It is a requirement that, when necessary, chaperones are provided to protect and safeguard both patients and clinicians during intimate examinations and or procedures.

All clinical and non-clinical staff may at some point be asked to act as a chaperone at this organisation. Therefore, it is essential that training is given and trained chaperones are aware of their individual responsibilities when performing chaperone duties.

The CQC GP Mythbuster 15: Chaperones advises that for children and young people, their parents, relatives and carers should be made aware of the policy and why this is important.

To raise awareness, the chaperone policy should be clearly advertised. At this organisation, a chaperone poster is clearly displayed in the waiting area, in all clinical areas and annotated in the organisation leaflet as well as on the organisation website.

1.2 Status

The organisation aims to design and implement policies and procedures that meet the diverse needs of our service and workforce, ensuring that none are placed at a disadvantage over others, in accordance with the Equality Act 2010. Consideration has been given to the impact this policy might have regarding the individual protected characteristics of those to whom it applies.

This document and any procedures contained within it are non-contractual and may be modified or withdrawn at any time. For the avoidance of doubt, it does not form part of your contract of employment. Furthermore, this document applies to all employees of the organisation and other individuals performing functions in relation to the practice such as agency workers, locums and contractors.

2.1 Who can act as a chaperone

The GMC Intimate examinations and chaperones Guidance explains that the patient should be given the option of having an impartial observer (a chaperone) present whenever possible.

As per the GMC guidance, relatives or friends of the patient are not considered to be an impartial observer so would not usually be a suitable chaperone but staff at this organisation should comply with a reasonable request to have such a person present in addition to the chaperone. It is policy that any member of the organisation team can act as a chaperone only if they have undertaken appropriate chaperone training as detailed in CQC GP Mythbuster 15.

Additionally, all staff must complete chaperone awareness training which covers the role of the chaperone.

2.2 General guidance

The GMC guidance states that before conducting an intimate examination, the clinician should:

• Explain to the patient why the particular examination is necessary and give the patient the opportunity to ask questions
• 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 pain or discomfort
• Get the patient’s permission before the examination and record that the patient has given it
• Offer the patient a chaperone
• If dealing with a child or young person:
  • Assess their capacity to consent to the examination
  • If they lack the capacity to consent, seek parental consent
• Give the patient privacy to undress and dress and keep them covered as much as possible to maintain their dignity; they should not help the patient to remove clothing unless they have been asked to or they have checked with the patient that they want help

During the examination, the clinician should:

• Explain what they are going to do before they do it, and if this differs from what they previously told the patient, explain why and seek the patient’s permission
• Stop the examination if the patient asks them to
• Keep discussion relevant and not make unnecessary personal comments

When a chaperone is present, the details of the chaperone must be recorded in the patient’s clinical record.

2.3 Expectations of a chaperone

At this organisation, chaperones will adhere to the GMC guidance which states chaperones will:

• Be sensitive and respect the patient’s dignity and confidentiality
• Reassure the patient if they show signs of distress or discomfort
• Be familiar with the procedures involved in a routine intimate examination
• Stay for the whole examination and be able to see what the doctor is doing, if practical
• Be prepared to raise concerns if they are concerned about the doctor’s behaviour or actions

The CQC advises that for most patients and procedures, respect, explanation, consent and privacy are all that are needed. These take precedence over the need for a chaperone. A chaperone does not remove the need for adequate explanation and courtesy. Neither can a chaperone provide full assurance that the procedure or examination is conducted appropriately.

2.4 When a chaperone is unavailable

The GMC advises that if either the clinician or the patient does not want the examination to go ahead without a chaperone present, of if either is uncomfortable with the choice of chaperone, the clinician may offer to delay the examination until a later date when a suitable chaperone will be available as long as the delay would not adversely affect the patient’s health.

2.5 When a patient refuses a chaperone

If the clinician does not want to proceed with the examination without a chaperone but the patient has refused a chaperone, the clinician must clearly explain why they want a chaperone present. The GMC states that ultimately the patient’s clinical needs must take precedence. The clinician may wish to consider referring the patient to a colleague who would be willing to examine them without a chaperone as long as a delay would not adversely affect the patient’s health.

Any discussion about chaperones and the outcome should be recorded in the patient’s medical record, and in particular:

• Who the chaperone was
• Their title
• That the offer was made and declined

2.6 Disclosure and Barring Service (DBS) check

Clinical staff who undertake a chaperone role at this organisation will already have a DBS check. The CQC states that non clinical staff who carry out chaperone duties may need a DBS check. This is due to the nature of chaperoning duties and the level of patient contact. Should the organisation decide not to carry out a DBS check for any non-clinical staff, then a clear rationale for this decision must be given including an appropriate risk assessment.

2.7 Using chaperones during a video consultation

CQC GP Mythbuster 15 explains that many intimate examinations will not be suitable for a video consultation. When online, video or telephone consultations take place, GMC guidance explains how to protect patients when images are needed to support clinical decision making. This includes the appropriate use of photographs and video consultations as part of patient care.

When intimate examinations are performed, it is important that a chaperone is offered. Documentation should clearly reflect this. It is important to document who provided the chaperoning and this should also state what part of the consultation they were present for.

This guidance explains how to conduct intimate examinations by video and the use of chaperones.

2.8 Practice procedure (including SNOMED codes)

If a chaperone was not requested at the time of booking the appointment, the clinician will offer the patient a chaperone explaining the requirements:

• Contact reception and request a chaperone
• Record in the individual’s healthcare record that a chaperone is present and identify them
• The chaperone should be introduced to the patient
• The chaperone should assist as required but maintain a position so that they are able to witness the procedure/examination (usually at the head end)
• The chaperone should adhere to their role at all times
• Post procedure or examination, the chaperone should ensure they annotate in the patient’s healthcare record that they were present during the examination and there were no issues observed
• The clinician will annotate in the individual’s healthcare record the full details of the procedure as per current medical records policy

Detail	SNOMED CT Code
The patient agrees to a chaperone	1104081000000107
Refusal to have a chaperone present	763380007
No chaperones available	428929009

2.9 Escorting of visitors and guests (including VIPs)

There may be, on occasion, a need to ensure that appropriate measures are in place to escort visitors and guests including VIPs. On such occasions, this organisation will follow the recommendations outlined in the Lampard Report (2015). If media interest is likely, the Practice Manager is to inform the local ICB, requesting that the communication team provides guidance and/or support where necessary