This ethical hub topic shows ways in which our ethical guidance can be applied in this area of care and signposts to relevant resources. It does not set new professional standards and is not intended to replace the formal guidance.
As doctors, you often see patients at times of distress and difficulty. It is likely that you may come into contact with someone who is at-risk or suffering from abuse or neglect.
Take prompt action if you think that patient safety, dignity or comfort is or may be seriously compromised.
Whether or not you have vulnerable adults as patients, consider their needs and welfare and offer them help if you think their rights have been abused or denied.
Treat patients as individuals and respect their dignity and privacy.
Support patients in caring for themselves to empower them to improve and maintain their health.
Treat information about patients as confidential.
Be satisfied that you are handling personal information lawfully.
Disclose the minimum information necessary for the purpose.
Give patients information about all the options available to them in a way they can understand.
Listen to patients, take account of their views, and respond honestly to their questions.
Keep up to date with, and follow, the law, our guidance and other regulations relevant to your work.
- Adults have the right to live in safety, free from abuse and neglect
- People are supported to make decisions in their own interests
- Any intervention should be the least restrictive of the adult adult’s freedom
- The adult should participate as fully as possible in any decision that is made. Professionals should work collaboratively to provide appropriate protection, help and support.
What is abuse and neglect?
There are many forms of abuse that doctors and health care professionals need to be aware of. These include:
- Physical abuse
- Domestic violence/abuse
- Sexual abuse
- Psychological or emotional abuse
- Financial or material abuse
- Modern Slavery
- Organisational/ institutional abuse
- Neglect/acts of omission
- Self neglect
If you are familiar with the types of abuse and the clinical indications of abuse it will help you to identify which patients are at risk of harm. Many forms of abuse are criminal offences.
Disclosing information about adults at risk of harm
Safeguarding law and practice differs across the UK. You must be familiar with the procedures where you work.
In England, certain persons or bodies must give information to a Safeguarding Adults Board, at its request, to enable or assist the board to perform its functions. The explanatory notes to the Care Act 2014 make clear that individual doctors can be asked for information under this provision. You can find further information about Safeguarding Adults Boards in the Care and Support Statutory Guidance.
“…adults sometimes have complex interpersonal relationships and may be ambivalent, unclear or unrealistic about their personal circumstances.
…People have complex lives and being safe is only one of the things they want for themselves. Professionals should work with the adult to establish what being safe means to them and how that can be best achieved.”
Care Act 2014 Statutory Guidance
There are legal requirements in Wales for certain persons and bodies (including Health Boards and NHS Trusts) to provide information in response to requests from Safeguarding Boards and local authorities. Further information on Safeguarding Boards can be found in Social Services and Well being (Wales) Act 2014 Code of Practice: Working Together to Safeguard People Volume I Introduction and Overview.
Similar requirements exist in Scotland for public bodies (including Health Boards) to provide information to councils, where they know/believe an adult is at risk of harm action is required to protect them, and to Adult Protection Committees. Further guidance can be found in the Adult Support and Protection Code of Practice.
In Northern Ireland, arrangements exist for information to be shared in respect of vulnerable adults with the Northern Ireland Adult Safeguarding Partnership (NIASP). More information on NIASP is contained in 'Adult Safeguarding Prevention and Protection in Partnership'.
It will usually be appropriate tell patients about any disclosures you make, even if they are required by law.
What should I do if an adult who appears to be at risk of harm refuses help?
All adult safeguarding processes and laws in the UK say that safeguarding procedures must be person-centred and must take account of the views and wishes of the adult concerned. Safeguarding is not something that is ‘done to’ a person and the steps you take will usually be agreed with your patient, in line with local safeguarding processes.
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, and who refuse offers of help.
If you are faced with this situation, and there are no legal requirements to disclose information, ask yourself the following questions.
- Do they have capacity to decide whether to accept help?
- Is anyone else at risk of serious harm?
- Could disclosure be justified even if no one else is at risk of harm?
1. Do they have capacity to decide whether to accept help?
Start from the presumption that the adult has capacity to make the decision, and maximise their ability to do so:
- Communicate with them in a way that best meets their needs. If necessary check with those close to them, or others in the healthcare team, about how to best communicate with them
- Discuss their options at a time and place that helps them understand and remember what you say
- Ask if having a friend or relative with them would help them to remember information or make the decision
- Offer written or audio information if it will help
If the adult doesn't doesn’t have capacity to decide, it will usually be appropriate to tell a responsible person or authority (such as a local safeguarding lead, or the local authority) if you believe that the person is experiencing, or at risk of, abuse or neglect. You should follow local safeguarding processes.
2. Is anyone else at risk of serious harm?
It is important to respect the adult’s wishes and confidentiality. But if their circumstances could put someone else at risk of serious harm, it may be in the public interest to disclose information to the appropriate person or agency.
3. Could disclosure be justified even if no one else is at risk of harm?
An important principle in our guidance is that doctors must respect patients’ rights to self-determination as long as they have capacity to make decisions for themselves, and their decisions do not expose others to a risk of death or serious harm. We therefore emphasise the importance of seeking consent to disclose confidential information, and abiding by patients’ wishes.
But in very exceptional circumstances, you may be able to justify disclosing information without consent, where:
- it is necessary to prevent a serious crime such as murder, manslaughter or serious assault
- there is clear evidence of an imminent risk of serious harm to the individual and no alternative (and less intrusive) methods of preventing that harm.
This is an uncertain area of law and, if you can, you should seek independent legal advice before making such a disclosure without consent.
Good medical practice
Confidentiality: good practice in handling patient information
Decision making and consent
The Royal College of General Practitioners have produced an Adult Safeguarding Toolkit that sets out duties and responsibilities around safeguarding in primary care.
The BMA’s Adult Safeguarding Toolkit is about doctors doctors’ responsibilities to safeguard adults who may be at risk of abuse or neglect.