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Chaperoning policy

1 Policy summary

The relationship between a patient and their healthcare professional is based on trust. The healthcare professional may have no doubts about a patient they have known for a long period of time and feel it is not necessary to offer a formal chaperone. This should not detract from the fact that any patient is entitled to the right to request or be offered a chaperone with whom they are comfortable being present during any consultation, within the boundaries of each individual service or planned appointment made and especially when undergoing any procedure or examination. This policy identifies the roles of chaperone both formal and informal and the responsibilities of the practitioner around the offer of and use of chaperones.

2 Introduction

The role of a chaperone can vary, depending on the needs of the patient, and can be classed as informal or formal. Care Quality Commission (CQC) have a different definition of a chaperone. A chaperone is an impartial observer present during an intimate examination of a patient and witness to the continuing consent to the procedure. The Royal College of Nursing (RCN) (2013) say that all women should be offered a chaperone to be present during an intimate examination, procedure or treatment or care, irrespective of organisational constraints or the settings in which this is carried out. The offer and the response should be documented.

2.1 Informal chaperone

Many patients may feel reassured by the presence of a familiar person, for example, a family member for a friend and this in almost all cases should be accepted, the chaperone will be there to provide emotional support and reassurance to the patient. Health care professionals must not expect an informal chaperone to take an active part in the examination or to witness the procedure directly.

2.2 Formal chaperone

A formal chaperone implies a clinical health professional. This person will have a specific role to play in the consultation, and this role should be made clear both to the patient and the person undertaking the chaperone role. This role may include assisting with undressing or assisting in the procedure. In this situation, the chaperone should have sufficient understanding to undertake the role expected of them.

Under standard 6.2 of the Nursing and Midwifery Council (NMC) code, nurses are required to maintain the knowledge and skills they “need for safe and effective practice” (NMC, 2018b). Therefore, if they are not properly trained to act as chaperones, they may be putting themselves at risk professionally.

The General Medical Council (GMC) have published guidelines “intimate examinations and chaperones 2013, which recommend all patients irrespective of gender be offered a chaperone during an intimate examination”. All patients have the right to have their privacy and dignity respected. The patient should be given the opportunity to state their preferences in relation to the sex of the chaperone. This must be documented in their clinical records.

3 Purpose

The purpose of this policy is to raise colleague awareness for the use of chaperones and provides the procedure to follow for the protection of both patient and healthcare professionals.

4 Scope

This policy applies to all healthcare professionals working within in-patient, clinic or community settings.

For further information about responsibilities, accountabilities and duties of all employees, please see appendix A.

5 Procedure

5.1 Quick guide

5.1.1 Consent

  • Obtain consent from the patient to proceed with any examination.
  • Refer to relevant Mental Capacity Act guidance where there are concerns regarding capacity.

5.1.2 Mental capacity

  • There is a basic assumption that every adult has the capacity to decide whether to consent to or refuse a proposed intervention.
  • Where there are concerns about a person’s ability to give consent an assessment of capacity should be undertaken.
  • If a patient lacks capacity, a decision should be made in their best interest whether to proceed.

5.1.3 Using a chaperone

  • All patients have the right to have their privacy and dignity respected.
  • The patient should have the opportunity to decline a particular person if that person is not acceptable to them for any reason. They must then decide if they wish the examination to proceed.
  • If a chaperone is present to witness an examination or procedure being undertaken, they must stand in a position whereby they can see the examination or procedure being carried out.
  • it would not be lawful to use a chaperone if the person has capacity to refuse.

5.1.4 Religious ethnicity or culture

  • Staff should identify who the patient would like to act as a chaperone.
  • Under normal circumstances family members or friends (and not a child) should not be asked to act as an interpreter or formal chaperone.
  • However, a family member or friend may offer support as an informal chaperone.

5.1.5 Examination of children under 16 years of age

  • Before carrying out a procedure or examination on a child less than 16 years of age, verbal consent must be obtained from the child and from the parent or person with parental responsibility.
  • However, if a child is assessed as being Gillick competent and therefore has “sufficient understanding and intelligence to enable him or her to understand fully what is being proposed”, they can consent to an examination or procedure without parental involvement or consent.
  • For a child assessed as competent the same guidance relating to adults is applicable, including the option to decline a chaperone.

5.2 Mental capacity

There is a basic assumption that every person aged 16 and over has the capacity to decide whether to consent to or refuse a proposed intervention. Before proceeding with an examination, you must check that the patient:

  • has received sufficient information about the purpose, the nature, the risks and benefits of the intervention in a way they can understand
  • not be acting under duress
  • has the mental capacity to make the decision regarding the specific intervention or process

See the trusts’ consent to care and treatment policy.

If the patient has the capacity to make the decision and requests a chaperone (this should be documented in the patient’s record).

If the patient prefers to undergo an examination or procedure without the presence of a chaperone, wherever possible this should be respected. This should be recorded in their health record.

Where there are concerns about a person’s ability to give consent an assessment of capacity should be undertaken.

Colleagues should refer to the trust Mental Capacity Act (2005) policy for guidance.

See section 5.5 for guidance regarding patients who lack capacity). It is only necessary to carry out an assessment if there is doubt as you only have to prove someone lacks capacity. The rights of the staff member and patient are considered and will not be compromised. A record of mental capacity assessment form (MCA1) should be completed in the patient record to evidence the lack of capacity.

If it is established that the person lacks capacity to make the decision, a decision should be made in their best interests in line with the trust Mental Capacity Act process policy. This should be recorded on the MCA2 form in the patient electronic record.

A familiar individual such as a family member or carer may be the best chaperone and be able to act as an advocate for patients with health problems that may affect capacity.

For intimate examinations, a formal chaperone must be sought.

If the person who lacks capacity has appointed someone to act on their behalf under a registered Lasting Power of Attorney for Health and Welfare, then consent should be sought from the relevant attorney.

5.3 Issues specific to patients who are lacking mental capacity

A familiar individual such as a family member or carer may be the best chaperone and be able to act as an advocate for patients with health problems that may affect capacity.

Adults with learning difficulties or mental health problems who resist any intimate examination or procedure must be interpreted as refusing to give consent, and the procedure must be abandoned, and an assessment should be made of whether the patient can be considered as having capacity to consent to the procedure or not. Then a decision would need to be made whether to use one against their wishes.

Completion of the MCA1 and MCA2 forms if competed must be recorded within the electronic patient record (EPR).

5.4 Using a chaperone

Under standard 6.2 of the Nursing and Midwifery Council (NMC) code, nurses are required to maintain the knowledge and skills they “need for safe and effective practice” (NMC, 2018b). Therefore, if they are not properly trained to act as chaperones, they may be putting themselves at risk professionally.

All patients have the right to have their privacy and dignity respected. The patient should be given the opportunity to state their preferences in relation to the sex of the chaperone. This must be documented in their electronic patient record (EPR).

The patient should have the opportunity to decline a particular person if that person is not acceptable to them for any reason. They must then decide if they wish the examination to proceed or be re-scheduled and this documented decision should be recorded in their clinical records.

Any consultation, examination, procedure, treatment or care that is of an intimate nature, will be practised in a sensitive and respectful manner. Obvious examples of an intimate examination include examination of the breasts, genitalia and the rectum, but it also extends to any examination where it is necessary to touch or be close to the patient. This will take into account personal preferences, cultural, religious wishes of patients or service users, and ensuring wherever possible misinterpretation or misunderstandings do not occur.

If a chaperone is present to witness an examination or procedure being undertaken, they must stand in a position whereby they can see the examination or procedure being carried out, to provide assurance that it has been conducted appropriately.

Therefore, a chaperone in this situation will be a formal chaperone (another colleague competent to fulfil this role).

If the patient prefers to undergo an examination or procedure without the presence of a chaperone, wherever possible this should be respected. This should be recorded in their health records if the following is satisfied.

The patient is capable of making that decision and has the capacity to do so (this should be documented in the patient’s record). Staff should refer to the trust Mental Capacity Act (2005) policy for guidance. See section 5.5 for guidance regarding patients who lack capacity). It is only necessary to carry out an assessment if there is doubt as you only have to prove someone lacks capacity. The rights of the staff member and patient are considered and will not be compromised. A mental capacity assessment form (MCA1) should be used to evidence the lack of capacity.

It would not be lawful to use a chaperone if the person has capacity to refuse. If they lack capacity, then a decision would need to be made whether to use one against their wishes.

If the situation is deemed an emergency, and the patient declines a chaperone, it is acceptable to perform an intimate examination or procedure with or without a chaperone. This should be recorded in the patient’s clinical record. If a patient declines to have a chaperone present, but one is deemed to be necessary for safety reasons, this will be explained to the patient or service user. If they continue to decline the presence of a chaperone the clinician will need to undertake an assessment of the level of risk, should they proceed. It may be necessary to postpone the examination or procedure until advice can be sought, and to complete an IR1 form on the trust’s safeguard reporting system. A culture of openness between patients or service users and healthcare professionals should be actively encouraged

Details of any examinations or procedures should be recorded in the patient’s clinical record and the presence or absence of a chaperone recorded, including the name of the chaperone.

5.5 Issues specific to religion, ethnicity or culture

The ethnic, religious, and cultural background of some women can make intimate examinations particularly difficult, so the background of patients must be taken into account, as some patients may have strong cultural or religious beliefs that restrict being touched by others.

If there is a language barrier it would be unwise for a procedure to take place if the healthcare professional is unsure that the patient understands what is going to happen. With the aid of an interpreter, staff should identify who the patient would like to act as a chaperone. Under normal circumstances family members or friends (and not a child) should not be asked to act as an interpreter or formal chaperone. However, a family member or friend may offer support as an informal chaperone.

5.6 Lone working

Healthcare professionals are at an increased risk of their actions being misconstrued or misrepresented if they conduct intimate examinations where no other person is present.

Where a healthcare professional is working in a situation away from other colleagues for example, home visit, out-of-hours centre, the same principles for offering the use of chaperones and should apply as previously identified in section 1, where it is appropriate family members or friends may take on the role of informal chaperone. In cases where a formal chaperone would be appropriate, for example, intimate examinations, the healthcare professional would be advised to reschedule the examination to a more convenient location or arrange for a colleague to attend the appointment alongside themselves (double-up visit). Where this is not an option, for example due to the urgency of the situation, then good communication and record keeping are paramount. For further guidance, see lone working policy.

5.7 Examination of children under 16 years of age

Before carrying out a procedure or examination on a child less than 16 years of age, verbal consent must be obtained from the child and from the parent or person with parental responsibility.

However, if a child is assessed as being Gillick competent and therefore has “sufficient understanding and intelligence to enable him or her to understand fully what is being proposed” they can consent to an examination or procedure without parental involvement or consent.

For a child assessed as competent the same guidance relating to adults is applicable, including the option to decline a chaperone. However, a chaperone acts as a safeguard for the patient and the healthcare professional and should be encouraged.

For a child assessed as not competent the practitioner will need consent to examine from the child’s legal guardian, and it would be appropriate for both an informal and formal chaperone to be present.

In situations where abuse has been identified or is suspected, practitioners should follow child protection procedures in line with the trust’s safeguarding children’s manual.

It is imperative that the child’s clinical records evidence that this process has been followed; good record keeping is paramount. For further guidance, see healthcare record keeping policy.

6 Training implications

There is no specific training for staff who act as a chaperone. However, their knowledge and skills should be appropriate to support the procedure or examination being undertaken. These include having an understanding of:

  • why a chaperone needs to be present
  • their role as a chaperone
  • mechanism for raising any concerns

It is the responsibility of each clinical service to be satisfied that staff have a good level of understanding in relation to the above. Staff have a personal responsibility to identify that they have enough understanding and support to undertake this role.

7 Equality impact assessment screening

To access the equality impact assessment for this policy, please email rdash.equalityanddiversity@nhs.net to request the document.

7.1 Privacy, dignity and respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, “not just clinically but in terms of dignity and respect”.

As a consequence, the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

7.1.1 How this will be met

The content of this policy emphasises the need throughout that the service user’s privacy and dignity are respected.

7.2 Mental Capacity Act

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals’ capacity to participate in the decision-making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005) to ensure for that the rights of individual are protected and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

7.2.1 How this will be met

All individuals involved in the implementation of this policy should do so in accordance with the guiding principles of the Mental Capacity Act (2005).

9 References

10 Appendices

10.1 Appendix A responsibilities, accountabilities and duties

10.1.1 Board of directors

The board of directors has the responsibility to ensure that the trust has policies and procedures in place to provide best practice.

10.1.2 Healthcare professionals

Healthcare professionals have a responsibility to the patient to be offered a chaperone, to be present with them during the consultation, examinations or procedure.

10.1.3 Matrons or managers

Matrons and managers are responsible for making staff aware of:

  • this policy and their responsibilities
  • that staff are competent and have the knowledge and skills to undertake the role of a chaperone as detailed below

10.1.4 Chaperones (formal)

The Ayling Report (Department of Health 2004) found that there was no common definition of the role of a chaperone. The role can vary depending on the needs of the patient, the healthcare professional and the examination or procedure being carried out. A chaperone acts as a safeguard for the patient and healthcare professional and is a witness to continuing consent of the procedure or examination. A chaperone’s role can include:

  • always respect and maintain the privacy and dignity of the patient
  • provide emotional comfort and reassurance
  • be courteous
  • encourage questions
  • be alert for any signs of distress from the patient, verbal and non-verbal
  • be able to observe the examination or procedure
  • assist in the procedure if required to do so
  • act as the patient’s advocate
  • identify unusual or unacceptable behaviour on the part of the healthcare professional and question or raise concerns at the time and, or with their line manager who may then make a referral under the safeguarding adults policy
  • assist with undressing or dressing, if requested
  • help the patient to understand what is being communicated to them

10.2 Appendix B monitoring arrangement

10.2.1 Any feedback, complaints or your opinion counts which relate to none compliance with the standards in this policy

  • How: investigation and feedback review.
  • Who by: matrons or managers.
  • Reported to: care group leadership and quality groups.
  • Frequency: ongoing as the need arises.

10.2.2 IR1 analysis

  • How: any IR1 information relating to chaperoning to be analysed in line with this policy.
  • Who by: matrons and managers.
  • Reported to: care group leadership and quality groups.
  • Frequency: as they occur.

10.2.3 The offer of a chaperone and the recording of the offer of a chaperone in clinical records

  • How: during supervision when clinical cases and records are reviewed.
  • Reported to: team leader if any areas require follow up.
  • Frequency: during clinical supervision.

Document control

  • Version: 11.
  • Unique reference number: 364.
  • Approved by: clinical effectiveness meeting.
  • Date approved: 4 November 2025.
  • Name of originator or author: nurse consultant children’s care group.
  • Name of responsible individual: chief nursing officer.
  • Date issued: 19 December 2025.
  • Review date: 31 December 2025.
  • Target audience: colleagues in clinical areas, inpatient and community settings.

Page last reviewed: December 19, 2025
Next review due: December 19, 2026

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