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Chaperone Policy

Document type:  Governance
Document Version 1.0
Ratified Date: 18/03/2024                                
Document Manager Christina Tranda
Approved Date: 18/03/2024
Review Date 18/03/2026



The relationship between a patient and their healthcare professional (HCP) is one based on trust. However, during any type of examination, the patient is entitled to request/be offered a chaperone, of the same sex, being present during any consultation or when undergoing any procedure or examination.


This policy sets out guidance for the use of chaperones and the types of procedures they should be in place for:


Clinicians should always consider being accompanied by a formal chaperone during intimate procedures, including:


  • Intimate examination, treatment or care.
  • Does not use English as their first language.
  • Has hearing, visual or speech impairment.



This policy applies to all staff employed or undertaking work for or on behalf of Galen Clinic. The aim of this policy is to ensure those involved in providing care to patients are aware of their responsibility to work in line with their own professional code of conduct. This policy aims to provide guidance on providing/offering a chaperone during all intimate examinations and procedures.





There is no clear definition of a chaperone since there is considerable variation on the needs of the patient, the healthcare professional and the examination or procedure being carried out.

A chaperone may refer to a person who witnesses a medical examination or procedure on behalf of the healthcare professional and the patient. This person must be able to safeguard patients with the ability to challenge inappropriate behaviour.

Informal Chaperone An individual that would not be expected to actively take part in the examination or directly witness the procedure. For example, this could be a family member or friend who may give reassurance and emotional comfort to the patient.
Formal Chaperone Implies a health professional such as a Registered Nurse, or an unregistered staff member who may assist the examiner during the procedure. For example, hand instruments to the health professional. A formal chaperone will hold a minimum of Level 2 safeguarding certification.


The chaperone will be familiar with safeguarding and unacceptable behaviour on the part of the health care professional. They should immediately report any incidence of inappropriate behaviour to the manager or local authority.

A chaperone will safeguard healthcare professionals against unfounded allegations of inappropriate behaviour made by the patient.

The healthcare professional is responsible to accurately record any clinical contact, including a record of the patient accepting or refusing a chaperone.


When there is no Chaperone available


In an event where a formal chaperone is not available, an incident form should be completed outlining the reasons and action taken, the patient must be notified as soon as possible that a chaperone is not available and recorded in their notes. It is at the HCP’s own discretion to proceed without the formal chaperone present, but this decision remains with the HCP as they will be held answerable for any allegations made against them.

If the HCP decides not to proceed, a new appointment must be made and the HCP must organise a chaperone.

Conduct of a Chaperone


Amongst literature a definitive definition of the role of a chaperone has not been made, the Ailing Report (Department of Health 2004) found that there was no common definition and the role varied depending on the needs of the patient, the healthcare professional and the examination or procedure being carried out.  A chaperone provides protection to the patient and healthcare professional and acts as a witness to continuing consent of the procedure/examination.

A chaperone’s role can include:

  • Ensuring the patient’s privacy and dignity is maintained.
  • Reassure patients when they are distressed.
  • Be considerate of the patient’s needs.
  • Encourage questions.
  • Detect any signs of distress from the patient – verbal and non-verbal.
  • Observe the examination/procedure.
  • Act as an advocate/interpreter.
  • Highlight unusual or unacceptable behaviour on the part of the healthcare professional and raise concerns at the time with them or their manager who may then make a referral under Safeguarding Adult Procedures. Support patient to understand what is being communicated.


Areas for consideration



Consent is an agreement between patient and health professional to provide care.  It is the healthcare professional’s responsibility to obtain consent before examining and treating any person.


Healthcare professionals will obtain consent based on the assumption that every adult has the capacity to decide whether to consent to or refuse proposed treatment, unless they have reason to believe the patient cannot understand information conveyed to them in a clear way.


This means that the patient must:

  • Have capacity to make the decision.
  • Have received sufficient information and understand the information.
  • Not be acting under pressure.


If the patient is deemed not to have the capacity to consent for themselves the HCP should stop any treatment or examination and refer the patient to their general medical practitioner.


Religion, Ethnicity or Culture 

When examining or treating patients the healthcare professional should take into consideration the patient’s ethnic, religious and cultural background.


Lone Working 

Where a healthcare professional is working alone, the same principles for offering and using a chaperone should apply. If it is appropriate a family member/friend may act as an informal chaperone only. However, in cases where the patient is undergoing an intimate examination, the healthcare professional would be advised to reschedule the examination to a more convenient location or arrange for a formal chaperone.


Communication and Record Keeping 

The healthcare professional must record all details of the examination/event requiring presence of a chaperone. The record should include the presence or absence of a chaperone and their details. This must be documented in the patient’s record. The notes should also record if the patient was offered a chaperone and if it had been declined by the patient.  


  • General Medical Council (GMC) (2013) Intimate examinations and chaperones.