced guidance containing tips for healthcare professionals who have concerns that a patient or colleague might be at risk of radicalisation.

If you are concerned that a patient may have been radicalised and that you need to disclose information to protect individuals or the wider public from serious harm, it is important to firstly reflect on the factors that make the person vulnerable to abuse or exploitation and what aspects of their behaviour give you cause for concern. 

The Prevent guidance includes possible warning signs and says healthcare workers should use their judgement in determining the significance of any unusual changes in behaviour.

Next, consider whether raising concerns is a proportionate response, given the ongoing risk to the individual and others. Balance this against the possible harm and distress to the patient of sharing information about them – for example, the implications for their future engagement with healthcare. 

Tell the patient

However, it is generally considered appropriate to disclose information if a vulnerable person is at risk of abuse, if a patient has confessed to a serious crime or if they pose a risk to the public.

If you decide to disclose information, the GMC says you should ‘tell patients about such disclosures whenever practicable, unless it would undermine the purpose of the disclosure to do so’.  

In some circumstances, including a risk of serious harm to yourself or others, such discussions with the patient may be impracticable.

The Government guidance advises that you raise concerns though a local policy, if there is one, and that in the absence of such arrangements you should usually go via the local safeguarding lead, who would contact the local police Prevent lead.  

Record the steps you took to discuss the issue with the patient and your justifications if it is necessary to disclose information without their consent. 

Additionally, it may be necessary to share safeguarding information with other organisations, such as social services, to ensure the patient receives appropriate support.

Finally, remember to seek advice from your medical defence organisation if you are unsure how to proceed.

Dr Sally Old is a medico-legal adviser at the Medical Defence Union (MDU)

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If they decline a chaperone

If you have a patient who declines a chaperone during an intimate examination, then what is the best thing to do? Dr Sally Old explains.

 

 

 

 

Dilemma 2

Did I behave in the right way?

QI’m a male, private GP who recently had a consultation with a patient who initially declined a chaperone for an intimate examination saying: ‘Oh, that’s OK. I’m sure you’re trustworthy and I’m in a bit of a hurry. Just go ahead.’

I felt uncomfortable with this and explained that I would prefer to have a chaperone present. After further discussion, the patient agreed and the examination proceeded without incident.

I wonder if I could have done anything differently? 

ADoctors are expected to use their professional judgement when deciding whether a chaperone should be offered. However, having a chaperone present during intimate examinations can offer reassurance and act as a safeguard for both the patient and the doctor.

The GMC’s guidance, Intimate examinations and chaperones (2013) states that patients, regardless of gender, should be offered a chaperone before conducting an intimate examination.  

It says an intimate examination could include ‘any examination where it is necessary to touch or even be close to a patient’ and that doctors should be sensitive to what a patient might consider intimate. 

The purpose of a chaperone is to protect the patient’s dignity and confidentiality, offer emotional support at an embarrassing or uncomfortable time and to facilitate communication. 

Having a chaperone present during intimate examinations may also help protect a doctor from unfounded allegations of improper conduct.

The chaperone should be a trained health professional who is familiar with the procedure as opposed to a family member or friend, as they may not be considered an impartial observer. However, a friend or family member may be present alongside a chaperone.

Uncomfortable position

Sometimes a patient may insist on not having a chaperone. While this is the patient’s right, it can leave doctors in an uncomfortable position. In such cases, you should follow the GMC’s guidance and explain why you would prefer a chaperone present. 

If the patient continues to decline, it may be possible to defer the examination and refer the patient to a colleague who is willing to examine the patient without a chaperone. 

However, if the examination is needed immediately, then there may be no other option but to proceed without a chaperone. If this occurs, then you should document the discussion with the patient in the clinical record and why it was necessary to proceed.

Other reasons to defer a non-urgent examination are if you or the patient want a chaperone, but no one is available or if the patient is unhappy with the chaperone offered – particularly if the patient knows the chaperone, such as in a small community. 

It is helpful to have a chaperone policy for the practice and to publicise the benefits and availability of chaperones to patients. This may encourage patients to communicate their preferences early on so that you can best meet their needs.

• See ‘Going to a multi-agency meeting’