1. Context

NHS organisations should use this guidance to support their review and improvement of local chaperoning practices.

Engagement with stakeholders and local chaperone policy owners has demonstrated that organisations need a set of principles to guide their co-ordinated approach to the use of chaperones during consultations, examinations and procedures across healthcare settings, one that ensures patient safety, dignity and staff protection. 

2. Scope

Organisations should determine their own chaperone policies, to allow for flexibility in how chaperoning requirements are delivered based on specific needs, practices and settings. This should include consideration of any specialist services provided, specific patient cohort requirements and clinical settings (including primary care, maternity, virtual services and other settings where appropriate).

However, all local policies should be underpinned by a shared set of principles to ensure a level of commonality in our offer to patients and service users. The principles below provide a framework for organisations to develop and refine their local chaperoning policy and practice. They support more consistent implementation through providing clarity on:

• the purpose, terminology and role of chaperoning
• communication on the offer of a chaperone
• escalation process
• records management and information requirements
• training and competency frameworks
• alignment to legislative, regulatory guidance and local policies

3. Principles

3.1 Organisational requirements

As recommended by the Ayling report (2004), all NHS organisations are required to have a chaperone policy, with a regular policy review process in place.

All members of staff should be aware of the policy and it should be made readily available to ensure it is applied effectively.

Policies should also be made available and advertised to patients, the public and service users. This should include availability online and in easy-read formats.

Policies should align with wider safeguarding policies and practice.

3.2 Primary role and responsibility for chaperoning

An NHS chaperone is an appropriately trained member of staff who is present during an examination or treatment of a patient. The primary role of the chaperone is to assist the clinician undertaking the procedure in supporting the patient and to act as the patient’s advocate, being sensitive to their needs and respecting and maintaining their privacy and dignity.

Local policies should clearly set out who can act as a chaperone and have as a minimum requirement that anyone undertaking the role has received appropriate training.

Organisations may wish to consider prioritising the use of clinical staff to undertake chaperoning duties where this is possible. Staff may undertake the role of chaperone as part of their wider clinical or support duties, in line with their training and the requirements of the service. In instances where clinical supervision is in place, the clinical supervisor may wish to consider whether they can also act in a chaperoning capacity to make the patient more comfortable and to minimise disruption. However, in making this decision they should ensure that this does not impact on their ability to discharge either function effectively 

3.3 Provision of chaperones

It should be considered best practice to offer a chaperone to patients when undertaking examinations. The offer of a chaperone should be clear to the patient before any consultation, ideally at the time of booking the appointment in line with Care Quality Commission guidance. The offer should be reinforced at the time of the examination.

Staff must demonstrate cultural sensitivity and respect each patient’s individual values regarding privacy, dignity and intimacy. When offering or providing a chaperone, staff should consider the patient’s preferences in relation to choice of chaperone, which might include considerations relating to sex, religious beliefs or other personal circumstances.

Staff should also identify where patients may have additional needs, such as communication difficulties or learning disabilities, and make reasonable adjustments to ensure they understand the offer and feel supported. This may include using accessible information, involving carers or advocates, or allowing extra time for discussion.

The purpose of the examination and the role of the chaperone must be communicated using culturally appropriate and respectful language.

Intimate examinations

In all cases of intimate examinations, a chaperone should be offered and consent taken. The patient retains the right to decline.

It is acceptable for a healthcare professional to perform an intimate examination without a chaperone if the situation is life-threatening or time-critical.

The General Medical Council (2024) definition of an intimate examination is agreed as a guiding principle: “Examinations of the breast, genitalia and rectum but could also include any examination where it is necessary to touch, examine intimate parts of the patient’s body digitally, or even be close to the patient.”

Presence of family members or carers

The presence of a family member, parent or carer does not replace the need for a chaperone. A chaperone is for the organisation to provide, under their organisational chaperoning policy, on request of the patient or their family or carer. However, the patient may wish to decline the offer of a chaperone if they feel that their family member or carer is able to provide the support they need.

Any intimate examination on children and young people under 18 years should be carried out in the presence of a formal chaperone. A parent, carer or someone known and trusted by the child may also be present during the examination or procedure to provide reassurance. Parents or guardians must receive an appropriate explanation of the procedure to provide informed consent when the young person is unable to do so themselves.

Primary and community care and lone working

The provision of chaperoning in primary and community care will have unique challenges including the one-on-one nature of many consultations, less observed team-working and patients being visited by lone clinicians.

Though it is important that patients and service users are provided with the offer of chaperones in these settings, the need for adaptability in how this is fulfilled must be recognised. This may include a greater need for the use of the wider non-clinical workforce as chaperones. Where this is the case, those acting as chaperones would still require appropriate training and support to act in this role effectively. 

Practices should display information about the chaperone policy in waiting areas, consultation rooms and on practice websites to ensure patients are aware of their rights.

Healthcare professionals working alone, especially during intimate examinations or in isolated settings like a patient’s home, face increased risk of their actions being misinterpreted. To mitigate this, they should offer a chaperone in advance of the appointment where possible. Where this is not possible, they should ensure clear communication and thorough documentation explaining why the examination proceeded without a chaperone present and that this was agreed with the patient.

Virtual consultation and appointments

Chaperoning policies should be applied to video, telephone and online consultations. Where these consultations take place, local policies should explain how to protect patients when images are needed to support clinical decision-making.

Consent and reasonable adjustments for vulnerable patients

If the patient cannot make an informed decision, the healthcare professional must use their clinical judgement and be able to justify their course of action. Organisations have a duty to ensure that reasonable adjustments are made for vulnerable patients as per their duty under the Equality Act.

Availability

If a patient requests a chaperone and one is not immediately available – whether due to patient preference or resource limitations – they must be offered the option to reschedule the appointment within a reasonable timeframe, taking into account the urgency of their clinical needs.

If postponing the examination would pose a risk due to the severity of the condition, this must be explained to the patient and recorded in their clinical notes. The decision to proceed or defer should be made collaboratively between the patient and the healthcare professional.

Patient declines a chaperone

Patients have the right to decline a chaperone for any reason, including personal, cultural or privacy concerns, the presence of a family member or carer, or because they do not feel it is necessary. Staff must respect this decision while ensuring the patient’s safety and dignity.

If a clinician believes that proceeding without a chaperone would compromise professional standards or patient safety, they should risk assess and the examination should be postponed until an appropriate chaperone is available. The rationale for deferral must be clearly documented in the patient’s record.

When a chaperone is declined, staff should consider appropriate safeguards, such as:

• documenting the discussion and decision
• maintaining clear and respectful communication throughout
• ensuring the examination takes place in a private and appropriate setting

3.4 Training and competency frameworks

Only individuals who have received appropriate training in the role and are deemed competent to be a chaperone may act as chaperones. It is suggested that awareness of local chaperoning policies should be incorporated into local staff training and embedded within staff induction programmes.

Where not already in place, chaperones must undergo a Disclosure and Barring Service (DBS) check. This should be at least a standard DBS check, but eligibility should be assessed individually based on the specific context of the ask.

Organisations must maintain an auditable record of staff who have completed chaperone training.

Training should be local and responsive to local settings and systems. Chaperoning training resources should consider:

• the role and purpose of chaperoning, aligned with national principles
• the responsibilities of a chaperone, including understanding the purpose of the examination or procedure
• the definition of an intimate examination and how it may vary based on patient perception
• why chaperones need to be present, taking into account privacy and dignity (for example, chaperones should be able to observe the examination and respond to patient needs and therefore will need to be inside any screened-off area)
• the rights of the patient
• records management procedures related to chaperoning including all documentation and recording processes
• the policy and mechanisms for raising concerns, including escalation routes
• relevant safeguarding policies and national guidance

Training should also cover the expectations of chaperones, which are:

• be sensitive and respect the patient’s dignity and confidentiality
• reassure the patient if they show signs of distress or discomfort
• be familiar with the procedures involved in a routine intimate examination
• stay for the whole examination and be able to see what the examining clinician is doing, if practical
• be prepared and supported to raise concerns if they are concerned about any behaviours or actions they observe

Supporting chaperones

In all cases where a chaperone is used, the chaperone should be provided with sufficient information on the reason for the examination and background to the patient to allow them to provide sufficient support. In cases of intimate examinations, they should be provided with a clear rationale for this being required.

Local chaperone policies should consider how the organisation supports chaperones to:

• ensure that the patient understands why they are in attendance and has consented to this
• act as a witness as to the continuing consent of the procedure
• ensure time is provided for chaperones and patients to ask questions
• confirm the clinician has clearly communicated the role of the chaperone where the presence of one has been agreed
• promote awareness of chaperoning policies to staff and patients

3.5 Escalation and raising concerns

All organisations should have clear routes in place for raising concerns via line management or local operational escalation processes. More formal escalation processes such as Freedom To Speak Up (FTSU) policies and mechanisms should be followed as required. Within these, all staff should feel safe and empowered to raise concerns, supported by a culture and leadership that create psychological safety for everyone.

In this context, local chaperoning policies should consider:

• how concerns can be raised both during the examination and subsequently
• highlighting the duty of care to raise concerns about unsafe practices, in line with wider NHS policies
• how chaperones encourage patients to ask questions and seek clarification and be alert to signs of distress
• supporting chaperones to act as the patient’s advocate when required
• processes for identifying and raising concerns about any unusual or unacceptable behaviour
• how chaperones support families to raise concerns, by providing clear signposting to standard organisational policies for the complaints process

3.6 Records management

Chaperoning policies should ensure that there are appropriate record management processes in place to record the offer and use of chaperones, and that minimum information requirements are met, including:

• explanation of the need for the examination or procedure clearly documented by the professional undertaking the examination. This should include confirmation of the patient’s capacity and best interest
• confirmation that an active offer of a chaperone was made
• document the patient’s decision regarding the examination and the offer of a chaperone in the clinical record. Recognise that patients have the right to decline a chaperone or refuse a specific individual offered as a chaperone, and record the outcome if either is the case
• any decision to proceed, postpone or cancel the examination or procedure, along with any alternative arrangements made, including the name and title of alternative chaperones
• any incidents or complaints related to the examination, procedure or use of chaperones, recorded in accordance with local policies and procedures
• ensure robust governance structures are in place to identify risks and unusual activity, and provide clear escalation procedures
• where possible, use a structured clinical electronic note to standardise record keeping, enable traceability and support effective auditing. To be complete the record should include:
  • date and time of examination or procedure
  • examination or procedure
  • indication – why the examination is required
  • consent to the procedure and a chaperone including details of the discussion between the practitioner and the patient regarding the offer of a chaperone and the name and title of the chaperone offered
  • name and role of chaperone and any additional persons present
  • if no chaperone present, explain why this was declined
• where possible the chaperone should confirm their presence within the record to allow for identification and audit
• the recording of chaperoning should be sufficient to support an auditable process where required, including the monitoring of trends and exemptions.

3.7 Alignment to legislative, regulatory guidance and local policies

It is not within the role of a chaperone to provide a ‘second opinion’ or challenge clinical decision-making by the primary clinician. However, in line with clinical professional standards and broader NHS guidance on raising concerns (for example, FTSU), staff should be empowered to raise concerns where appropriate.

Chaperoning policies must align with national guidance to improve care quality and safety, privacy and dignity. This includes reflecting lone working policies, safeguarding, Mental Capacity Act, sexual safety in healthcare, clinical challenge and ‘second opinion’ including Martha’s Rule.

The procedures requiring chaperoning and all intimate examinations must follow good clinical practice including a full assurance that the procedure or examination is conducted appropriately, respecting patients’ choices and preferences through clear communication and informed consent.

Clinicians adhere to professional standards that describe good practice and set out the principles, values and standards of care and professional behaviour expected from all registered healthcare professionals. They should consider guidance from their professional regulatory bodies and Royal Colleges.

Policies must be accessible to staff, patients, the public and service users, ensuring inclusivity for everyone by providing alternative formats for those who are visually impaired, have learning difficulties or face language barriers, for example.

Executive accountability

The chaperoning policy should clearly identify the executive lead responsible for ensuring its implementation and assuring quality and safety governance. This includes ensuring staff are trained and competent to act as chaperones and that record keeping procedures are clear and well-implemented. Structures should be in place to identify risks and unusual activity, and provide clear escalation procedures.

Oversight of chaperone policies should be embedded within broader clinical governance structures, including the clear provision of auditing and monitoring compliance. This should include actively seeking feedback from patients and staff and triangulating data to learn and improve.

All policies should have a review date and scheduled basis for ongoing review, with responsibility assigned. This ensures alignment with evolving national guidance and local service needs.

Annex A – Example list of core responsibilities of the chaperone

This annex lists the core roles and responsibilities of a chaperone. The list is not exhaustive and organisations may wish to amend or add to it to reflect local service configuration or specialist requirements.

• Receive appropriate and necessary training.
• Be sensitive to the patient’s needs, respecting and maintaining their privacy and dignity.
• Provide emotional comfort and reassurance.
• Be courteous and professional at all times.
• Encourage patients to ask questions and seek clarification.
• Be alert to signs of patient distress – both verbal and non-verbal.
• Understand the clinical context and be able to appropriately observe the examination or procedure.
• Act as the patient’s advocate when required.
• Identify and raise concerns about any unusual or unacceptable behaviour by the healthcare practitioner.
• Assist with undressing or dressing if requested by the patient.
• Help the patient understand what is being communicated to them.
• While chaperones may support clinicians, this is not their primary role.
• Chaperones are not required to be registered clinicians. It is outside their remit to challenge the clinical decision to perform an examination or procedure. However, they have a duty of care to raise concerns about unsafe practices, in line with wider NHS policies.
• The formal chaperone should document their presence in the clinical record, noting the date, time and nature of the examination or procedure.

Publication reference: PRN02280_ii