Chaperone Policy


This policy is in line with current legislation at the time of writing and is subject to periodic review.

In the event of any incident linked to this policy; findings of an audit that identifies a gap or a need for a review or a change of legislation impacting on this policy, the policy will be updated and will supersede this policy. Unless there are changes to regulations that affect this policy then this policy will be reviewed on a regular basis.


The purpose of this policy is to provide guidance for staff and assurance to patients that Hall Green Health is committed to continually providing high quality healthcare for all patients and supporting the staff who provide this care. The aim of the policy is to safeguard patients and staff during intimate examinations.

All patients regardless of age, gender, ethnic background, culture, cognitive function, sexual orientation, or marital status have the right to have their privacy and dignity respected.

This respect, explanation, consent, and privacy are more important than the need for a chaperone for the majority of patients.

This policy provides evidence to ensure when intimate examinations are necessary, that these are performed in a respectful, sensitive, and professional manner and that a chaperone is available for such times that it is identified necessary. By encouraging the use of a chaperone, Hall Green Health wishes to promote a culture of openness between patients and healthcare professionals.



A chaperone is a trained, impartial observer present during an intimate examination of a patient.

He or she is a health professional who is familiar with the procedures involved in the examination. A chaperone is usually the same sex as the patient.

Intimate examination

All medical examinations can be felt to be potentially upsetting to patients.

However, intimate examinations are examinations of the breast, genitalia, and rectum.

However, some patients may regard any examination in which the doctor needs to touch or be very close to them as intimate.

For example, examination of the retina using an ophthalmoscope in a darkened room.

Chaperones will be offered before all intimate examinations for all patients.


This policy applies to all employees of Hall Green Health, contractors, seconded staff, placements, and agency staff.

Roles, rights, and responsibilities


The patient has the right to a chaperone for any examinations, particularly examinations that they feel may be intimate.

The patient has the right to a chaperone of the same sex.

The patient has the right to a chaperone who has been trained and understands their examination.

The patient has the right to have their dignity and privacy respected.

The patient has the right to decline a chaperone. Please see section People who decline a chaperone for more information.

The Patient can expect the chaperone to be:

  • Available if requested
  • Pleasant/approachable/professional in manner, able to put them at ease 
  • Competent and safe
  • Clean and presentable
  • Confidential


Clinicians have a responsibility to offer a chaperone for all appropriate examinations, particularly intimate examinations.

Before an examination they should:

  • Explain to the patient why the particular examination is necessary and what it entails so they can give fully informed consent.
  • Record the consent discussion in the notes, in addition to the details of chaperone or if a chaperone was offered but declined.
  • Allow the chaperone to hear the explanation of the examination and the patient’s consent.

During the examination you should:

  • Ensure patients’ privacy during the examination and when they are dressing and undressing, for example by using screens and gowns/sheets.
  • Position the chaperone where they can see the patient and how the examination is being conducted.
  • Explain what you are going to do before you do it and seek consent if this differs from what you have told the patient before.
  • Stop the examination if the patient asks you to.

After an examination you should allow the chaperone to leave the consultation.


Have a responsibility to:

  • Understand the nature of the examination.
  • Respect the patient’s dignity and confidentiality.
  • Be present throughout the entire examination.
  • Reassure the patient if they experience distress.
  • Protect the patient’s dignity and confidentiality at all times.
  • Offer emotional support at an embarrassing or uncomfortable time.
  • Facilitate communication, especially if there is a language barrier.
  • Be prepared to raise concerns about the clinician’s behavior.

Practice manager

To update the policy, ensure that it is aligned with national guidelines, distribute appropriately, and ensure that staff are trained at induction and at regular intervals to, so they are aware of the principles of chaperoning and the content of the practice policy.

Principles of this policy

This chaperone policy adheres to local and national guidance and policy, including the “NCGST Guidance on the Role and Effective Use of chaperones in Primary and Community Care settings”.

The chaperone policy is clearly advertised through patient information leaflets, websites, and on notice boards.

All patients are encouraged to ask for a chaperone if required at the time of booking an appointment wherever possible.

All staff are aware of, and have received appropriate information in relation to, this chaperoning policy.

All formal chaperones understand their role and responsibilities and are competent to perform that role.

Where will the chaperone stand?

The positioning of the chaperone will depend on several factors, for example the nature of the examination and whether or not the chaperone has to help the clinician with the procedure.

The clinician will explain to the patient what the chaperone will be doing and where they shall be in the room.

The chaperone must always be able to properly observe the procedure so as to be a reliable witness about what happened during the examination/procedure.

Should the chaperone have any concerns about anything which has happened during the examination they should raise it with their Line Manager immediately.

Issues of Consent

Consent may be implicit in attending a consultation – for example, a patient attending with a breast lump may reasonably be assumed to expect a breast examination. However, it is always prudent to obtain consent after explanation before all intimate examinations. Verbal consent is sufficient and must be documented in the record (for more information refer to the Consent Policy).

The clinician may assume that the patient is seeking treatment and therefore consenting to necessary examinations. However before proceeding with an examination, healthcare professionals should always seek to obtain, by word or gesture, some explicit indication that the patient understands the need for examination and agrees to it being carried out. Consent should always be appropriate to the treatment or investigation being carried out.

The clinician must however be aware that:

  • an assessment of capacity may occasionally be necessary to ensure consent is valid.
  • that if consent is given, either actual or implied, this is nothing to do with the offer of a chaperone. A patient may consent to an intimate examination, but still request, assume or prefer a chaperone to be present so a chaperone offer should still, always, be made.

Good practice principles for specific issues

Children and young people

Young people and children will always be provided with a chaperone if they need an examination.

If the young person or child lacks the capacity to consent to examination, we will seek parental consent to undertake this examination, as a parent is often a suitable chaperone for children.

However, in the situation of potential abuse by a parent an alternative will be sought. In this situation, the local child safeguarding lead advice will be sought.

Issues Specific to Religion, Ethnicity or Culture

The ethnic, religious and cultural background of some women can make intimate examinations particularly difficult, for example, some patients may have strong cultural or religious beliefs that restrict being touched by others.

Patients undergoing examinations should be allowed the opportunity to limit the degree of nudity by, for example, uncovering only that part of the anatomy that requires investigation or imaging.

Wherever possible, particularly in these circumstances, a female healthcare practitioner should perform the procedure.

It would be unwise to proceed with any examination if the healthcare professional is unsure that the patient understands due to a language barrier.

If an interpreter is available, they may be able to double as an informal chaperone.

In life saving situations every effort should be made to communicate with the patient by whatever means available before proceeding with the examination.

People who decline a chaperone

Where a patient is offered but does not want a chaperone, the clinician will record that the offer was made and declined.

The clinician should explain that they would prefer to have a chaperone, explain that the role of the chaperone is in part to assist with the procedure and provide reassurance. It is important to explore the reasons why the patient does not wish to have a chaperone and to address any concerns they may have.

If the patient still declines, the clinician needs to decide whether or not they are happy to proceed in the absence of a chaperone.

This will be a decision based on both clinical need and the requirement for protection against any potential allegations of an unconsented examination/improper conduct.

Another option to consider is whether or not it would be appropriate to ask a colleague to undertake the examination.

A further option would be to consider referring the patient to secondary care for the examination.

In these cases, it is important to consider whether the potential that this delay in examination and subsequent treatment would not adversely affect the patient’s health.

People who lack capacity

Vulnerable people will always be provided with a chaperone if they need an examination.

For people who require who cannot provide consent or who do not have capacity to provide consent, this will be sought from their legal guardian or carer.

However, in the situation of potential abuse by a carer an alternative will be sought.

In this situation, the local safeguarding lead advice will be sought.

Issues Specific to Learning Difficulties/Mental Health Problems

For patients with learning difficulties or mental health problems that affect capacity, a familiar individual such as a family member or carer may be the best chaperone.

A careful simple and sensitive explanation of the technique is vital. This patient group is a vulnerable one and issues may arise in initial physical examination, “touch” as part of therapy, verbal and other “boundary-breaking” in one to one “confidential” settings and indeed home visits.

Adult patients 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, unless the patient has been sectioned.

In life-saving situations the healthcare professional should use professional judgement and where possible discuss with a member of the Mental Health Care Team.

People who have been abused

People who have previously been abused may be more acutely aware of and concerned about physical examination.

In these situations, the clinician may feel that they would prefer to involve a chaperone to provide an additional layer of reassurance to their people for all examinations.

Where no chaperone is available

There may be occasions when a chaperone is unavailable (for example, on a home visit or in the out-of-hours setting).

In such circumstances, the clinician should first consider whether or not on a clinical basis the examination is urgent.

If either the clinician or the patient does not want the examination to go ahead without a chaperone present, or if either of you is uncomfortable with the choice of chaperone, you may offer to delay the examination to a later date when a suitable chaperone will be available, as long as the delay would not adversely affect the patient’s health.

If the examination is clinically indicated on an urgent basis, and the clinician has enough information from the history to indicate that the patient would require an admission to hospital in any event, then it may be appropriate to defer this examination until admission to hospital, again explaining this to the patient and in the referral letter.

If the examination is urgent, and hospital admission is not indicated on the history alone, any delay must not adversely affect the patient’s health, so there may be occasions when a doctor goes ahead in the absence of a chaperone. In such circumstances, the patient’s written consent should be obtained. In addition, the fact that the patient was examined in the absence of a chaperone should be recorded, together with the rationale for this.

Where a friend or relative offers to be a chaperone

In these situations the GMC (General Medical Council) advice is that ‘a relative or friend of the patient is not an impartial observer and so would not usually be a suitable chaperone, but you should comply with a reasonable request to have such a person present as well as a chaperone’.


Employees will be made aware of this policy via TeamNet.

Patients will be made aware of this policy using patient leaflets and on the practice website.


All staff will be given training on the appropriate use of chaperones at induction and at regular intervals thereafter.

Any training requirements will be identified within an individual’s Personal Development Reviews. Training is available in the Training module within TeamNet.

Equality and diversity impact assessment

In developing this policy, an equalities impact assessment has been undertaken. An adverse impact is unlikely, and on the contrary the policy has the clear potential to have a positive impact by reducing and removing barriers and inequalities that currently exist. For example, the ethnic, religious, and cultural background of some women can make intimate examinations particularly difficult; Muslim and Hindu women have a strong cultural aversion to being touched by men other than their husbands.

By having a chaperone of the same sex as the patient present the examination may be made more acceptable. Also, alternatives would be sought, i.e., appointment at a later date when a chaperone is available or at alternative site if correct gender of chaperone not available.

If, at any time, this policy is considered to be discriminatory in any way, the author of the policy should be contacted immediately to discuss these concerns.

Monitoring and reporting

Monitoring and reporting in relation to the chaperone policy are the responsibility of the practice manager.

The following sources will be used to provide evidence of any issues raised in relation to chaperoning:

  • PALS.
  • Complaints.
  • Significant and learning events.
  • Equality and Diversity Training.

Any incidents relating to chaperones will be monitored via incident reporting.


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Page last reviewed: 29 December 2023