Where any intimate examination is proposed, a chaperone should always be offered, particularly if a patient has been sedated, even if the doctor and patient are of the same sex, says Gabrielle Pendlebury, Medicolegal Consultant at Medical Protection.

Examining doctors should always consider what the patient would deem to be appropriate intimate contact.

Intimate examinations include examination of the breasts, as well as the genitalia and rectum. Doctors need to ensure that their actions are above reproach. They need to make sure that they have clear written documentation to support their actions.

Intimate examinations can be embarrassing or distressing for patients and whenever a doctor examines a patient they should be sensitive to what they may think of as intimate. This is likely to include examinations of breasts, genitalia and rectum, but could also include any examination where it is necessary to touch or even be close to the patient.

An allegation of sexual misconduct involving patients can be potentially devastating for a doctor, impacting negatively on their career and reputation. It is therefore essential that doctors do not become complacent and overlook the use of chaperones, when faced with multiple clinical commitments. These allegations can often arise when least expected, especially at times of high clinical demand, when the search for a chaperone may seem like an unnecessary hindrance to the efficient use of time.

Doctors should consider what the patient would deem to be an intimate examination. Allegations of assault have arisen in relation to the placing of ECG leads, fundoscopy or inadvertent touching of the patient in what is a legitimate clinical examination. Therefore, clear and comprehensive communication of the nature of the examination is essential to prevent the possibility of misunderstanding, but also to allow the patient to decline the examination, if they choose.

TIPS TO ENSURE ACTIONS ARE BEYOND REPROACH

Awareness of the chaperone policy in your practice and procedure for accessing chaperones.

Be prepared to defer examination if the patient is uncomfortable or a chaperone is not available.

Communication – explain clearly what the examination will entail and the clinical rationale behind it.

Document carefully that a chaperone was offered, if no chaperone is available or the patient declines. Outline the reasons why examination was necessary at that time and details of the examination undertaken.

THE UNCONSCIOUS OR SEDATED PATIENT

A striking number of allegations of sexual assault or inappropriate sexual behaviour arise in connection with the administration of general anaesthetics or sedation. In these situations it is important (for reasons of patient safety, as well as chaperonage) that a doctor is never left alone with an unconscious or sedated patient.

In relation to anaesthesia and sedation, sexual hallucinations are more common with newer agents such as midazolam and propofol. It is not uncommon for doctors to be accused of inappropriate and potentially criminal behaviour as a result of the hallucinogenic effects of these drugs.

Any allegations of this nature should be taken seriously, even if the patient was never alone with the doctor, as the patient is likely to be distressed and fearful, completely believing the veracity of their accusation. Doctors should make sure that the consent process outlines details of the procedure to reduce the possibility of the patient misinterpreting clinically indicated procedures.

In the event of an allegation, a full explanation of the cause must be offered, along with reassurance that there was a chaperone present. Allegations have arisen even when the patient was in theatre with numerous others present. The nature of these hallucinations can mean that it may be difficult for the patient to accept the explanation and prolonged counselling might be necessary. Doctors should be prepared and accurate in their response to an accusation of this nature. Any discussions around the event should be witnessed and documented and hopefully the records of events while under sedation or anaesthesia will corroborate the explanation.

Medical Protection suggest dealing with complaints of this nature promptly, as this will help the patient process the matter, thus relieving their distress and hopefully preventing matters escalating, potentially to the regulator or the Police. Even if the events are later exposed as sexual hallucinations, this scrutiny can damage both the patient and the doctor.

CASE STUDY

Mrs Smith underwent a colonoscopy under sedation. The procedure was unremarkable but post recovery Mrs Smith indicated to her husband that she had been assaulted in recovery. She indicated that the surgeon had placed his penis in her hand. Mr Smith immediately called the South African Police Service (SAPS), the doctor called the advice line as the police were requesting that he attend the police station for an interview under caution.

The doctor had made meticulous notes. He had reviewed Mrs Smith in recovery, in the presence of a nurse. Mrs Smith was groggy from the sedation. The doctor had placed two of his fingers in the palm of her hand and asked her to squeeze them. Mrs Smith had misinterpreted this stimulus due to the hallucinatory effect of the sedation.

Medical Protection was able to support the doctor by instructing a solicitor to attend the Police interview with him. During this interview, supported by the medical notes, the doctor was able to explain the clinical rationale for all the actions he took in respect of this patient. The presence of a chaperone protected the doctor, as the nurse was able to give a witness statement, supporting the doctor’s position. As a result of this and a full explanation to the patient, the matter did not progress further.