Dr Sarah Jarvis
When patients are at risk of abuse or neglect, doctors must decide whether or not to breach their duty of confidentiality and share information with the relevant authorities. Dr Sarah Jarvis explains how these decisions are made.
There are three types of situations where doctors are asked to release information. Firstly, where the patient has provided informed consent, and secondly when the law compels a disclosure.
The third area is less straightforward and this can include release of information without consent if it is in 'the public interest' or will benefit patients or others.
Doctors are sometimes requested to disclose information falling into this third category when there are issues of safeguarding regarding children or adults.
The Department of Health's guidance Working together to safeguard children provides valuable advice and there is also NICE guidance for when to suspect child abuse.
What constitutes abuse?
Abuse can take on many forms, which as a healthcare provider you will be expected to be alert to. These include:
- psychological – coercion, emotional abuse, humiliation, harassment, bullying, verbal abuse, enforced isolation or withdrawal from services
- financial – theft, fraud, misuse of property, finances and benefits, including coercion in relation to wills and other forms of inheritance
- discrimination on the basis of a protected category such as race, gender, sexual orientation.
- report concerns about a child to the appropriate statutory body
- respond to social services requests to provide information about a child, and to undertake a medical assessment
- respond to requests to provide services to a child or family as part of a Child Protection Plan.
The GMC document 0-18 years: guidance for all doctors sets out the responsibilities of all doctors in relation to child protection:
'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 interest or necessary to protect other children or young people. You must be able to justify a decision not to share such a concern.'
Confidentiality is not an absolute duty.
The GMC also advises that doctors should:
- consider all requests for information in a timely manner
- check that the request for information is valid and satisfies one of the criteria for disclosure
- only share relevant information, which would not usually include providing the complete medical records.
The criteria for disclosure is defined as below:
'Confidentiality is not an absolute duty. You can share confidential information about a person if any of the following apply:
a You must do so by law or in response to a court order.
b The person the information relates to has given you their consent to share the information (or a person with parental responsibility has given their authority if the information is about a child who does not have the capacity to give consent).
c It is justified in the public interest; for example, 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.'
Dr A is a consultant in substance misuse. The eight-year old child of a patient she is treating is subject to child protection procedures. The patient Dr A is treating is non-compliant and has been using large amounts of non-prescribed medications. The patient has declined consent for Dr A to provide information regarding the substance misuse to the child protection team.
Dr A speaks to the Caldicott Guardian and child protection lead at her trust. They agree that it is appropriate to release relevant information without consent in order to protect the child.
A vulnerable adult is usually regarded as a person who:
- is or may be in need of community care services by reason of mental or other disability, age or illness; and
- is or may be unable to take care of him or herself, or unable to protect him or herself against significant harm or exploitation.
The GMC's confidentiality guidance advises about patients who lack capacity:
'You must disclose personal information about an adult who may be at risk of serious harm if it is required by law. 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.'
However, the same guidance differentiates between adults who do have capacity:
'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. 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.'
It is therefore very important to consider whether an adult patient has capacity to consent to disclosure. Our previous journal has a useful article about assessing a patient's capacity to make decisions regarding their treatment.
Dave is the son of a frail elderly patient with dementia. He is her carer. He is overheard to be abusive to the patient by calling her names when she is incontinent, and she is often left in soiled underwear for hours. The patient cannot consent to disclosure as she lacks capacity.
The named GP discusses the case with colleagues and makes a referral to the local Vulnerable Adults Team.
Top tips on safeguarding vulnerable patients
- Be aware of safeguarding policies in your organisation.
- Know who the leads are for both Adult and Children Safeguarding.
- Consider issues carefully and discuss with suitable colleagues.
- Be aware of GMC guidance and Department of Health policies.
- Always carefully document your decisions and the reasoning behind them, in case you are asked to justify them.
Dr Sarah Jarvis
BSc MBBS MRCGP
Sarah Jarvis studied at St George's Hospital medical school, intercalating a BSc as part of her studies. After completing her GP training she became a GP principal, a position she held for 12 years alongside roles as a GP trainer, prescribing lead and child protection lead within her practice. Sarah also sat on (and later chaired) the GMC and MPTS fitness to practise panels for 10 years.
See more by Dr Sarah Jarvis