Background

Cervical cancer is the 14th most common cancer in women, with over 3,000 new cases per year in the UK. Research has shown that cervical screening prevents 2,000 cervical cancer deaths each year in the UK. Screening for cervical cancer started in the 1980s and since then the rates of cervical cancer have halved.

Women aged 25 to 49 are invited for screening every three years, and every five years after that until the age of 64. It is estimated that women having screening between the ages of 35 and 64 have a 60-80% lower risk of being diagnosed with cervical cancer in the five years following the test compared with women who have not been screened.

Although many healthcare professionals consider cervical screening a routine test, it is an intimate procedure and many women find it distressing. It is therefore perhaps unsurprising that complaints can arise if patients feel they haven't been dealt with in an appropriate and sensitive manner.

Audit

We reviewed files of complaints reported to the MDU related to cervical cancer for the five years between 2012 to 2016.

There were 23 cases of complaints about nurses regarding cervical cancer screening.

Consent

In all of the cases, the patient complained that poor information was given before and after the procedure. Patients commented that they were not told what the procedure would entail, and did not know what to expect even when they had had a screening procedure before.

They also commented that they had not been told about changes in the procedure since their last test, such as not using lubricant and not using a sheet to cover them before the procedure. Some of these comments may be explained by changes in national guidance; for example, new cytology methods have meant that use of lubricants is discouraged.

Withdrawal of consent

Five (22%) of the patients complained that the nurse carried on with the procedure after the patient asked them to stop due to pain or discomfort.

Pain and discomfort

Twelve (52%) of the patients complained that they had experienced pain during the procedure, and of these, seven had problems afterwards such as bleeding, ongoing pain and infection. Eight patients (34%) required further appointments with doctors due to ongoing pain, bleeding or other gynaecological problems.

One patient said the procedure made her feel violated but she did not feel pain during the procedure.

Attitude of nurse

Seven (30%) of patients complained about the attitude of the nurse. Patients described nurses as being rude and abrupt or rough and uncaring. Several patients complained that the nurse did not answer their questions or explain what she was doing during the procedure.

Chaperones

There were no chaperones present for any of the 23 complaints reviewed and no record in the notes of patients being asked if they wanted a chaperone.

Outcome of cases

In three cases nurses were referred to the Nursing and Midwifery Council (NMC) but the cases did not proceed past the investigation stage. One case was referred to the Parliamentary and Health Services Ombudsman (PHSO) when the patient was not satisfied with the response to the complaint. The complaint was partially upheld by the PHSO due to the practice's handling of the complaint.

There were no complaints to the police in this group of cases as yet but there have been police complaints and investigations in cases outside the audit dates chosen.

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Comment

Although this was a small number of cases, there are several important issues that were highlighted by the audit. These were around consent, chaperones and potential consequences to the nurse and the patient.

Consent

Consent is vital for any examination or treatment for both legal and clinical reasons. An examination without consent is an assault in law. Clinically, cooperation from the patient is necessary for most examinations or procedures. In order to be valid, consent needs to be voluntary, informed and free from coercion.

Healthcare professionals need to give patents the information they want or need to make a decision in their own particular circumstances, and that information needs to be tailored to the particular patient. Even if patients have been invited for cervical screening, the responsibility for giving information and taking consent lies with the professional undertaking the procedure.

Consent is a process rather than a one-off event, and patients have a right to give or withdraw consent at any time. If the health care professional continues with an examination after consent is withdrawn then they are committing an assault. Therefore, if a patient says that she wants the nurse to stop the procedure, the nurse should do so and clarify the wishes of the patient.

Practitioners should take care to record what information or explanation has been given to the patient in the clinical notes.

Intimate examinations and chaperones

The Royal College of Nursing has produced guidance on genital examination in women, which explains that a chaperone present at an examination safeguards both patient and nurse. The chaperone is a witness to continued consent to the procedure and can act as an advocate for the patient, ensuring that the patient feels safe and comfortable during the procedure. All women should be offered a chaperone for intimate examinations or procedures, even when the nurse is the same gender as the patient.

In order to be valid, consent needs to be voluntary, informed and free from coercion.

The offer of a chaperone should be documented in the notes and also whether the patient accepts or refuses the chaperone. If the patient accepts, the name of the person acting as a chaperone should also be recorded.

In a recent MDU audit of allegations against healthcare professionals of sexual assault or inappropriate examination by patients, 25% were allegations by patients of the same gender as the healthcare professional. Patients may not raise the allegations immediately; in the audit only 42% of allegations were raised within three months and another 42% did not raise their concerns for over a year.

Potential consequences for patient and practitioner

The consequences of not obtaining informed consent or continuing with a procedure when consent has been withdrawn can be serious for the practitioner. Consequences can range from upset patients to complaints to the practice, NMC or even the police. All of these potential consequences are obviously stressful for the practitioner concerned.

If patients have an unpleasant experience during cervical screening it may make them reluctant to engage in the screening programme. Since screening can reduce the risk of patients being diagnosed with cervical cancer by 60-80%, anything that discourages patients from engaging with the programme could have life threatening consequences.

Top tips

  1. Give patients full information about the procedure and allow her to ask questions.
  2. Offer a chaperone and document the offer and the patient's decision in the records.
  3. Explain what you are doing before and during the procedure.
  4. If the patient withdraws consent, stop the procedure when it is safe to do so.
  5. Try to preserve the dignity of the patient.

This article was correct at publication on 14/08/2018. It is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.

Dr Carol Chu

MDU Medico-legal adviser

MB, ChB, MSc (Medical genetics), MD, MRCPI, MPhil (Medical Law) DLM

Carol qualified at Sheffield University. She attained her CCST in clinical genetics and spent 13 years as a consultant clinical geneticist, the last six of these also being the Head of Department, managing not only the clinical department; doctors, counsellors and administrative staff (including records) but also the three laboratories. She left the NHS to pursue a longstanding interest in medical ethics and medical law as a medicolegal adviser for the MDU in 2011. She was also chair of a research ethics committee for 10 years.

See more by Dr Carol Chu