SJT Flashcards

Question

SCENARIO 1 - Good medical practice - Basic Care Introduction Dr Sharma has recently been appointed a Consultant Physician based in the Stroke Unit of the general district hospital where she was previously a Specialist Registrar. She witnesses a number of incidents on the Unit where patients are not receiving basic care and has to decide how to act. As she is leaving the ward on her way to see another patient she notices that Mr Johnson, who was transferred from intensive care two days ago, hasn't touched his food or drink. She stops to talk to him. Dr Sharma Good morning Mr Johnson. My name is Dr Sharma. How are you today? I notice you haven't eaten your breakfast. Weren't you hungry? Mr Johnson Hello...sorry, sleeping...didn't see them come by. Where is it? Dr Sharma On the table, by your bed. To your left, just there. Mr Johnson [Struggling a little to reach over and hand shaking]. Very weak on that side...can't reach...very tired...took it away yesterday too. Dr Sharma When did you last eat or drink something? Mr Johnson Can't remember...my wife helped me yesterday sometime...oh when was it? I tried to get a nurse...they were so busy...really can't remember... What should the doctor do...? (Select A, B, C or D) A Ask Mr Johnson what help he needs to eat his breakfast and feed him herself? B Report the problem to the nurse in charge of the Unit? C Reassure Mr Johnson that the nursing staff will come and help him and leave the ward, planning to check on Mr Johnson again later? D Find a nurse and ask them to help Mr Johnson to eat his breakfast?

Answer 1

This would be in line with GMC guidance D This would be in line with GMC guidance and would address the immediate situation. But it might not address any underlying issues and make sure that the reason for the problem is identified and addressed. It may not just be a one-off incident and Dr Sharma should investigate further. Dr Sharma See what the doctor did Dr Sharma assured Mr Johnson that she would sort the problem out. She checked Mr Johnson's chart to make sure that there were no identified problems with his swallowing and that the food offered was appropriate. Dr Sharma went to speak to the nursing staff. With some assistance Mr Johnson was able to feed himself but Dr Sharma was concerned to make sure that Mr Johnson got the necessary assistance at every meal. She asked the trainee doctor to check that Mr Johnson was helped to eat his afternoon and evening meals when she would be off duty, and to let her know if there were any problems. She also asked the nurses to make sure that Mr Johnson's food and fluid intake was recorded on his chart. Finally, Dr Sharma resolved to check on Mr Johnson again when she started her shift the next day. References You must take prompt action if you think that patient safety, dignity or comfort is or may be seriously compromised. a. If a patient is not receiving basic care to meet their needs, you must immediately tell someone who is in a position to act straight away. (Good Medical Practice paragraph 25a) All patients are entitled to food and drink of adequate quantity and quality, and to the help they need to eat and drink...You should be satisfied that nutrition and hydration are being provided in a way that meets your patient's needs and that if necessary patients are being given adequate help to enable them to eat and drink (Treatment and care towards the end of life: good practice in decision making paragraph 109) If you are responsible for supervising staff, whatever your role, you must understand the extent of your supervisory responsibilities, give clear instructions about what is expected and be available to answer questions or provide help when needed. You must support any colleagues you supervise or manage to develop their roles and responsibilities by appropriately delegating tasks and responsibilities. You must be satisfied that the staff you supervise have the necessary knowledge, skills and training to carry out their roles.

Answer 2

This would be in line with GMC guidance. C All doctors should be encouraged and supported to raise concerns and to develop their skills and experience. As Dr Piper has raised these issues, it is appropriate for Dr Sharma to support her to address the issue. But she should agree appropriate arrangements for being informed about the progress and outcome and get involved where necessary. This would be in line with GMC guidance. D Consultants can reasonably be expected to take the lead in resolving issues about patient care. Speaking directly to the nurse in charge may help to emphasise how seriously issues about basic care are taken. However, Dr Sharma should make sure that Dr Piper's role in raising these issues is recognised and encourage her to be involved in the audit to develop his skills and experience. See what the doctor did The doctors agreed that Dr Piper would speak to the nurse in charge of the Unit about undertaking a short audit of basic care standards. The nurse agrees that this is a good idea and she and Dr Piper work together and set up a multi disciplinary team to carry out the audit. Dr Sharma is kept informed of progress and a meeting is arranged with the team to discuss the outcomes and agree actions to make sure that patient's needs for basic care are met. References You must take part in systems of quality assurance and quality improvement to promote patient safety. This includes: a. taking part in regular review and audits of your work and that of your team, responding constructively to the outcomes, taking steps to address any problems and carrying out further training where necessary. (Good Medical Practice paragraph 22a) You must promote and encourage a culture that allows all staff to raise concerns openly and safely. You must take prompt action if you think that patient safety, dignity or comfort is or may be seriously compromised. a. If a patient is not receiving basic care to meet their needs, you must immediately tell someone who is in a position to act straight away. b. If patients are at risk because of inadequate premises, equipment or other resources, policies or systems, you should put the matter right if that is possible. You must raise your concern in line with our guidance and your workplace policy. You should also make a record of the steps you have taken. (Good Medical Practice paragraphs 24, 25a-b) You must work collaboratively with colleagues, respecting their skills and contributions. (Good Medical Practice paragraph 35) Wherever possible, you should first raise your concern with your manager or an appropriate officer of the organisation you have a contract with or which employs you - such as the consultant in charge of the team, the clinical or medical director or a practice partner. If you are a doctor in training, it may be appropriate to raise your concerns with a named person in the deanery - for example, the postgraduate dean or director of postgraduate general practice education. (Raising and acting on concerns about patient safety paragraph 13) You should contact a regulatory body such as the General Medical Council or another body with authority to investigate the issue (such as those listed at the end of this guidance) in the following circumstances. You must take prompt action if you think that patient safety, dignity or comfort is or may be seriously compromised. a. If you cannot raise the issue with the responsible person or body locally because you believe them to be part of the problem. b. If you have raised your concern through local channels but are not satisfied that the responsible person or body has taken adequate action. c. If there is an immediate serious risk to patients, and a regulator or other external body has responsibility to act or intervene. (Raising and acting on concerns about patient safety 16) If you are responsible for supervising staff, whatever your role, you must understand the extent of your supervisory responsibilities, give clear instructions about what is expected and be available to answer questions or provide help when needed. You must support any colleagues you supervise or manage to develop their roles and responsibilities by appropriately delegating tasks and responsibilities. You must be satisfied that the staff you supervise have the necessary knowledge, skills and training to carry out their roles.

Answer 3

This would be in line with GMC guidance. B Doctors should be willing to find and take part in structured support opportunities offered by their employer (for example, mentoring) and they should do this whenever their role changes significantly throughout their career. Even if Dr Sharma doesn't think her hospital offers any structured support, she should discuss the options with her Medical Director and try and find a solution. See what the doctor did Dr Sharma makes an appointment to see her Medical Director. Before the meeting she collects information about support and mentoring services that are offered locally that she may be able to participate in. Her Medical Director is supportive and they put in place a plan which includes Dr Sharma being mentored by a Senior Consultant in a Stroke Unit at another hospital in the area. Dr Sharma also joins an online forum for new Consultants that provides her with peer support. References You should be willing to find and take part in structured support opportunities offered by your employer or contracting body (for example, mentoring). You should do this when you join an organisation and whenever your role changes significantly throughout your career. (Good medical practice paragraph 10) Understanding the systems in place and how an organisation operates helps to make sure that doctors can deliver safe, effective and efficient care to patients as soon as they start a new job. Induction and mentoring schemes and access to other support mechanisms are important ways of achieving this. While important for all doctors, this may be particularly important for doctors if they are new to clinical practice, have trained outside the UK or are taking on a role in a new area or at a higher level. You must take part in the induction offered by your employer when your join and organisation or move into a new role. You should also contribute to the induction of colleagues when asked. You must make sure that any new doctor or other healthcare professional you manage is offered relevant induction and that induction policies and procedures contain information that is relevant, accessible and proportionate to the doctor's role and length of employment with your organisation.

Answer 4

This would be in line with GMC guidance. B Katy needs help to manage her anxiety attacks whatever their cause. However Dr Newell will need to bear in mind the risk of Katy abusing the benzodiazepines or selling them on. An alternative may be to prescribe a less addictive medication to help Katy sleep. This would be in line with GMC guidance C This would be in line with GMC guidance but, depending on the waiting time for counselling, this option on its own may not be enough to deal with Katy's current distress. Dr Newell See what the doctor did Dr Newell decided to prescribe Katy the tranquilisers, and told her about the dangers of taking them while drinking alcohol or taking other drugs. She also referred her to the practice counsellor. Dr Newell also advised Katy about the potential effects of her lifestyle on her health and well-being and suggested that if she was serious about her exams she really must settle down. She also gave Katy a follow-up appointment for two weeks' time. References You must treat patients fairly and with respect whatever their life choices and beliefs. (Good Medical Practice paragraph 48) You must support patients in caring for themselves to empower them to improve and maintain their health. This may, for example include improve and maintain their health. This may, for example, include: a. advising patients on the effects of their life choices and lifestyle on their health and wellbeing. b. supporting patients to make lifestyle changes where appropriate. (Good Medical Practice paragraph 51)

Answer 5

This would be in line with GMC guidance. A Dr Newell does not approve of abortion but has helped Katy to access appropriate care. GMC guidance does not require doctors with a conscientious objection to abortion to refer patients, even to another GP, provided that patients are able to access alternative care in good time. This would be in line with GMC guidance. C However, time is critical in referrals for termination in any stage of pregnancy. If Dr Newell does not feel comfortable with referring Katy to another GP, she needs to make sure that the patient can easily access alternative care. See what the doctor did Dr Newell explains to Katy that referring her for abortion conflicts with her religious beliefs but is careful not to say anything that might upset Katy or make her think she is judging her for her decision to terminate the pregnancy. She gives her the details of the other GP practice in the area and also tells her about the Family Planning Clinic. References You must explain to patients if you have a conscientious objection to a particular procedure. You must tell them about their right to see another doctor and make sure they have enough information to exercise that right. In providing this information you must not imply or express disapproval of the patient's lifestyle, choices or beliefs. If it is not practical for a patient to arrange to see another doctor, you must make sure that arrangements are made for another suitably qualified colleague to take over your role.17 (Good Medical Practice paragraph 52) You must not express your personal beliefs (including political, religious and moral beliefs) to patients in ways that exploit their vulnerability or that are likely to cause them distress.17 (Good Medical Practice paragraph 54) You must not unfairly discriminate against patients or colleagues by allowing your personal views to affect your professional relationships or the treatment you provide or arrange. You should challenge colleagues if their behaviour does not follow this guidance, and follow the guidance in paragraph 25c if the behaviour amounts to abuse or denial of a patient's or colleague's rights. (Good Medical Practice paragraph 59)

Answer 6

This would be in line with GMC guidance. B Although prescribing over the phone may be appropriate in some circumstances, doctors need to ensure that the medication will meet the patient's needs. An adequate assessment of the patient's condition must be carried out and this will not always be possible over the phone. This would be in line with GMC guidance. C Dr Newell judges that if Katy feels she really needs the medication before her holiday, she will make an appointment for a proper assessment. See what the doctor did Dr Newell decides not to prescribe further medication for Katy without a face-to-face assessment, including finding out how the counselling sessions are going. She is reassured that Katy is sounding much more positive and judges that she can wait until after her holiday to discuss her treatment. References You must provide a good standard of practice and care. If you assess, diagnose or treat patients you must: a. Adequately assess the patient's conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors) and their views and values. Where necessary, examine the patient. (Good Medical Practice paragraph 15) In providing clinical care you must: b. prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient's health, and are satisfied that the drugs or treatment serve the patient's needs12 20 (Good Medical Practice paragraph 16)

Answer 7

This would be in line with GMC guidance. B Nobody can make a decision on behalf of an adult who has capacity to do so, so Dr Liebowitz should help Mrs Ford to think the decision through herself. In doing so, he should give her all the information she wants and needs to help her decide how to proceed. This will include the potential benefits, risks and burdens of the various treatment options, including information about serious potential side effects. This may be in line with GMC guidance, C but Dr Liebowitz should also ensure Mrs Ford understands the risks that the treatment entails, including the very small risk of a serious adverse outcome and ensure that she is aware of the other available treatment options. See what the doctor did Dr Liebovitz told Mrs Ford that, if he were in her position, he would try the recommended treatment because it offered the best chance of improving her condition and controlling and reducing her symptoms. He reiterated that no treatment is entirely without risk, and emphasised that she needed to take into consideration the small possibility of an adverse reaction, but he didn't go into any detail about the potential side effects of taking the new medication. References 5b. The doctor explains the options to the patient, setting out the potential benefits, risks, burdens and side effects of each option, including the option to have no treatment. The doctor may recommend a particular option which they believe to be best for the patient, but they must not put pressure on the patient to accept their advice. 19. You should give information to patients in a balanced way. If you recommend a particular treatment or course of action, you should explain your reasons for doing so. But you must not put pressure on a patient to accept your advice. 32. You must tell patients if an investigation or its treatment might result in a serious adverse outcome, even if the likelihood is very small. You should also tell patients about less serious side effects or complications if they occur frequently, and explain what the patient should do if they experience any of them. (Consent: patients and doctors making decisions together paragraphs 5b, 19, and 32)

Answer 8

This would be in line with GMC guidance, C although the doctor should be careful not to badger the patient. Breaching Mrs Ford's confidentiality by writing to her GP without her consent would only be justified if Dr Liebowitz judges the risks of withholding the information from her GP to outweigh the benefit of keeping the information confidential (that is, maintaining Mrs Ford's trust in him). This would be in line with GMC guidance. A However, the ideal situation is for the GP to act as a central point for information about all of the patient's medical care, so Dr Liebowitz might wish to explore Mrs Ford's concerns in more detail before accepting her refusal. Dr Liebowitz See what the doctor did Dr Liebowitz did not press the point and did not write to Mrs Ford's general practitioner. A few weeks after starting the treatment, Mrs Ford experienced heart palpitations and collapsed at home. The casualty officer contacted her GP, who was unable to provide any information about her current medical care, and this caused a delay in identifying the problem. Mrs Ford recovered from the heart arrhythmias but it was subsequently discovered that she had impaired kidney function. References You must respect the wishes of any patient who objects to particular personal information being shared within the healthcare team or with others providing care, unless disclosure would be justified in the public interest. If a patient objects to a disclosure that you consider essential to the provision of safe care, you should explain that you cannot refer them or otherwise arrange for their treatment without also disclosing that information. (Confidentiality, paragraph 27)

Answer 9

This response best fits with GMC guidance. B The doctor should do his best to assist the court while making clear the limitations on his ability to do so. This would be in line with GMC guidance: C Dr Abdullah can explain that his refusal is on the basis of his professional responsibility not to mislead the court by commenting on matters that lie outside his area of expertise. If he is pressed for an answer he must make clear that he considers the matter to be outside his competence. See what the doctor did Dr Abdullah gave his view on the question put before him. However, he emphasised that this should not be considered as an expert opinion as it related to matters where he did not feel that he had the necessary knowledge and experience. He explained to the court his professional duty to practise within his area of competence, and recommended that questions on this point be directed to another expert for consideration. References You must recognise and work within the limits of your competence (Good Medical Practice, paragraph 14)

Answer 10

This would be in line with GMC guidance. A It is important to be honest with patients, and it can help to explain about policies and procedures that restrict your practice. Patients will be more likely to trust you if they understand your motives. Many doctors might say they don't have enough time in a consultation to discuss things like this; however, time invested in increasing patients' understanding and involvement can be regained later. This would be in line with GMC guidance. C Although some patients may have unrealistic expectations of doctors' knowledge, most will trust doctors more if they are direct with them. Honesty is important for building trust in the doctor-patient relationship, and patients who trust their doctors may be more likely to comply with treatment. See what the doctor did Dr Williams decides that Jason is a well-informed patient who wants to be fully involved in his treatment. It's quite likely that he'd be reassured by having more information rather than less, so she explains that cost isn't the issue in these circumstances, but that the NICE guideline recommends prescribing Zolpac in the first instance as a replacement for his current medication. References In providing clinical care you must: a. prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient's health, and are satisfied that the drugs or treatment serve the patient's needs12 20 b. provide effective treatments based on the best available evidence (Good Medical Practice paragraph 16) You must listen to patients, take account of their views, and respond honestly to their questions. (Good Medical Practice paragraph 31) You must work in partnership with patients, sharing with them the information they will need to make decisions about their care,5 including: a. their condition, its likely progression and the options for treatment, including associated risks and uncertainties b. the progress of their care, and your role and responsibilities in the team c. who is responsible for each aspect of patient care, and how information is shared within teams and among those who will be providing their care (Good Medical Practice paragraph 49)

Answer 11

This answer best reflects GMC guidance. B Although talking through the risks and benefits of each option will inevitably take time, it is vital that patients have enough information to make an informed choice about treatment. This is partly in line with GMC guidance. C Talking through the risks and benefits of each option is vital to enable patients to make informed decisions. Doctors should usually tell the patient which option they feel is best for them and why. See what the doctor did: Dr Williams talked Jason through how the risks of any treatment must be balanced against the benefits. She explained why, out of the options available to him, she judged taking Zolpac would be the best option for him. Jason goes away with the prescription for Zolpac. References You must listen to patients, take account of their views, and respond honestly to their questions. You must give patients the information they want or need to know in a way they can understand. You should make sure that arrangements are made, wherever possible, to meet patients' language and communication needs. (Good Medical Practice paragraphs 31 and 32)

Answer 12

This answer best reflects GMC guidance. C If patients feel fully involved in their care and are encouraged to combine their own knowledge about their condition with the doctor's professional judgement, they may be more likely to comply with treatment. See what the doctor did Dr Williams is concerned about Jason's non-compliance. She wants him to use his knowledge about his condition in making decisions but still feels that Zolpac is the best option for him. She encourages him to talk about his concerns and they discuss ways of dealing with an increase in anxiety should it arise. References In providing clinical care you must: a. prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient's health, and are satisfied that the drugs or treatment serve the patient's needs12 20 b. provide effective treatments based on the best available evidence (Good Medical Practice paragraph 16) You must support patients in caring for themselves to empower them to improve and maintain their health. (Good Medical Practice paragraph 51)

Answer 13

This would be in line with GMC guidance. B Although the surgeon would be able to talk through the options again, Mrs Conti might not feel as comfortable raising her concerns with a new doctor, so Dr Oloko should explore her concerns with her at this stage. This would be in line with GMC guidance C Dr Oloko should explore Mrs Conti's concerns about surgery and should be able to reassure her without giving an unrealistic impression about the risks involved. See what the doctor did Dr Oloko talks more to Mrs Conti about her fears and concerns, and whether her decision to agree to the referral is really what she wants and not just what she thinks everyone else wants. He also reassures her that she is not obliged to agree to surgery if the cardiac surgeon recommends it, but can consider her options again at that stage. He suggests that Mrs Conti asks the surgeon to explain the risks in detail and agrees to highlight her concerns in his referral letter to the surgeon. References 41. Patients may be put under pressure by employers, insurers, relatives or others, to accept a particular investigation or treatment. You should be aware of this and of other situations in which patients may be vulnerable. Such situations may be, for example, if they are resident in a care home, subject to mental health legislation, detained by the police or immigration services, or in prison. 42. You should do your best to make sure that such patients have considered the available options and reached their own decision. If they have a right to refuse treatment, you should make sure that they know this and are able to refuse if they want to. (Consent: patients and doctors making decisions together, paragraphs 41- 42)

Answer 14

BEST REFLECTS GMC: C This would be in line with GMC guidance. Mrs Conti's capacity to consent could be maximised, for example by discussing the research with a friend or family member present, at the time of day when she is best able to understand and retain the information. However, Dr Ellis should remain sensitive to Mrs Conti's situation and should respect her wishes if she is reluctant to engage in the discussion. See what the doctor did: Dr Ellis asked Mrs Conti whether she would like to participate in the research project. She talked to Mrs Conti early in the day, when she was at her most alert, and gave her a patient leaflet so that she could talk the matter over with her son and his wife when they visited that afternoon. After talking to her family, Mrs Conti decided that she would like to be involved in the project, not only because the trial would provide an alternative to surgery but also because the research might help other people with the same condition. References 64. You must work on the presumption that every adult patient has the capacity to make decisions about their care, and to decide whether to agree to, or refuse, an examination, investigation or treatment. You must only regard a patient as lacking capacity once it is clear that, having been given all appropriate help and support, they cannot understand, retain, use or weigh up the information needed to make that decision, or communicate their wishes. 65. You must not assume that a patient lacks capacity to make a decision solely because of their age, disability, appearance, behaviour, medical condition (including mental illness), their beliefs, their apparent inability to communicate, or the fact that they make a decision that you disagree with. (Consent: patients and doctors making decisions together, paragraphs 64 and 65) 66. A patient's ability to make decisions may depend on the nature and severity of their condition, or the difficulty or complexity of the decision. Some patients will always be able to make simple decisions, but may have difficulty if the decision is complex or involves a number of options. Other patients may be able to make decisions at certain times but not others, because fluctuations in their condition impair their ability to understand, retain or weigh up information, or communicate their wishes. 67. If a patient's capacity is affected in this way, you must follow the guidance in paragraphs 18-21, taking particular care to give the patient the time and support they need to maximise their ability to make decisions for themselves. For example, you will need to think carefully about the extra support needed by patients with dementia or learning disabilities. 68. You must take all reasonable steps to plan for foreseeable changes in a patient's capacity to make decisions. This means that you should: a. discuss treatment options in a place and at a time when the patient is best able to understand and retain the information b. ask the patient if there is anything that would help them remember information, or make it easier to make a decision; such as bringing a relative, partner, friend, carer or advocate to consultations, or having written or audio information about their condition or the proposed investigation or treatment c. speak to those close to the patient and to other healthcare staff about the best ways of communicating with the patient, taking account of confidentiality issues. 69. If a patient is likely to have difficulty retaining information, you should offer them a written record of your discussions, detailing what decisions were made and why. 70. You should record any decisions that are made, wherever possible while the patient has capacity to understand and review them. You must bear in mind that advance refusals of treatment may need to be recorded, signed and witnessed. (Consent: patients and doctors making decisions together, paragraphs 66 - 70) You must make sure that decisions at all stages of research, especially for recruitment, are free from discrimination and respect participants' equality and diversity. You should take all reasonable steps to make sure that people eligible to participate in a project are given equal access to take part and the opportunity to benefit from the research. Where appropriate, you should use patient and public involvement groups at all stages of the project to help make sure that the research is well designed and conducted. (Good practice in research, paragraph 10) Some adults with capacity may be vulnerable to pressure to take part in research. You should be aware that their health or social circumstances might make them vulnerable to pressure from others. Vulnerable adults may be, for example, living in care homes or other institutions, or have learning difficulties or mental illness. In these circumstances, it is particularly important that you check whether they need any additional support to understand information or to make a decision. You must make sure that they know they have the right to decline to participate in research, and that they are able to decline if they want to. The Royal College of Physicians of London provides further guidance on involving vulnerable groups in research. (Consent to research, paragraph 21)

Answer 15

This would be in line with GMC guidance. C Doctors should not make assumptions about a patient's wishes, but should explore in a sensitive way how willing a patient might be to know about a DNACPR decision. While some patients may want to be told, others may find such discussion of little value. This might be in line with GMC guidance, A but the individual patient's wishes and needs must be paramount. Doctors should not force information upon patients, but should rather approach such discussions with sensitivity. Dr Ellis See what the doctor did "Mrs Conti was reluctant to engage in discussion with Dr Ellis about CPR, or much else about her condition, and asked that her son deal with everything from now on. With Mrs Conti's agreement secured, Dr Ellis took Mrs Conti's son and daughter-in-law aside and explained the DNACPR decision. Although upset, they understood the reasons behind it, and felt that this would be helpful in ensuring that Mrs Conti had a peaceful death at home. Dr Ellis recorded the DNACPR decision in Mrs Conti's notes and also arranged for her GP and out-of-hours doctor services to be informed." References 129. If cardiac or respiratory arrest is an expected part of the dying process and CPR will not be successful, making and recording an advance decision not to attempt CPR will help to ensure that the patient dies in a dignified and peaceful manner. It may also help to ensure that the patient's last hours or days are spent in their preferred place of care by, for example, avoiding emergency admission from a community setting to hospital. These management plans are called Do Not Attempt CPR (DNACPR) orders, or Do Not Attempt Resuscitation or Allow Natural Death decisions. (Treatment and care towards the end of life: good practice in decision-making, paragraph 129) 134. If a patient is at foreseeable risk of cardiac or respiratory arrest and you judge that CPR should not be attempted, because it will not be successful in restarting the patient's heart and breathing and restoring circulation, you must carefully consider whether it is necessary or appropriate to tell the patient that a DNACPR decision has been made. You should not make assumptions about a patient's wishes, but should explore in a sensitive way how willing they might be to know about a DNACPR decision. While some patients may want to be told, others may find discussion about interventions that would not be clinically appropriate burdensome and of little or no value. You should not withhold information simply because conveying it is difficult or uncomfortable for you or the healthcare team. 135. If you conclude that the patient does not wish to know about or discuss a DNACPR decision, you should seek their agreement to share with those close to them, with carers and with others, the information they may need to know in order to support the patient's treatment and care. (Treatment and care towards the end of life: good practice in decision-making, paragraphs 134 - 135) 13. No one else can make a decision on behalf of an adult who has capacity. If a patient asks you to make decisions on their behalf or wants to leave decisions to a relative, partner, friend, carer or another person close to them, you should explain that it is still important that they understand the options open to them, and what the treatment will involve. If they do not want this information, you should try to find out why. 14. If, after discussion, a patient still does not want to know in detail about their condition or the treatment, you should respect their wishes, as far as possible. But you must still give them the information they need in order to give their consent to a proposed investigation or treatment. This is likely to include what the investigation or treatment aims to achieve and what it will involve, for example: whether the procedure is invasive; what level of pain or discomfort they might experience, and what can be done to minimise it; anything they should do to prepare for the investigation or treatment; and if it involves any serious risks. 15. If a patient insists that they do not want even this basic information, you must explain the potential consequences of them not having it, particularly if it might mean that their consent is not valid. You must record the fact that the patient has declined this information. You must also make it clear that they can change their mind and have more information at any time. 16. You should not withhold information necessary for making decisions for any other reason, including when a relative, partner, friend or carer asks you to, unless you believe that giving it would cause the patient serious harm. In this context 'serious harm' means more than that the patient might become upset or decide to refuse treatment. 17. If you withhold information from the patient you must record your reason for doing so in the patient's medical records, and you must be prepared to explain and justify your decision. You should regularly review your decision, and consider whether you could give information to the patient later, without causing them serious harm. (Consent: patients and doctors making decisions together, paragraphs 13-17)

Answer 16

This would be in line with GMC guidance. A It may be appropriate sometimes for doctors to encourage patients to consent to disclosures that are necessary for their own protection, and to warn them of the risks of refusing to consent. Dr Gallagher should do his best to provide Miss Cieslak with the information and support she needs to make a decision in her own interests, for example by arranging contact with agencies which supports victims of domestic violence. This may not be in line with GMC guidance. B A competent adult patient's refusal to consent to disclosure should usually be respected, even if that decision leaves the patient at risk of serious harm. However, disclosure without consent may be justified if others (apart from the patient) are at risk. Dr Gallagher should therefore establish whether Miss Cieslak has any children or vulnerable adults living with her. Dr Gallagher See what the doctor did Despite Marlena's reluctance to open up, Dr Gallagher persisted and asked a few more questions about her injuries when she suddenly began to cry. She told Dr Gallagher that her relationship with her boyfriend had broken down and he'd been acting violently towards her for several months now. She explained that she thought she may be suffering from depression and felt powerless and afraid, unable to tell anyone about the abuse. Dr Gallagher gave her advice about support services and encouraged her to contact them. He also offered to write to her GP, with her permission, to recommend a referral for counselling to address her depression. References 50. All patients have the right to a confidential medical service. Challenging situations can however arise when confidentiality rights must be balanced against duties to protect and promote the health and welfare of patients who may be unable to protect themselves 52. As a rule, you should make decisions about how best to support and protect adult patients in partnership with them, and should focus on empowering patients to make decisions in their own interests. You must support and encourage patients to be involved, as far as they want and are able, in decisions about disclosing their personal information 53. There are various legal requirements to disclose information about adults who are known or considered to be at risk of, or to have suffered, abuse or neglect.18 You must disclose information if it is required by law. You should: a. satisfy yourself that the disclosure is required by law b. only disclose information that is relevant to the request, and only in the way required by the law c. tell patients about such disclosures whenever practicable, unless it would undermine the purpose of the disclosure to do so 55. You must disclose personal information about an adult who may be at risk of serious harm if it is required by law (see paragraph 53). Even if there is no legal requirement to do so, you must give information promptly to an appropriate responsible person or authority if you believe a patient who lacks capacity to consent is experiencing, or at risk of, neglect or physical, sexual or emotional abuse, or any other kind of serious harm, unless it is not of overall benefit to the patient to do so. 56. If you believe it is not of overall benefit to the patient to disclose their personal information (and it is not required by law), you should discuss the issues with an experienced colleague. If you decide not to disclose information, you must document in the patient�s records your discussions and the reasons for deciding not to disclose. You must be able to justify your decision. 57. As a principle, adults who have capacity are entitled to make decisions in their own interests, even if others consider those decisions to be irrational or unwise. You should usually ask for consent before disclosing personal information about a patient if disclosure is not required by law, and it is practicable to do so. 58. If an adult patient who has capacity to make the decision refuses to consent to information being disclosed that you consider necessary for their protection, you should explore their reasons for this. It may be appropriate to encourage the patient to consent to the disclosure and to warn them of the risks of refusing to consent. 59. You should, however, usually abide by the patient's refusal to consent to disclosure, even if their decision leaves them (but no one else) at risk of death or serious harm (see endnote 19). You should do your best to give the patient the information and support they need to make decisions in their own interests � for example, by arranging contact with agencies to support people who experience domestic violence. Adults who initially refuse offers of assistance may change their decision over time. (Confidentiality: good practice in handling patient information (2017), paragraphs 50-59) Endnote 19 19. In very exceptional circumstances, disclosure without consent may be justified in the public interest to prevent a serious crime such as murder, manslaughter or serious assault even where no one other than the patient is at risk. This is only likely to be justifiable where there is clear evidence of an imminent risk of serious harm to the individual, and where there are no alternative (and less intrusive) methods of preventing that harm. This is an uncertain area of law and, if practicable, you should seek independent legal advice before making such a disclosure without consent.

Answer 17

This would be in line with GMC guidance. C Doctors are advised not to accept any gift or hospitality which may affect or be seen to affect the way they prescribe for, treat or refer patients. Dr Gallagher must ensure he always acts in a way that justifies his patients' trust in him, and the public's trust in the medical profession. See what the doctor did Dr Gallagher thanked Marlena for her offer but, feeling it would be inappropriate under the circumstances (she had only just finished counselling and was still likely to be vulnerable) he declined, saying that he was unable to accept gifts even from former patients. He told her how glad he was that she was doing so well, and went back to work, wishing her all the best for the future. References You must make sure that your conduct justifies your patients' trust in you and the public's trust in the profession. (Good Medical Practice, paragraph 65) You must not ask for or accept - from patients, colleagues or others - any inducement, gift or hospitality that may affect or be seen to affect the way you prescribe for, treat or refer patients or commission services for patients. (Good Medical Practice, paragraph 80)

Answer 18

This would be in line with GMC guidance, B which states that doctors must not pursue a sexual relationship with a former patient where at the time of the professional relationship the patient was vulnerable. This option is the only way Dr Gallagher could be certain he could defend his actions in the face of a future complaint about his conduct. Dr Gallagher See what the doctor did Dr Gallagher went back to Marlena's flat but decided not to begin a physical relationship with her, because she had been so vulnerable when they first met, and was still very grateful to him for helping her. Despite the fact that their relationship did not progress, Marlena's ex-boyfriend found out about Dr Gallagher's visit to Marlena's flat and made a complaint about him to the GMC. The case did not progress to a Fitness to Practice panel as Dr Gallagher was able to explain - with Marlena's co-operation - that he had not abused his professional position. Dr Gallagher received a letter of advice from the GMC but his fitness to practice was not found to be impaired. References 53. You must not use your professional position to pursue a sexual or improper emotional relationship with a patient or someone close to them (Good Medical Practice, paragraph 53)

Answer 19

This might be in line with GMC guidance. B But doctors must make good use of the resources available to them, including time. Dr May should certainly allow more time for his consultation with Amber (some doctors book double appointments for patients in similar circumstances) but not to the unreasonable detriment of other patients.References 19. You should give information to patients in a balanced way. If you recommend a particular treatment or course of action, you should explain your reasons for doing so. But you must not put pressure on a patient to accept your advice. Dr May See what the doctor did Dr May allowed some extra time for his consultation with Amber and remembered to keep his face turned towards her most of the time to allow her to lip-read. However, during the consultation Dr May made an insensitive comment about Amber's deafness. Amber made a complaint about Dr May to the hospital management. This was investigated and resolved with an action plan including an apology from Dr May and his agreement to undergo additional training in disability awareness and communication skills. 20. You may need to support your discussions with patients by using written material, or visual or other aids. If you do, you must make sure the material is accurate and up to date. 21. You should check whether the patient needs any additional support to understand information, to communicate their wishes, or to make a decision. You should bear in mind that some barriers to understanding and communication may not be obvious; for example, a patient may have unspoken anxieties, or may be affected by pain or other underlying problems. You must make sure, wherever practical, that arrangements are made to give the patient any necessary support. This might include, for example: using an advocate or interpreter; asking those close to the patient about the patient's communication needs; or giving the patient a written or audio record of the discussion and any decisions that were made. (Consent: patients and doctors making decisions together, paragraphs 19-21) 8. You should not make assumptions about a. the information a patient might want or need b. the clinical or other factors a patient might consider significant, or c. a patient's level of knowledge or understanding of what is proposed. 9. You must give patients the information they want or need about: a. the diagnosis and prognosis b. any uncertainties about the diagnosis or prognosis, including options for further investigations c. options for treating or managing the condition, including the option not to treat d. the purpose of any proposed investigation or treatment and what it will involve e. the potential benefits, risks and burdens, and the likelihood of success, for each option; this should include information, if available, about whether the benefits or risks are affected by which organisation or doctor is chosen to provide care f. whether a proposed investigation or treatment is part of a research programme or is an innovative treatment designed specifically for their benefit g. the people who will be mainly responsible for and involved in their care, what their roles are, and to what extent students may be involved h. their right to refuse to take part in teaching or research i. their right to seek a second opinion j. any bills they will have to pay k. any conflicts of interest that you, or your organisation, may have l. any treatments that you believe have greater potential benefit for the patient than those you or your organisation can offer. 10 You should explore these matters with patients, listen to their concerns, ask for and respect their views, and encourage them to ask questions. 11. You should check whether patients have understood the information they have been given, and whether or not they would like more information before making a decision. You must make it clear that they can change their mind about a decision at any time. (Consent: patients and doctors making decisions together, paragraphs 8-11)

Answer 20

This answer best fits GMC guidance. B Dr Rosin has a duty to deal openly and supportively with problems in the conduct of team members, and to make sure that team members have the opportunity to learn from mistakes. By removing Dr May from the rotation until the problem has been addressed, Dr Rosin would also be protecting patients since Dr May's failure to listen to experienced professionals in his team may well be putting his patients at risk of harm. See what the doctor did Dr Rosin spoke to Dr May and with advice from the Deanery they agreed that Dr May would undergo remedial training in communication skills and team-working before continuing with the post in Obstetrics and Gynaecology. However, after completing the training, Dr May did not return to Obstetrics & Gynaecology, but switched to a trust-grade post in a non-clinical specialty, where he would not be directly responsible for patient care. References 7. All doctors have a duty to raise concerns where they believe that patient safety or care is being compromised by the practice of colleagues or the systems, policies and procedures in the organisations in which they work. They must also encourage and support a culture in which staff can raise concerns openly and safely. Raising and acting on concerns about patient safety, paragraph 7 20. Concerns about patient safety can come from a number of sources, such as patients' complaints, colleague's concerns, critical incident reports and clinical audit. Concerns may be about inadequate premises, equipment, other resources, policies or systems, or about the conduct, health or performance of staff or multidisciplinary teams. If you receive this information, you have a responsibility to act on it promptly and professionally. You can do this by putting the matter right (if that is possible), investigating and dealing with the concern locally, or referring serious or repeated incidents or complaints to senior management or the relevant regulatory authority. 21. If you are responsible for clinical governance or have wider management responsibilities, you have a duty to help people report their concerns and to enable people to act on concerns that are raised with them. Raising and acting on concerns about patient safety, paragraphs 20-21. 6. It is essential for good and safe patient care that doctors work effectively with colleagues from other health and social care disciplines, both within and between teams and organisations. Whatever the composition of the teams you work in, you must respect and value each person's skills and contribution. 7. You must tackle discrimination where it arises and encourage your colleagues to do the same. You must treat your colleagues fairly and with respect. You must not bully or harass them or unfairly discriminate against them. You should challenge the behaviour of colleagues who do not meet this standard. Leadership and management for all doctors, paragraphs 6-7)

Answer 21

This might be in line with GMC guidance. A However Dr Rosin must be careful to satisfy himself that the content of the reference is fair and objective, that it relates directly to Dr May's suitability for the post, and that he can substantiate any comments that he makes about Dr May's professional conduct or performance. In this instance, for example, it would be appropriate to mention in the reference the problems identified with Dr May's attitude and communication skills and the training arranged to address them. This would not be in line with GMC guidance. B The fact that it may be uncomfortable to write a reference that includes negative information should not be used as a reason not to provide one. If Dr Rosin is the person best placed to provide a reference on Dr May's performance in the Obstetrics & Gynaecology post, he should do so. This would not be in line with GMC guidance. C Attitude and communication problems that led to a patient complaint and had to be addressed by further training arranged by the Deanery are likely to be relevant to Dr May's suitability for future employment. Omitting this information could lead to his being employed in a post for which he is unsuitable, or to another more suitable candidate being rejected for the vacancy. This might put patients at risk of harm, and could undermine trust in the profession. See what the doctor did Dr Rosin wrote a reference for Dr May, being careful to ensure that what he wrote was factual and not based on his personal views, or those of his other team members. In commenting on Dr May's suitability for the general practice training scheme, Dr Rosin included information about a complaint made by a patient about Dr May, which he judged to be relevant. References You must be honest and objective when writing references, an when appraising or assessing the performance of colleagues, including locums and students. References must include all information relevant to your colleagues' competence, performance and conduct. (Good Medical Practice, paragraph 41) 4. Prospective employers use references to gather information about a candidate's qualifications and employment history and to help them assess their suitability for the post in question.1 They also give both employers and candidates an opportunity to verify the information supplied in an application. So you should write references in a way that is fair to both the candidate2 and the prospective employer. 5. Employers need to be confident that they can rely on the information in references, particularly when they are employing healthcare professionals. Candidates also need to be confident that references written about them are accurate and reliable. A reference that presents an inaccurate picture of a prospective employee could lead either to an unsuitable candidate being appointed or the most suitable person not being appointed. In some cases this will put patients at risk of serious harm and it may undermine trust in the profession. 6. You must be honest and fair when providing references. You should usually provide a reference if you are the person best placed to do so. When providing a reference, you should state the basis upon which you are making your assessment of the candidate, such as how long you have known them and in what capacity. 7. When assessing whether information is relevant, you should consider whether including it (or leaving it out) could mislead an employer3 about either a specific issue or the overall suitability of a candidate. If you agree to provide a reference, you must do the following. Only provide comments that you can substantiate. Provide comments that are objective, fair and unambiguous. Do not base comments on your personal views about a candidate that have no bearing on the candidate's suitability 8. You should include all information you are aware of that is relevant to a candidate's professional competence and be prepared to provide evidence to support this, where appropriate. 9. You should provide information about a candidate's conduct, including matters that might affect a patient's trust in the individual candidate or the public's trust in the profession as a whole. 10. You should draw attention to any other issues that could put patients at risk. This may include information relating to unresolved, outstanding or past complaints about the candidate's competence, performance or conduct, if you judge that this is relevant to the candidate's suitability. You should take reasonable steps to check the information you provide. If this is not practical, or the information is incomplete, you should make this clear. 11. You should not usually include personal information about a candidate, for example in relation to their health, in a reference. However, a situation may arise where you are aware of confidential information about a candidate that has a direct bearing on their suitability for the particular post in question. In these circumstances, you should get consent to disclose the information. If this is not practical, or consent is withheld, you should consider whether the benefits (to individual patients or the public) of disclosing the information would outweigh the possible harm to the individual candidate. For example, including health information may be justified if it is necessary to protect patients from risk of serious harm.5 You can find more guidance on releasing information in the public interest in paragraphs 36-56 of Confidentiality.6 13. If you are not sure about whether to include information in a reference, you should consider getting advice from your medical defence body or a professional association such as the British Medical Association. (Writing References, paragraphs 4 - 13)

Answer 22

This is in line with GMC guidance. C Dr Oloko must assess Shannon's capacity to make this particular decision, starting from the presumption that she has capacity. See what the doctor did Dr Oloko explained to Shannon that he needed to examine her to try and find out if anything was causing her discomfort. Shannon, communicating with her mother's help, understood that Dr Oloko wanted to examine her, but not why. Dr Oloko, concluding that Shannon did not have the capacity to make the decision, decided that an examination was a necessary step in assessing Shannon's condition and, with Mrs Baillie's guidance, that it would not cause Shannon distress. Shannon complied with the physical examination with Mrs Baillie's support. After examination and some further questions, Dr Oloko suspected faecal impaction and felt that a hospital referral for further investigation and treatment if necessary would be appropriate. After discussing the best way of communicating with Shannon, and using the practice materials designed for patients with learning disabilities, Dr Oloko concluded that Shannon did not have the capacity to consent to the proposed course of action. He made a decision based on Shannon's medical needs, taking Mrs Baillie's views about Shannon's preferences into consideration,1 and made the hospital referral. References You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must: a. adequately assess the patient's condition, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values. Where necessary, examine the patient. (Good Medical Practice, paragraph 15a) You must treat patients as individuals and respect their dignity and privacy. (Good Medical Practice, paragraph 47) You must give patients the information they want or need to know in a way they can understand. You should make sure that arrangements are made, wherever possible, to meet patients' language and communication needs. (Good Medical Practice, paragraph 32) You must be satisfied that you have consent or other valid authority before you carry out any examination or investigation, provide treatment or involve patients or volunteers in teaching or research. (Good Medical Practice, paragraph 17) How you discuss a patient's diagnosis, prognosis and treatment options is often as important as the information itself. You should share information in a way that the patient can understand and, whenever possible, in a place and at a time when they are best able to understand and retain it. (Consent: patients and doctors making decisions together, paragraph 18a) You should check whether the patient needs any additional support to understand information, to communicate their wishes, or to make a decision. You should bear in mind that some barriers to understanding and communication may not be obvious; for example, a patient may have unspoken anxieties, or may be affected by pain or other underlying problems. You must make sure, wherever practical, that arrangements are made to give the patient any necessary support. This might include, for example: using an advocate or interpreter; asking those close to the patient about the patient's communication needs; or giving the patient a written or audio record of the discussion and any decisions that were made. (Consent: patients and doctors making decisions together, paragraph 21) 64. You must work on the presumption that every adult patient has the capacity to make decisions about their care, and to decide whether to agree to, or refuse, an examination, investigation or treatment. You must only regard a patient as lacking capacity once it is clear that, having been given all appropriate help and support, they cannot understand, retain, use or weigh up the information needed to make that decision, or communicate their wishes. 65. You must not assume that a patient lacks capacity to make a decision solely because of their age, disability, appearance, behaviour, medical condition (including mental illness), their beliefs, their apparent inability to communicate, or the fact that they make a decision that you disagree with. (Consent: patients and doctors making decisions together, paragraphs 64-65) 66. A patient's ability to make decisions may depend on the nature and severity of their condition, or the difficulty or complexity of the decision. 67. If a patient's capacity is affected in this way, you must [take] particular care to give the patient the time and support they need to maximise their ability to make decisions for themselves. For example, you will need to think carefully about the extra support needed by patients with dementia or learning disabilities. 68. You must take all reasonable steps to plan for foreseeable changes in a patient's capacity to make decisions. This means that you should: a. discuss treatment options in a place and at a time when the patient is best able to understand and retain the information b. ask the patient if there is anything that would help them remember information, or make it easier to make a decision; such as bringing a relative, partner, friend, carer or advocate to consultations, or having written or audio information about their condition or the proposed investigation or treatment c. speak to those close to the patient and to other healthcare staff about the best ways of communicating with the patient, taking account of confidentiality issues 69. If a patient is likely to have difficulty retaining information, you should offer them a written record of your discussions, detailing what decisions were made and why. (Consent: patients and doctors making decisions together, paragraphs 66-69) 71. You must assess a patient's capacity to make a particular decision at the time it needs to be made. You must not assume that because a patient lacks capacity to make a decision on a particular occasion, they lack capacity to make any decisions at all, or will not be able to make similar decisions in the future.. 72. ...If your assessment is that the patient's capacity is borderline, you must be able to show that it is more likely than not that they lack capacity. 73. If your assessment leaves you in doubt about the patient's capacity to make a decision, you should seek advice from: a. nursing staff or others involved in the patient's care, or those close to the patient, who may be aware of the patient's usual ability to make decisions and their particular communication needs b. colleagues with relevant specialist experience, such as psychiatrists, neurologists, or speech and language therapists 74. If you are still unsure about the patient's capacity to make a decision, you must seek legal advice with a view to asking a court to determine capacity.

Answer 23

This would be in line with GMC guidance. C Although it may take more time with some patients than with others, it is important that all patients are given assistance to understand the issues relating to their health and care. Dr May See what the doctor did Dr May follows his consultant's instructions and asks Shannon's mother whether there is any chance that Shannon may be pregnant (she says not) and fills in the consent form. The x-ray confirms that Shannon has severe constipation and she is admitted to the ward for the procedure to take place under general anaesthetic the next morning. References 26. If you are the doctor undertaking an investigation or providing treatment, it is your responsibility to discuss it with the patient. If this is not practical, you can delegate the responsibility to someone else, provided you make sure that the person you delegate to: a. is suitably trained and qualified b. has sufficient knowledge of the proposed investigation or treatment, and understands the risks involved c. understands, and agrees to act in accordance with, the guidance in this booklet 27. If you delegate, you are still responsible for making sure that the patient has been given enough time and information to make an informed decision, and has given their consent, before you start any investigation or treatment. (Consent: patients and doctors making decisions together, paragraphs 26-27) You must give patients the information they want or need to know in a way they can understand. You should make sure that arrangements are made, wherever possible, to meet patients' language and communication needs. Good Medical Practice, paragraph 32) You must be satisfied that you have consent or other valid authority before you carry out any examination or investigation, provide treatment or involve patients or volunteers in teaching or research. (Good Medical Practice, paragraph 17) You must not unfairly discriminate against patients or colleagues by allowing your personal views to affect your personal views to affect your professional relationships or the treatment you provide or arrange. You should challenge colleagues if their behaviour does not comply with this guidance and following the guidance in paragraph 25c if the behaviour amounts to abuse or denial of a patient's rights.

Answer 24

This would be in line with GMC guidance. C Capacity depends on the nature and severity of the patient's condition, and also on the complexity of the decision, and so should be assessed for each decision at the time it needs to be made. If Mr Pillai concludes that Shannon does not understand the consequences of not staying in hospital for the further investigation, then he must make a decision based on what best meets Shannon's needs and consulting those who know her well, like her mother. See what the doctor did Mr Pillai went to speak to Shannon himself by which time her mother had returned. Mrs Baillie agreed with Mr Pillai's suspicion that Shannon was in pain, because her behaviour had been so out of character. Mrs Baillie gently held Shannon's arms while the nurse administered additional pain relief, and Shannon soon began to calm down. After some discussion, they all agreed that - wherever possible - the medical and nursing staff would not try to treat Shannon unless Mrs Baillie was present to support her, at least until they got to know her better and gained her trust. References 71. You must assess a patient's capacity to make a particular decision at the time it needs to be made. You must not assume that because a patient lacks capacity to make a decision on a particular occasion, they lack capacity to make any decisions at all, or will not be able to make similar decisions in the future... 72. ...If your assessment is that the patient's capacity is borderline, you must be able to show that it is more likely than not that they lack capacity. 73. If your assessment leaves you in doubt about the patient's capacity to make a decision, you should seek advice from: a. nursing staff or others involved in the patient's care, or those close to the patient, who may be aware of the patient's usual ability to make decisions and their particular communication needs b. colleagues with relevant specialist experience, such as psychiatrists, neurologists, or speech and language therapists 74. If you are still unsure about the patient's capacity to make a decision, you must seek legal advice with a view to asking a court to determine capacity. 75. In making decisions about the treatment and care of patients who lack capacity, you must: a. make the care of your patient your first concern b. treat patients as individuals and respect their dignity c. support and encourage patients to be involved, as far as they want to and are able, in decisions about their treatment and care< d. treat patients with respect and not discriminate against them 76. You must also consider: a. whether the patient's lack of capacity is temporary or permanent b. which options for treatment would provide overall clinical benefit for the patient c. which option, including the option not to treat, would be least restrictive of the patient's future choices d. any evidence of the patient's previously expressed preferences, such as an advance statement or decision e. the views of anyone the patient asks you to consult, or who has legal authority to make a decision on their behalf, or has been appointed to represent them f. the views of people close to the patient on the patient's preferences, feelings, beliefs and values, and whether they consider the proposed treatment to be in the patient's best interests g. what you and the rest of the healthcare team know about the patient's wishes, feelings, beliefs and values (Consent: patients and doctors making decisions together, paragraphs 71-76) You must not deny treatment to patients because their medical condition may put you at risk. If a patient poses a risk to your health or safety, you should take all available steps to minimise the risk, before providing treatment or making other suitable alternative arrangements for the provision of treatment.

Answer 25

This is in line with GMC guidance. C There may sometimes be a difference between the amount of information that the patient wants, and that which the doctor believes they need, but as long as Suzie knows basically what the procedure is intended to achieve, what it will involve, including any serious risks, and what she should do if there are any problems afterwards, Dr Austin can accept her consent as valid. See what the doctor did Dr Austin explains to Suzie that, while he won't force information on her that she doesn't want, there are certain things, including risks, that she really needs to know about - for example, how soon the stitches can be removed and which symptoms (such as bleeding, continued soreness) might warrant getting the mole site checked by her GP in the meantime. He makes an outpatient appointment for her to have the mole removed. References If, after discussion, a patient still does not want to know in detail about their condition or the treatment, you should respect their wishes, as far as possible. But you must still give them the information they need in order to give their consent to a proposed investigation or treatment. This is likely to include what the investigation or treatment aims to achieve and what it will involve, for example: whether the procedure is invasive; what level of pain or discomfort they might experience, and what can be done to minimise it; anything they should do to prepare for the investigation or treatment and if it involves any serious risks. (Consent: patients and doctors making decisions together, paragraph 14) Clear, accurate information about the risks of any proposed investigation or treatment, presented in a way patients can understand, can help them make informed decisions. The amount of information about risk that you should share with patients will depend on the individual patient and what they want or need to know. Your discussions with patients should focus on their individual situation and the risk to them. (Consent: patients and doctors making decisions together, paragraph 28) You must tell patients if an investigation or treatment might result in a serious adverse outcome9, even if the likelihood is very small. You should also tell patients about less serious side effects or complications if they occur frequently, and explain what the patient should do if they experience any of them.

Answer 26

This is in line with GMC guidance. A Although Dr Austin cannot spend as much time with Suzie as he would like, he ensures that she has good quality information to review when she is ready. He also recognises that other members of the healthcare team have a role to play in supporting patients and answering their questions. B+C = partly in line See what the doctor did Dr Austin apologises for not being able to spend more time on the consultation. He tells Suzie that he will arrange for her to see the surgeon as soon as possible, but in the meantime, if she would like to talk to someone about the diagnosis, he can introduce her to one of the nurses in his department, or provide contact details for her. He also gives Suzie a leaflet about melanoma, and recommends some good quality online sources of information. References How you discuss a patient's diagnosis, prognosis and treatment options is often as important as the information itself. You should: a. share information in a way that the patient can understand and, whenever possible, in a place and at a time where they are best able to understand and retain it b. give information that the patient may find distressing in a considerate way c. involve other members of the healthcare team in discussions with the patient, if appropriate d. give the patient time to reflect, before and after they make a decision, especially if the information is complex, or what you are proposing involves significant risks e. make sure the patient knows if there is a time limit on making their decision, and who they can contact in the healthcare team if they have any questions or concerns (Consent: patients and doctors making decisions together, paragraph 18) It is sometimes difficult, because of pressures on your time or the limited resources available, to give patients as much information or support in making decisions as you, or they, would like. To help in this, you should consider the role that other members of the healthcare team might play, and what other sources of information and support are available. These may be, for example, patient information leaflets, advocacy services, expert patient programmes, or support groups for people with specific conditions.

Answer 27

This is in line with GMC guidance, B although Mrs Glenn remains responsible for delegating responsibility to Dr Aiken, and must be sure that Dr Aiken has sufficient knowledge to give Suzie the information that she wants and needs. If she is any doubt, she should talk to Suzie herself. This is partly in line with GMC guidance, C although Mrs Glenn remains responsible for delegating responsibility to Dr Aiken, and must be sure that Dr Aiken has sufficient knowledge to give Suzie the information that she wants and needs. If she is any doubt, she should talk to Suzie herself. See what the doctor did Because Suzie has some specific questions about the surgery which Dr Aiken is not confident about addressing, Mrs Glenn goes to see Suzie herself, answers her questions and confirms that Suzie is happy to go ahead with the surgery the following morning. References "If you are the doctor undertaking an investigation or providing treatment, it is your responsibility to discuss it with the patient. If this is not practical, you can delegate the responsibility to someone else, provided you make sure that the person you delegate to: a. is suitably trained and qualified b. has sufficient knowledge of the proposed investigation or treatment, and understands the risks involved c. understands, and agrees to act in accordance with, the guidance in this booklet If you delegate, you are still responsible for making sure that the patient has been given enough time and information to make an informed decision, and has given their consent, before you start any investigation or treatment. (Consent: patients and doctors making decisions together, paragraph 26-27) Before accepting a patient's consent, you must consider whether they have been given the information they want, or need, and how well they understand the details and implications of what is proposed. This is more important than how their consent is expressed or recorded.

Answer 28

This may be in line with GMC guidance. B Dr Singh needs to find out what Mr Hartley wants and Clementine is answering for him and interrupting him when he speaks. However, Dr Singh must be careful not to make Clementine feel excluded. Often carers or close relatives are best placed to know what patients themselves would want if they lack the capacity to make decisions about their healthcare. See what the doctor did Dr Singh politely explains to Clementine that he really needs to hear from her father himself about what he wants. Mr Hartley is initially a little confused about what is proposed, and upset about the idea of going to hospital. However, Dr Singh decides that - with some extra support - Mr Hartley does have capacity to decide whether or not to have the ultrasound scan, and manages to persuade him that it would be in his best interests. Mr Hartley agrees to the referral. References 64. You must work on the presumption that every adult patient has the capacity to make decisions about their care, and to decide whether to agree to, or refuse, an examination, investigation or treatment. You must only regard a patient as lacking capacity once it is clear that, having been given all appropriate help and support, they cannot understand, retain, use or weigh up the information needed to make that decision, or communicate their wishes. 65. You must not assume that a patient lacks capacity to make a decision solely because of their age, disability, appearance, behaviour, medical condition (including mental illness), their beliefs, their apparent inability to communicate, or the fact that they make a decision that you disagree with. (Consent: patients and doctors making decisions together, paragraphs 64-65) 66. A patient's ability to make decisions may depend on the nature and severity of their condition, or the difficulty or complexity of the decision. Some patients will always be able to make simple decisions, but may have difficulty if the decision is complex or involves a number of options. Other patients may be able to make decisions at certain times but not others, because fluctuations in their condition impair their ability to understand, retain or weigh up information, or communicate their wishes. 67. If a patient's capacity is affected in this way, you must...[take] particular care to give the patient the time and support they need to maximise their ability to make decisions for themselves. For example, you will need to think carefully about the extra support needed by patients with dementia or learning disabilities. 68. You must take all reasonable steps to plan for foreseeable changes in a patient's capacity to make decisions. This means that you should: a. discuss treatment options in a place and at a time when the patient is best able to understand and retain the information b. ask the patient if there is anything that would help them remember information, or make it easier to make a decision; such as bringing a relative, partner, friend, carer or advocate to consultations, or having written or audio information about their condition or the proposed investigation or treatment c. speak to those close to the patient and to other healthcare staff about the best ways of communicating with the patient, taking account of confidentiality issues. 69. If a patient is likely to have difficulty retaining information, you should offer them a written record of your discussions, detailing what decisions were made and why. 70. You should record any decisions that are made, wherever possible while the patient has capacity to understand and review them... (Consent: patients and doctors making decisions together, paragraphs 66-70) 71. You must assess a patient's capacity to make a particular decision at the time it needs to be made. You must not assume that because a patient lacks capacity to make a decision on a particular occasion, they lack capacity to make any decisions at all, or will not be able to make similar decisions in the future. 72. You must take account of the advice on assessing capacity in the Codes of Practice that accompany the Mental Capacity Act 2005 and the Adults with Incapacity (Scotland) Act 2000 and other relevant guidance. If your assessment is that the patient's capacity is borderline, you must be able to show that it is more likely than not that they lack capacity. 73. If your assessment leaves you in doubt about the patient's capacity to make a decision, you should seek advice from: a. nursing staff or others involved in the patient's care, or those close to the patient, who may be aware of the patient's usual ability to make decisions and their particular communication needs b. colleagues with relevant specialist experience, such as psychiatrists, neurologists, or speech and language therapists. 74. If you are still unsure about the patient's capacity to make a decision, you must seek legal advice with a view to asking a court to determine capacity.

Answer 29

This would be in line with GMC guidance. B However, Dr Aiken should try to avoid causing offence to Clementine when Mr Hartley may be perfectly content for her to share information about his condition with her. It might help if Dr Aiken explains this to Clementine when asking her to come back to the hospital later. This may be in line with GMC guidance. C When a patient lacks capacity it is reasonable to assume they would want those closest to them to be kept informed of their general condition and prognosis, unless they have indicated otherwise. However, doctors must still be careful to disclose only relevant information. See what the doctor did Dr Aiken told Clementine that the ultrasound scan suggested that Mr Hartley had a gastric ulcer but that further investigation - an endoscopy and perhaps a biopsy - would be necessary to determine what treatment may be required. She suggested that Clementine come back in the morning when her father woke up so that she could support him in making decisions about the investigations and the subsequent treatment options. References 64. You should establish with the patient what information they want you to share, who with, and in what circumstances. This will be particularly important if the patient has fluctuating or diminished capacity or is likely to lose capacity, even temporarily. Early discussions of this nature can help to avoid disclosures that patients would object to. They can also help to avoid misunderstandings with, or causing offence to, anyone the patient would want information to be shared with. 65. If a patient lacks capacity, you should share relevant information in accordance with the advice in paragraphs 57 to 63. Unless they indicate otherwise, it is reasonable to assume that patients would want those closest to them to be kept informed of their general condition and prognosis.

Answer 30

This answer best fits GMC guidance. A Doctors should encourage patients to think about these issues, and - if the patient agrees - should consider involving family and other people close to them in the discussion.Dr Singh See what the doctor did Dr Singh gave Mr Hartley some written material about advance care planning to help him think about what he might want to happen if he should lose capacity to make decisions about his healthcare. These included leaflets on appointing a proxy decision-maker, and making decisions to refuse treatment in advance. Dr Singh suggested that Mr Hartley consider involving his children in thinking about the options, and that he come back to the surgery in a week's time - either alone or with one of them - to talk through the issues further. Dr Singh made a note of the discussion in the records, and the fact that Mr Hartley had said he would like his son to make decisions for him, but emphasised to Mr Hartley that this was the beginning of a process of discussion rather than an end in itself. References If a patient: a. has a condition that will affect the length or quality of their life, or b. has a condition that will impair their capacity as it progresses, such as dementia, or c. is otherwise facing a situation in which loss or impairment of capacity is a foreseeable possibility you should encourage them to think about what they might want for themselves in the event that they cannot make their own decisions, and to discuss their wishes and concerns with you and the healthcare team. 58. Such discussions might cover: a. the patient's wishes, preferences or fears in relation to their future care, including any treatments they would want to refuse, and under what circumstances b. the feelings, beliefs or values that may be influencing the patient's preferences and decisions c. the relatives, friends, carers or representatives that the patient would like to be involved in decisions about their care d. interventions that are likely to become necessary in an emergency, such as cardio-pulmonary resuscitation (CPR). 59. You should approach such discussions sensitively. If the patient agrees, you should consider involving other members of the healthcare team, people who are close to the patient or an advocate. 60. If a patient wants to nominate someone to make decisions on their behalf if they lose capacity, or if they want to refuse a particular treatment, you should explain that there may be ways to formalise these wishes and recommend that they get independent advice on how to do this. 61. You must record the discussion and any decisions the patient makes. You should make sure that a record of the plan is made available to the patient and others involved in their care, so that everyone is clear about what has been agreed. This is particularly important if the patient has made an advance decision to refuse treatment.11. You should bear in mind that care plans need to be reviewed and updated as the situation or the patient's views change. (Consent: patients and doctors making decisions together, paragraphs 57-61) 11. The Mental Capacity Act 2005 requires advance decisions to refuse life-sustaining treatment to be in writing. Advance decisions to refuse other types of treatment may be written or verbal, but if verbal, they should be recorded in a person's healthcare record (see Mental Capacity Act 2005 Code of Practice chapter 9). It may be helpful under the provisions of the Adults with Incapacity (Scotland) Act 2000, for a written record to be made of a person's advance decision to refuse medical treatment (see Code of Practice for those authorised to carry out medical treatment or research under Part 5 of the Act, paragraphs 2.27-2.30). 20. You may need to support your discussions with patients by using written material, or visual or other aids. If you do, you must make sure the material is accurate and up to date. 21. You should check whether the patient needs any additional support to understand information, to communicate their wishes, or to make a decision. You should bear in mind that some barriers to understanding and communication may not be obvious; for example, a patient may have unspoken anxieties, or may be affected by pain or other underlying problems. You must make sure, wherever practical, that arrangements are made to give the patient any necessary support. This might include, for example: using an advocate or interpreter; asking those close to the patient about the patient's communication needs; or giving the patient a written or audio record of the discussion and any decisions that were made.

Answer 31

This would be in line with GMC guidance C This would be in line with GMC guidance - by speaking with Christopher and his father, Dr Williams will be better able to assess the distress caused by bullying and identify whether surgery is in Christopher's best interests. This might be in line with GMC guidance. B However to make a proper assessment of a child's best interests, doctors should consider children's own views as well as those of their parents and others with an interest in the child's welfare. See what the doctor did Dr Williams speaks to Christopher about his ears. Christopher says he is being teased a lot at school which upsets him. Although Mrs Rees is unhappy about it, Dr Williams tries to contact Christopher's father on two occasions, but isn't able to speak to him. In light of her discussions with Christopher and his mother, Dr Williams decides she will refer Christopher to a paediatric surgeon. References Doctors should always act in the best interests of children and young people. This should be the guiding principle in all decisions which may affect them. But identifying their best interests is not always easy. This is particularly the case in relation to treatment that does not have proven health benefits or when competent young people refuse treatment that is clearly in their medical interests. There can also be a conflict between child protection and confidentiality, both of which are vitally important to the welfare of children and young people. (0-18 years: guidance for all doctors, paragraph 8) An assessment of best interests will include what is clinically indicated in a particular case. You should also consider: a. the views of the child or young person, so far as they can express them, including any previously expressed preferences b. the views of parents c. the views of others close to the child or young person d. the cultural, religious or other beliefs and values of the child or parents2 e. the views of other healthcare professionals involved in providing care to the child or young person, and of any other professionals who have an interest in their welfare f. which choice, if there is more than one, will least restrict the child or young person's future options (0-18 years: guidance for all doctors, paragraph 12) You should talk directly and listen to children and young people who are able to take part in discussions about their care. Young people who are able to understand what is being said and who can speak for themselves resent being spoken about when they are present. But younger children might not be able to understand what their illness or proposed treatment is likely to involve, even when explained in straightforward terms. (0-18 years: guidance for all doctors, paragraph 19) Both the GMC and the law permit doctors to undertake procedures that do not offer immediate or obvious therapeutic benefits for children or young people, so long as they are in their best interests and performed with consent. To assess their best interests you should consider the religious and cultural beliefs and values of the child or young person and their parents as well as any social, psychological and emotional benefits. This may be relevant in circumcision of male children for religious or cultural reasons15, or surgical correction of physical characteristics that do not endanger the child's life or health. (0-18 years: guidance for all doctors, paragraphs 34-35) If providing treatment to children, you should be familiar with the detailed advice in 0-18 years: guidance for all doctors, which includes the key points set out in this section of guidance. You should take particular care if you consider providing cosmetic interventions for children or young people - you should make sure the environment for practice is appropriate to paediatric care, and work with multidisciplinary teams that provide expertise in treating children and young people where necessary. (Cosmetic interventions, paragraph 32) You must only provide interventions that are in the best interests of the child or young person. If a young person has capacity to decide whether to undergo an intervention, you should still encourage them to involve their parents in making their decision. (Cosmetic interventions, paragraph 33) A parent can consent to an intervention for a child or young person who does not have the maturity and capacity to make the decision, but you should involve the child in the decision as much as possible. If you judge that the child does not want to have the cosmetic intervention, then you must not perform it.

Answer 32

This would be in line with GMC guidance. B Doctors should let parents access their child's medical records if the child or young person consents or lacks capacity to consent and such access does not go against the child's best interests. Dr Williams See what the doctor did Dr Williams makes an appointment for Christopher's father to come to the surgery to view his son's records. Before the appointment, Dr Williams reviews Christopher's records to make sure that any information about his mother, or other third party, contained in the records, is not disclosed to Christopher's father without their consent. References You should let parents access their child's medical records if the child or young person consents, or lacks capacity, and it does not go against the child's best interests. If the records contain information given by the child or young person in confidence you should not normally disclose the information without their consent24.

Answer 33

This is in line with GMC guidance. B Doctors should try to facilitate resolution to conflicts between parents. This will enable doctors to better understand where the child's best interests lie. This would be in line with GMC guidance IF A This would be in line with GMC guidance where treatment was needed urgently to prevent harm or deterioration in the child's health. But as this is not the case with Christopher, and Mr Rees still has parental responsibility, Dr Williams should try to include Mr Rees's views in assessing Christopher's best interests. Doctors should also be considerate to patients' relatives and sensitive and responsible in providing information and support. See what the doctor did Dr Williams arranges a meeting with both of Christopher's parents, so they can discuss whether or not Christopher's referral to have his ears pinned back should be cancelled. At the meeting it is agreed that Christopher's school should be contacted to establish the extent of the bullying before making a final decision about whether he should have surgery. References An assessment of best interests will include what is clinically indicated in a particular case. You should also consider: a. the views of the child or young person, so far as they can express them, including any previously expressed preferences b. the views of parents c. the views of others close to the child or young person ...The weight you attach to each point will depend on the circumstances, and you should consider any other relevant information. You should not make unjustified assumptions about a child or young person's best interests... (0-18 years: guidance for all doctors , paragraph 12 a-c, 13) If providing treatment to children, you should be familiar with the detailed advice in 0-18 years: guidance for all doctors, which includes the key points set out in this section of guidance. You should take particular care if you consider providing cosmetic interventions for children or young people - you should make sure the environment for practice is appropriate to paediatric care, and work with multidisciplinary teams that provide expertise in treating children and young people where necessary. (Cosmetic interventions, paragraph 32) You must only provide interventions that are in the best interests of the child or young person. If a young person has capacity to decide whether to undergo an intervention, you should still encourage them to involve their parents in making their decision. (Cosmetic interventions, paragraph 33) A parent can consent to an intervention for a child or young person who does not have the maturity and capacity to make the decision, but you should involve the child in the decision as much as possible. If you judge that the child does not want to have the cosmetic intervention, then you must not perform it.

Answer 34

This would be in line with GMC guidance. B Dr Simpson should work with Andrew's parents to provide him with information he can understand which is appropriate to his age and maturity, at an appropriate time and pace. This might be in line with GMC guidance. A Doctors should be honest and open with all their patients, including children and young people. However, doctors should be careful not to overburden young children, who might not understand what their illness is likely to involve. his might be in line with GMC guidance. C However, Dr Simpson would need to satisfy herself that Andrew has the maturity to understand the information she's providing. Also, doctors should try to work with parents in identifying children's best interests and their capacity for understanding news that might be distressing. See what the doctor did Dr Simpson met with Andrew and assessed his capacity. She decided that as he was rather unwell at the moment he wasn't able to understand the implications of his diagnosis. So she agreed with Andrew's parents that for the time being she would not tell Andrew his diagnosis. However, she explained to Andrew's parents that she would review this decision if there was any change in his condition. References Effective communication between doctors and children and young people is essential to the provision of good care. You should find out what children, young people and their parents want and need to know, what issues are important to them, and what opinions or fears they have about their health or treatment. In particular you should: a. involve children and young people in discussions about their care b. be honest and open with them and their parents, while respecting confidentiality c. listen to and respect their views about their health, and respond to their concerns and preferences d. explain things using language or other forms of communication they can understand e. consider how you and they use non-verbal communication, and the surroundings in which you meet them f. give them opportunities to ask questions, and answer these honestly and to the best of your ability g. do all you can to make open and truthful discussion possible, taking into account that this can be helped or hindered by the involvement of parents or other people h. give them the same time and respect that you would give to adult patients

Answer 35

This would be in line with GMC guidance. B Doctors should be open and honest with their patients, including children and young people. They should also work with parents in the best interests of their children. Andrew's parents might be better able to provide the support Andrew needs in digesting the news and implications of his diagnosis. This may be in line with GMC guidance. C However, doctors should try to work with parents in caring for their children, and if a short delay will help in doing that, it would be appropriate to wait and involve them. They might be better able to provide the support Andrew needs in digesting the news and implications of his diagnosis See what the doctor did Dr Simpson spoke to Andrew's parents and explained that she now believed Andrew had the capacity to understand his diagnosis and its implications. She advised them that because he had asked her a question she could not lie to him. While Andrew's parents were upset about this, they acknowledged that it wouldn't be fair to deceive Andrew. Dr Simpson and Andrew's parents agreed that they would explain what was wrong with him, but with Dr Simpson there to answer any questions they weren't able to. References When treating children and young people, doctors must also consider parents and others close to them; but their patient must be the doctor's first concern. (0-18: guidance for all doctors, paragraph 4) You should talk directly and listen to children and young people who are able to take part in discussions about their care. Young people who are able to understand what is being said and who can speak for themselves resent being spoken about when they are present. But younger children might not be able to understand what their illness or proposed treatment is likely to involve, even when explained in straightforward terms. (0-18: guidance for all doctors, paragraph 19)

Answer 36

This would be in line with GMC guidance. C Dr Simpson must consider carefully Andrew's refusal of treatment and should involve his parents and other professionals in addressing Andrew's concerns. Their views should also inform an assessment of whether continued treatment without Andrew's consent would be in his best interests. See what the doctor did Dr Simpson asked a counsellor with experience of working with young people to discuss Andrew's concerns with him, and also with his parents. The counsellor was able to allay Andrew's fears about his treatment and Dr Simpson provided reassurance that he would be involved in the decision-making as his treatment progressed. Andrew agreed to begin the treatment, and Dr Simpson agreed that she would review his progress with him at regular intervals. References Respect for young people's views is important in making decisions about their care. If they refuse treatment, particularly treatment that could save their life or prevent serious deterioration in their health, this presents a challenge that you need to consider carefully. Parents cannot override the competent consent of a young person to treatment that you consider is in their best interests. But you can rely on parental consent when a child lacks the capacity to consent. In Scotland parents cannot authorise treatment a competent young person has refused10. In England, Wales and Northern Ireland, the law on parents overriding young people's competent refusal is complex11. You should seek legal advice if you think treatment is in the best interests of a competent young person who refuses12. You must carefully weigh up the harm to the rights of children and young people of overriding their refusal against the benefits of treatment, so that decisions can be taken in their best interests13. In these circumstances, you should consider involving other members of the multi-disciplinary team, an independent advocate, or a named or designated doctor for child protection. Legal advice may be helpful in deciding whether you should apply to the court to resolve disputes about best interests that cannot be resolved informally. You should also consider involving these same colleagues before seeking legal advice if parents refuse treatment that is clearly in the best interests of a child or young person who lacks capacity, or if both a young person with capacity and their parents refuse such treatment. (0-18: guidance for all doctors, paragraphs 30-33)

Answer 37

This would be in line with GMC guidance. A While confidentiality is important, Dr Clifford could share some limited information, even without Jacquie's consent, to help him decide if there is a risk that would justify further disclosures. However, he should still tell Jacquie of his intention to disclose the information, so as to keep any damage done to Jacquie's trust in the doctor-patient relationship to a minimum. Dr Clifford See what the doctor did After speaking to the named practitioner for child protection again, Dr Clifford contacts Jacquie and manages to persuade her that social services could provide support for her and Olly. Jacquie eventually agrees that Dr Clifford can share relevant information with the local social services team. Dr Clifford telephones social services and explains that Jacquie has been having difficulties, and that Olly has missed a few days of school. He confirms this in writing the same day. The social worker confirms that an initial assessment will be made of Olly's welfare and that she will also look into what extra support could be offered to Jacquie. References When treating adults who care for, or pose risks to, children and young people, the adult patient must be the doctor's first concern; but doctors must also consider and act in the best interests of children and young people. (0-18 years: guidance for all doctors, paragraph 5) Confidentiality is important and information sharing should be proportionate to the risk of harm. You may share some limited information, with consent if possible, to decide if there is a risk that would justify further disclosures. A risk might only become apparent when a number of people with niggling concerns share them. If in any doubt about whether to share information, you should seek advice from an experienced colleague, a named or designated doctor for child protection, or a Caldicott Guardian. You can also seek advice from a professional body, defence organisation or the GMC. You will be able to justify raising a concern, even if it turns out to be groundless, if you have done so honestly, promptly, on the basis of reasonable belief, and through the appropriate channels. (0-18 years: guidance for all doctors, paragraph 60) Your first concern must be the safety of children and young people. You must inform an appropriate person or authority promptly of any reasonable concern that children or young people are at risk of abuse or neglect, when that is in a child's best interests or necessary to protect other children or young people.26 You must be able to justify a decision not to share such a concern, having taken advice from a named or designated doctor for child protection or an experienced colleague, or a defence or professional body. You should record your concerns, discussions and reasons for not sharing information in these circumstances. (0-18 years: guidance for all doctors, paragraph 61) 26. A patient may no longer be in danger and request that you do not share information about past abuse, for example. Disclosure might still be justified if the abuser remains a risk to other children Whether or not you have vulnerable adults or children and young people as patients, you should consider their needs and welfare and offer them help if you think that their rights have been abused or denied. (Good Medical Practice, paragraph 27) When discussing your concerns with parents, you should explain that doctors have a professional duty to raise their concerns if they think a child or young person is at risk of abuse or neglect. You should explain what actions you intend to take, including if you are contacting the local authority children's services. You should give the parents this information when you first become concerned about a child's or young person's safety or welfare and throughout a family's involvement in child protection procedures. (Protecting children and young people, paragraph 21) You must tell an appropriate agency, such as your local authority children's services, the NSPCC or the police, promptly if you are concerned that a child or young person is at risk of, or is suffering, abuse or neglect unless it is not in their best interests to do so (see paragraphs 39 and 40). You do not need to be certain that the child or young person is at risk of significant harm to take this step. If a child or young person is at risk of, or is suffering, abuse or neglect, the possible consequences of not sharing relevant information will, in the overwhelming majority of cases, outweigh any harm that sharing your concerns with an appropriate agency might cause. (Protecting children and young people, paragraph 32)

Answer 38

This would be in line with GMC guidance. C Dr Clifford should consider any specific requests for information carefully. While it is preferable to have patients' consent to disclose any personal information about them, it may be justifiable to disclose information without consent where to do so would be in the public interest. This may be in line with GMC guidance. B Dr Clifford has already provided social services with the information about Jacquie which he considers to be relevant. There is no evidence to suggest Olly's grandmother may be a risk, so there does not seem to be a reason to disclose information about her without her consent. However, doctors should consider any specific requests for information carefully, since further disclosure may be justified without consent, in the public interest. See what the doctor did Dr Clifford explained to the social worker that he would review Jacquie's records to see if there was anything else that might be relevant to them and the services they might provide. He also explained that he would need to speak to Jacquie and her mother about any further disclosures, but that he would contact them with anything that indicated Olly was at risk of significant harm in the meantime. References 51. It may be appropriate to encourage patients to consent to disclosures you consider necessary for their protection, and to warn them of the risks of refusing to consent; but you should usually abide by a competent adult patient's refusal to consent to disclosure, even if their decision leaves them, but nobody else, at risk of serious harm. 22. You should do your best to provide patients with the information and support they need to make decisions in their own interests, for example, by arranging contact with agencies to support victims of domestic violence. 52. Disclosure without consent may be justified if it is not practicable to seek a patient's consent. See paragraph 38 for examples, and paragraph 63 for guidance on disclosures to protect a patient who lacks capacity to consent. 53. Disclosure of personal information about a patient without consent may be justified in the public interest if failure to disclose may expose others to a risk of death or serious harm. You should still seek the patient's consent to disclosure if practicable and consider any reasons given for refusal. 54. Such a situation might arise, for example, when a disclosure would be likely to assist in the prevention, detection or prosecution of serious crime, 23 especially crimes against the person. When victims of violence refuse police assistance, disclosure may still be justified if others remain at risk, for example, from someone who is prepared to use weapons, or from domestic violence when children or others may be at risk. 55. If a patient's refusal to consent to disclosure leaves others exposed to a risk so serious that it outweighs the patient's and the public interest in maintaining confidentiality, or if it is not practicable or safe to seek the patient's consent, you should disclose information promptly to an appropriate person or authority. You should inform the patient before disclosing the information, if practicable and safe, even if you intend to disclose without their consent. (Confidentiality (2009) paragraphs 51-56) 22. The Adult Support and Protection (Scotland) Act 2007 requires health boards in Scotland to report to local authorities if they know or believe that an adult is at risk of harm (but not necessarily incapacitated) and that action needs to be taken to protect them. The Act also requires certain public bodies and office holder to co-operate with local authorities making inquiries about adults at risk and includes powers to examine health records for related purposes. 23. There is no agreed definition of 'serious crime' Confidentiality: NHS Code of Practice (Department of Health, 2003) gives some examples of serious crime (including murder, manslaughter, rape and child abuse; serious harm to the security of the state and public order and 'crimes that involve substantial financial gain or loss are mentioned in the same category). It also gives examples of crimes that are not usually serious enough to warrant disclosure without consent (including theft, fraud and damage to property where loss or damage is less substantial). 36. You can share confidential information without consent if it is required by law, or directed by a court, or if the benefits to a child or young person that will arise from sharing the information outweigh both the public and the individual's interest in keeping the information confidential. You must weigh the harm that is likely to arise from not sharing the information against the possible harm, both to the person and to the overall trust between doctors and patients of all ages, arising from releasing that information. 37. If a child or young person with capacity, or a parent, refuses to give consent to share information, you should consider their reasons for refusing, and weigh the possible consequences of not sharing the information against the harm that sharing the information might cause. If a child or young person is at risk of, or is suffering, abuse or neglect, it will usually be in their best interests to share information with the appropriate agency. 38. If you share information without consent, you should explain why you have done so to the people the information relates to, and provide the information described in paragraph 35, unless doing this would put the child, young person or anyone else at increased risk. You should also record your decision as set out in paragraph 54.

Answer 39

This would be in line with GMC guidance. C Sharing information with parents can often be in a young person's best interests, but this should be done with the young person's consent where possible. If Sarah refuses consent to disclose to her parents, and Dr Williams believes a disclosure to be necessary, even without Sarah's consent, it may be more appropriate for Dr Williams to contact social services rather than Sarah's parents. Whatever she decides to do, Dr Williams should tell Sarah what she proposes to disclose and why (unless this would undermine the purpose, or place Sarah at increased risk of harm). This may be in line with GMC guidance. A Although Dr Williams should ask for Sarah's consent to share relevant information, in order to show her respect, and that she is involving her in decisions about her care. Even if Sarah doesn't agree to the disclosure, Dr Williams should still disclose if there is an overriding public interest in the disclosure; or if she judges that it's in Sarah's best interests but Sarah doesn't have the maturity or understanding to make a decision. See what the doctor did Dr Williams explains that she can't ignore her concerns, although she understands why Sarah doesn't want to talk to her parents. Dr Williams stresses that she is there to help Sarah and she manages to persuade her to make an appointment to come back and see her with her mother so they can discuss the situation together. References You should usually share information about abusive or seriously harmful sexual activity involving any child or young person, including that which involves: (a) a young person too immature to understand or consent (b) big differences in age, maturity or power between sexual partners (c) a young person's sexual partner having a position of trust (d) force or the threat of force, emotional or psychological pressure, bribery or payment, either to engage in sexual activity or to keep it secret (e) drugs or alcohol used to influence a young person to engage in sexual activity when they otherwise would not (f) a person known to the police or child protection agencies as having had abusive relationships with children or young people.29 (0-18: guidance for all doctors, paragraph 68) You should normally discuss any concerns you have about a child's or young person's safety or welfare with their parents. You should only withhold information about your concerns, or about a decision to make a referral, if you believe that telling the parents may increase the risk of harm to the child or young person or anyone else. If this is difficult to judge, or you are not sure about the best way to approach the situation, you should ask for advice from a designated or named professional or a lead clinician or, if they are not available, an experienced colleague. (Protecting children and young people, paragraph 20) 29. Working Together to Safeguard Children (HM Government, 2006) includes advice and a list of considerations (at 5.27) to be taken into account when assessing risk in underage sex. See also Working Together:Q&A on sexual activity of under 16s and under 13s (Department for Education and Skills, 2006), Children and Families: Safer from Sexual Crime - The Sexual Offences Act 2003 (Home Office 2003) and the Confidentiality and young people toolkit (Royal College of General Practitioners, 2000). You have the same duty of confidentiality to children and young people as you have to adults. But parents often want and need information about their children's care so that they can make decisions or provide care and support. Children and young people are usually happy for information to be shared with their parents. This sharing of information is often in the best interests of children and young people, particularly if their health would benefit from special care or ongoing treatment, such as a special diet or regular medication. Parents are usually the best judges of their children's best interests and should make important decisions up until children are able to make their own decisions. You should share relevant information with parents in accordance with the law and the guidance in paragraphs 27, 28 and 42 to 55. (0-18: guidance for all doctors, paragraph 21) Doctors play a crucial role in protecting children from abuse and neglect. You may be told or notice things that teachers and social workers, for example, may not. You may have access to confidential information that causes you to have concern for the safety or well-being of children. (0-18: guidance for all doctors, paragraph 56) Your first concern must be the safety of children and young people. You must inform an appropriate person or authority promptly of any reasonable concern that children or young people are at risk of abuse or neglect, when that is in a child's best interests or necessary to protect other children or young people.26 You must be able to justify a decision not to share such a concern, having taken advice from a named or designated doctor for child protection or an experienced colleague, or a defence or professional body. You should record your concerns, discussions and reasons for not sharing information in these circumstances. (0-18: guidance for all doctors, paragraph 61) 26. A patient may no longer be in danger and request that you do not share information about past abuse, for example. Disclosure might still be justified if the abuser remains a risk to other children. You can disclose relevant information when this is in the public interest (see paragraphs 47 to 50). If a child or young person is involved in abusive or seriously harmful sexual activity, you must protect them by sharing relevant information with appropriate people or agencies, such as the police or social services, quickly and professionally. (0-18: guidance for all doctors, paragraph 65) 47. When considering whether disclosure would be justified you should: a. tell the child or young person what you propose to disclose and why, unless that would undermine the purpose or place the child or young person at increased risk of harm b. ask for consent to the disclosure, if you judge the young person to be competent to make the decision, unless it is not practical to do so. 48. If a child or young person refuses consent, or if it is not practical to ask for consent, you should consider the benefits and possible harms that may arise from disclosure. You should consider any views given by the child or young person on why you should not disclose the information. But you should disclose information if this is necessary to protect the child or young person, or someone else, from risk of death or serious harm. Such cases may arise, for example, if: a. a child or young person is at risk of neglect or sexual, physical or emotional abuse (see paragraphs 56 to 63). b. the information would help in the prevention, detection or prosecution of serious crime, usually crime against the person c. a child or young person is involved in behaviour that might put them or others at risk of serious harm, such as serious addiction, self-harm or joy-riding. 49.If you judge that disclosure is justified, you should disclose the information promptly to an appropriate person or authority and record your discussions and reasons. If you judge that disclosure is not justified, you should record your reasons for not disclosing. 50. If you judge that disclosure is justified, you should disclose the information promptly to an appropriate person or authority and record your discussions and reasons. If you judge that disclosure is not justified, you should record your reasons for not disclosing. (0-18: guidance for all doctors, paragraphs 47-50) 22. The NHS Confidentiality Code of Practice explains that 'the definition of serious crime is not entirely clear. Murder, manslaughter, rape, treason, kidnapping,child abuse or other cases where individuals have suffered child serious harm may all warrant breaching confidentiality. 'Serious harm to the security of the state or to public order and crimes that involve substantial financial gain or loss will also generally fall within this category. In contrast, theft, fraud or damage to property where loss or damage is less substantial would generally not warrant breach of confidence.' IT goes on to explain that less serious crimes, such as 'comparatively minor prescription fraud' might be linked to serious harm, such as drug abuse, which may justify disclosure.

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