Working with doctors Working for patients

 

Introduction

Sarah returns to the surgery to see Dr Williams. She thinks that she may have contracted a sexually transmitted infection.

(The story so far...)

Sarah is 15 years old. A month ago, she came to the GP surgery seeking advice about contraception. Her boyfriend, who is 19, was aware of the visit, but her parents were not. Dr Williams prescribed the Pill for Sarah.

Dr Williams

Dr Williams

What made you decide to stop using condoms? We talked about this, Sarah. Used properly, the contraceptive pill should prevent an unwanted pregnancy but you should still be using condoms to protect you from STIs.

Sarah

Sarah

I know, I know, I'd meant to...I don't really remember what happened, I was quite drunk and Paul doesn't like using condoms and I guess I just gave in. Can't you just give me antibiotics or whatever and I'll promise to be more careful from now on?

Dr Williams

Dr Williams

Well, it might not be as simple as that Sarah, but we'll see. I'll order some tests today and if you make an appointment for a few days' time when the results will be back we can take it from there. But I have to say, Sarah, I'm concerned about you drinking alcohol. Have you spoken to your mum about any of this like we discussed?

Sarah

Sarah

No, I did try but it was just too embarrassing. And she'd go mad about me drinking. You won't tell her will you?

Dr Williams

Dr Williams

I'm not sure I feel comfortable with her not being aware of any of this. You're still only 15 Sarah and Paul's quite a bit older...is he encouraging you to drink?

Sarah

Sarah

Well, yeah but I know what I'm doing - I like it. Loads of my friends drink, some of them even do it with their parents!

What should the doctor do...? (Select A,B or C)

A

Contact children's social services and tell them about her concerns?

B

Decide not to tell anyone about her concerns, respecting Sarah's confidentiality?

C

Offer to make an appointment with Sarah and her mum so they can all discuss the situation together?

Dr Williams

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.