Consent to Examination or Treatment Policy - Nottinghamshire ...

Consent to Examination or Treatment – 1.03 

SECTION: 

1 – PATIENT CARE 

POLICY NO: 1.03 

NATURE AND SCOPE: 

SUBJECT: 

POLICY AND PROCEDURE – TRUST-WIDE 

CONSENT TO EXAMINATION OR TREATMENT 

Consent to examination or treatment is a critical factor in how the Trust operates. 

This policy sets out the key issues in obtaining informed consent, including capacity 

to give or withhold consent. 

DATE OF LATEST RATIFICATION: AUGUST 2012 

RATIFIED BY: 

EXECUTIVE LEADERSHIP TEAM 

IMPLEMENTATION DATE: AUGUST 2012 

REVIEW DATE: AUGUST 2015 

ASSOCIATED TRUST POLICIES 

AND PROCEDURES: 

Advance Decisions & Advance Statements – 8.11 & 

8.11A 

Development of Service User and Carer Information 

4.02 

Clinical Records Management - 7.06 

Multi-Agency Policy and Procedure on the Mental 

Capacity Act 2005 

ISSUE 6 – AUGUST 2012

NOTTINGHAMSHIRE HEALTHCARE NHS TRUST 

ISSUE 6 – AUGUST 2012 1 


CONSENT TO EXAMINATION OR TREATMENT POLICY 

CONTENTS 

1.0 Introduction 

2.0 Purpose 

3.0 Policy Principles 

4.0 Definitions 

5.0 Context of Consent 

6.0 Duties 

6.1 Chief Executive 

6.2 Executive Director: Clinical Governance and Medical Affairs 

6.3 Clinical Directors 

6.4 General Managers and Heads of Service 

6.5 All Healthcare Professionals 

6.6 Groups 

7.0 Documentation 

8.0 Process for identifying Staff Capable of Performing the Procedure and Authorised to Obtain 

Consent for the Procedure 

9.0 Process For The Delivery Of Procedure Specific Training On Consent, For Clinical Staff Who 

Are Not Capable Of Performing The Procedure, But Who Are Authorised To Obtain Consent 

For That Procedure 

10.0 Process for following up where an individual has obtained Consent without the authorisation 

to do so. 

11.0 Seeking Consent 

12.0 Procedure to Follow When Patients Lack Capacity to Give or Withhold Consent 

13.0 Seeking consent for Anaesthesia 

14.0 Emergencies 

15.0 Young People Aged 16 – 17 

16.0 Children Under 16 – The Concept of Gillick Competence 

17.0 The Requirement of Voluntariness 

18.0 Child or Young Person with Capacity Refusing Treatment 

19.0 Child Lacking Capacity 

20.0 Provision of Information 

21.0 Completing Consent Forms 

22.0 Responsibilities for Seeking Consent 

23.0 Attendance by Students and Trainees 

24.0 Refusal of Treatment 

25.0 Advance Decisions to Refuse Treatment 

26.0 Advance Statements


27.0 Tissue 

28.0 Clinical Photography and Conventional or Digital Video Recording 

29.0 Consent and the Mental Health Act 1983 

30.0 Capacity and the Mental Health Act 1983 

31.0 Treatment and the Mental Health Act 1983 

32.0 The Mental Health Act 1983 Three-Month Rule 

33.0 Training 

34.0 Implementation 

35.0 Equality Impact Assessment 

36.0 Consultation 

37.0 Monitoring Compliance 

38.0 Target Audience 

39.0 Champion and Expert Writers 

40.0 Review Date 

41.0 Legislation Compliance 

42.0 Reference and Source Documents 

Appendix 1 

Current Consent Forms in use in this organisation 

• Consent Form 1: Patient Agreement to Investigation or Treatment 

• Consent Form 2: Agreement Of parent (r persons who has parental responsibility ) To 

Investigation or Treatment for a Child Or Young Person 

• Consent Form 3: Patient / Parental Agreement to Investigation or Treatment Procedures where 

Consciousness not Impaired 

• Consent Form 4: Form for Adults who are Unable to Consent to Investigation or Treatment 

Appendix 2 Record of Changes 

Appendix 3 Record of Employee Having Read the Policy 

ISSUE 6 – AUGUST 2012 2

NOTTINGHAMSHIRE HEALTHCARE NHS TRUST 


CONSENT TO EXAMINATION OR TREATMENT POLICY 

1.0 INTRODUCTION 

1.1 Nottinghamshire Healthcare NHS Trust recognises that patients have a fundamental legal 

and ethical right to determine what happens to their own bodies and this is reflected in this 

policy. Valid consent to treatment is central in all forms of healthcare, from providing 

personal care to undertaking major surgery. Seeking consent is not only a legal obligation 

but also a matter of common courtesy between health professionals and patients. 

1.2. Health professionals in this Trust must comply with the standards and procedures in this 

policy which should be applied in conjunction with the principles set out in Consent: Patients 

and Doctors Making Decisions Together; General Medical Council. Please refer to the 

Mental Capacity Act/its Code of Practice and the Mental Health Act/its Code of 

Practice. 

1.3. While this policy is primarily concerned with healthcare and refers to health professionals, 

social care colleagues should also be aware of their obligations to obtain consent before 

providing certain forms of social care, such as those that involve touching the patient or 

service user. In this policy reference to an adult patient means a patient of 18 years or above 

‘young person’ for 16/17 year olds and a child is person who is under the age of 16. 

2.0 PURPOSE 

2.1 The Department of Health has issued a range of guidance documents on consent, and these 

should be consulted for details of the law and good practice requirements on consent. This 

policy sets out the standards and procedures within the Trust, which aim to ensure that 

health professionals are able to comply with the guidance. Unlike similar policies for acute 

Trusts, this policy also incorporates the guidance on consent that is relevant to patients 

detained under the Mental Health Act 1983. While this document is primarily concerned with 

healthcare, social care colleagues should also be aware of their obligations to obtain 

consent before providing certain forms of social care, such as those that involve touching the 

patient. 

2.2 Valid consent is essential for all forms of health care provided by the Trust. The approach to 

obtaining consent should meet the standards set out in this document, in all areas of the 

Trust. The Trust expects that only the forms in Appendix 1 will be used for obtaining written 

consent. It must be remembered that there are special considerations to be made for 

children, young people, patients without capacity and those subject to the Mental Health Act 

1983 (MHA 1983). 

3.0 POLICY PRINCIPLES 

3.1 Examination and treatment must be undertaken lawfully and this will mean where there has 

been valid consent or, where the patient lacks capacity, it has been assessed as being in the 

patient’s best interests to undertake the examination/treatment. 

3.2 Patients must be kept informed at each stage of treatment and as far as possible, their views 

sought at each stage of the examination/treatment process. 

4.0 DEFINITIONS 

4.1. Consent is a patient’s agreement for a health professional to provide care. Patients may 

indicate consent non-verbally (for example by presenting their arm for their pulse to be 

taken), orally, or in writing. For the consent to be valid, the patient must: 



• be competent to take the particular decision; 

• have received sufficient information to take it; and 

• not be acting under duress. 

5.0 CONTEXT OF CONSENT 

5.1 The context of consent can take many different forms, ranging from the active request by a 

patient for a particular treatment (which may or may not be appropriate or available) to the 

passive acceptance of a health professional’s advice. In some cases, the health professional 

will suggest a particular form of treatment or investigation and after discussion the patient 

may agree to accept it. In others, there may be a number of ways of treating a condition, and 

the health professional will help the patient to decide between them. The health professional 

must provide the patient with sufficient information to enable them to make an informed 

decision. Some patients, especially those with chronic conditions, become very well 

informed about their illness and may actively request particular treatments. In many cases, 

‘seeking consent’ is better described as ‘joint decision-making’: the patient and health 

professional need to come to an agreement on the best way forward, based on the patient’s 

values and preferences and the health professional’s clinical knowledge. 

5.2 In determining whether an adult patient lacks capacity (either temporarily or permanently) to 

give or withhold consent for themselves, health professionals will apply the principles set out 

in the Mental Capacity Act 2005 (MCA) and the Mental Capacity Act 2005 Code of Practice. 

It is the responsibility of the person carrying out the intervention to assess and determine 

capacity. It is important to remember that no-one other than a person who has authority 

under a Lasting Power of Attorney relating to personal welfare or is a Deputy appointed by 

the Court, can give consent on behalf of an adult patient. A patient who lacks capacity can, 

however, be given treatment if it is in their best interests in accordance with the Mental 

Capacity Act, as long as the patient has not made a valid and applicable Advance Decision. 

In certain circumstances however a Court application will be required before treatment can 

be given lawfully. Examples include: 

1. Non therapeutic sterilisation. 

2. Where there is a dispute as to what is in the patient’s best interests. 

5.3 When treating patients who may lack capacity, health professionals must have regard to the 

Mental Capacity Act 2005 Code of Practice. 

5.4 An individual is presumed to have the capacity to make a treatment decision unless they 

have impairment or disturbance in the functioning of the mind or brain; and this impairment 

or disturbance means they can’t make the treatment decision at the time it needs to be made 

because they are unable to: 

• understand the information relevant to the decision, or 

• retain the information, or 

• use or weigh the information as part of the process of making the decision, or 

• communicate the decision (whether by talking, using sign language, or by any other 

means) 

6.0 DUTIES 

6.1 Chief Executive 

The Chief Executive is responsible for the safe care and treatment of all patients regardless 

as to whether this is delivered by employed personnel or contractors. 


6.2 Executive Director: Clinical Governance and Medical Affairs 


6.2.1 The Executive Director: Clinical Governance and Medical Affairs is responsible for 

ensuring that there is an up-to-date Consent Policy that meets both legal and best 

practice guidance and that professional conduct relating to consent is maintained. 

6.2.2 Additionally he / she will monitor the practice of medical staff and dentists employed 

by the Trust relating to the obtaining of consent and will be responsible for notifying 

the General Medical Council (GMC) via the required form, of any individual who has 

obtained consent without the authorisation to do so. 

6.3 Clinical Directors 

6.3.1 Clinical Directors have overall responsibility for standards of clinical practice within 

their area of responsibility, ensuring that both legal and best practice standards are 

achieved. In some cases Clinical Directors are also responsible for the activities of 

medical staff within that area of responsibility and where this is the case they will 

work with the Associate Medical Director in maintaining their standards of practice in 

this regard. 

6.4 General Managers and Heads of Service 

6.4.1 General Managers and Heads of Service will hold the same level of responsibility for 

all of their staff groups within their area of responsibility and will work closely with the 

relevant Clinical Director in delivering this. 

6.5 All Healthcare Professionals 

6.5.1 All staff involved in obtaining consent or providing treatment are accountable both 

legally and professionally for their actions. However, the person actually providing 

the treatment must satisfy themselves that valid consent has been given before 

carrying out the treatment. 

6.6 Groups 

6.6.1 The Patient Safety Group will review the annual audit undertaken by Health 

Partnerships, Local and Forensic Services Divisions. For more detail about the 

content of the audit please refer to Section 37. 

7.0 DOCUMENTATION 

7.1 It is essential for health professionals to document clearly both the patient’s agreement to 

the intervention and the discussions which led up to that agreement. This may be achieved 

through the use of a consent form (with further details recorded in the patient’s healthcare 

record). Within the Mental Health Act 1983 there are statutory forms (e.g. T2 or T3) which 

must be completed when assessing and recording consent after 3 months have elapsed 

since the first administration for medicine for a mental disorder. 

7.2 Consent is often wrongly equated with a patient’s signature on a consent form. A signature 

on a form is evidence that the patient has given consent, but is not proof of valid consent. If 

a patient is rushed into signing a form, on the basis of too little information, the consent may 

not be valid, despite the signature. Similarly, if a patient has given valid verbal consent, the 

fact that they are physically unable to sign the form is no bar to treatment. Patients may also, 

if they wish, withdraw consent after they have signed a form: the signature is evidence of the 

process of consent-giving, not a binding contract. 



7.3 It is rarely a legal requirement to seek written consent from patients with capacity. However 

the Mental Health Act 1983 (as outlined in paragraph 28 below) and the Human Fertilisation 

and Embryology Act 1990 require written consent in certain circumstances but it is good 

practice to do so if any of the following circumstances apply: 

• the treatment or procedure is complex, or involves significant risks (the term ‘risk’ is 

used throughout to refer to any adverse outcome, including those which some health 

professionals would describe as ‘side-effects’ or ‘complications’); 

• the procedure involves general/regional anaesthesia or sedation; 

• providing clinical care is not the primary purpose of the procedure; 

• there may be significant consequences for the patient’s employment, social or 

personal life; 

7.4 Completed forms must be kept with the patient’s notes. Any changes to a form, made after 

the form has been signed by the patient, must be initialled and dated by both the patient and 

the health professional. 

7.5. It will not usually be necessary to document a patient’s consent to routine and low-risk 

procedures, such as providing personal care or taking a blood sample. However, if you have 

any reason to believe that the consent may be disputed later or if the procedure is of 

particular concern to the patient (for example if they have declined, or become very 

distressed about, similar care in the past), it would be helpful to do so. 

7.6 Standard consent forms and forms for adults who are unable to consent for themselves are 

reproduced in Appendix 1 and are available from the Trust intranet. There are three versions 

of the standard consent form: 

• Form 1 for adults with capacity or competent children; 

• Form 2 for parental consent for a child or young person; and 

• Form 3 for consent for a child or young person; for cases where it is envisaged that 

the patient will remain alert throughout the procedure and no anaesthetist will be 

involved in their care. 

• Form 4 for adults who lack the capacity to consent to investigations or treatment. 

7.7 The use of form 3 is optional but may be thought more appropriate than form 1 in situations 

where patients do not need to be made aware of issues surrounding general or regional 

anaesthesia and do not need to make any advance decisions about additional procedures 

because they will be in a position to make any such decisions at the time if necessary. 

7.8 Where an adult patient does not have the capacity to give or withhold consent to a significant 

intervention, this fact should be documented in form 4 (form for adults who are unable to 

consent to investigation or treatment), along with: 

• the assessment of the patient’s capacity; 

• why the health professional believes the treatment to be in the patient’s best interests 

as detailed in the MCA Code of Practice; and 

• the involvement of people close to the patient. 



7.9 The standard consent forms (1, 2 and 3) should never be used for adult patients unable to 

consent for themselves. For more minor interventions, this information should be entered in 

the patient’s notes. 

8.0 PROCESS FOR IDENTIFYING STAFF CAPABLE OF PERFORMING THE PROCEDURE 

AND AUTHORISED TO OBTAIN CONSENT FOR THE PROCEDURE 

8.1 During the period of induction new staff will be mentored to ensure that where this falls 

within the scope of their role and is necessary e.g. to maintain sufficient numbers of staff 

with this competence to provide reasonable coverage they are competent to both gain 

informed consent and/ or to perform specific procedures. Once the Line Manager has been 

assured that competency has been achieved the staff member can practice without 

supervision. The Manager of the Clinical Team is responsible for ensuring that there are 

sufficient staff trained / competent to obtain consent, even if they are not authorised to 

perform the procedure for which the consent has been gained. They are also responsible for 

monitoring the practice of these staff to ensure practice remains at the required level. In the 

main this will be achieved through clinical supervision processes but at least annually there 

will need to be a more formal , recorded review to confirm competency has been maintained 

e.g. as part of the PAD process. 

8.2 Existing staff who currently obtain consent and perform procedures do not require an 

additional appraisal following the introduction of this policy unless their annual review is due. 

They remain responsible for their decisions and actions. The Line Manager is responsible 

for maintaining records of those staff who are not competent to obtain consent and carry out 

specific procedures and for identifying when formal reviews will be undertaken 

. 

8.3 Clinical Directors and General Managers are responsible for maintaining a record of staff in 

relation to consent. This can be delegated to specific others at the operational level but 

there must always be a single record, updated as necessary for the service. This record will 

maintain as a minimum, the following information: 

• Staff member’s name, job title and place of work 

• A list of procedures for which the staff member has been assessed as being competent 

to obtain consent 

• A list of procedures for which the staff member has been assessed as being competent 

to obtain consent and to perform the procedure 

• Details of the specific training undertaken 

9.0 PROCESS FOR THE DELIVERY OF PROCEDURE SPECIFIC TRAINING ON CONSENT, 

FOR CLINICAL STAFF WHO ARE NOT CAPABLE OF PERFORMING THE 

PROCEDURE, BUT WHO ARE AUTHORISED TO OBTAIN CONSENT FOR THAT 

PROCEDURE 

9.1 The Line Manager is responsible for ensuring that records are maintained. Appropriate 

training and supervision is given to staff who are authorised to obtain informed consent even 

though they must be required to be competent to undertake the procedure for which consent 

is sought. 

9.2 Training on the specifics of obtaining appropriate informed consent in undertaking 

procedures must be provided by staff trained and competent in the procedures where 

consent will be sought). Training must cover the following issues:- 

• Defining consent and consideration of the principles of the Mental Capacity Act 2005. 

• The detail of the procedure to be undertaken. 

• The risks and benefits of that procedure, along with alternatives to the procedure. 

• Common questions asked by more junior staff and patients in relation to the procedure. 




9.3 Staff must be re-assessed annually as part of the PAD process or more frequently if 

considered necessary by their Line Manager to ensure standards are maintained in relation 

to obtaining consent and for undertaking procedures. 

10.0 PROCESS FOR FOLLOWING UP WHERE AN INDIVIDUAL HAS OBTAINED CONSENT 

WITHOUT THE AUTHORISATION TO DO SO 

10.1 Members of staff who obtain consent without the authorisation to do so will be the subject of 

a Conduct Investigation and action taken as necessary. If the breach is of sufficient severity 

the professional organisation for that staff member could be informed. They would then 

determine whether any further action is warranted. 

10.2 All such instances must be reported through the Trust Incident Reporting System 

(Safeguard) and an incident form completed. The circumstances of the breach will 

determine whether or not this should be reported as a serious incident. 

11.0 SEEKING CONSENT 

11.1 When a patient formally gives their consent to a particular intervention, this is only the 

endpoint of the consent process. It is helpful to see the whole process of information 

provision, discussion and decision-making as part of ‘seeking consent’. This process may 

take place at one time, or over a series of meetings and discussions, depending on the 

seriousness of what is proposed and the urgency of the patient’s condition. 

11.2 Single stage process: In many cases, it will be appropriate for a health professional to 

initiate a procedure immediately after discussing it with the patient. For example, during an 

ongoing episode of care a physiotherapist may suggest a particular manipulative technique 

and explain how it might help the patient’s condition and whether there are any significant 

risks. If the patient is willing for the technique to be used, they will then give their consent 

and the procedure can go ahead immediately. In many such cases, consent will be given 

orally. The consent process must always be recorded either by the use of the Consent Form 

or an entry into patient’s healthcare record. 

11.3 If a proposed procedure carries significant risks, written consent must be sought and an 

entry made in the patient’s healthcare record, health professionals must take into 

consideration whether the patient has had sufficient chance to absorb the information 

necessary for them to make their decision. As long as it is clear that the patient understands 

and consents, the health professional may then proceed. 

11.4 Two or more stage process: - In most cases where written consent is being sought, 

treatment options will generally be discussed well in advance of the actual procedure being 

carried out. This may be on just one occasion (either within primary care or in a hospital outpatient 

clinic), or it might be over a whole series of consultations with a number of different 

health professionals. The consent process will therefore have at least two stages: the first 

being the provision of information, discussion of options and initial (oral) decision, and the 

second being confirmation that the patient still wants to go ahead. The consent form must 

be used as a means of documenting the information stage(s), as well as the confirmation 

stage, and an entry made in the patient’s healthcare record. 

11.5 Patients receiving elective treatment or investigations for which written consent is 

appropriate should be familiar with the contents of their consent form before they arrive for 

the actual procedure, and should have received a copy of the page documenting the 

decision-making process. They may be invited to sign the form, confirming that they wish 

treatment to go ahead, at any appropriate point before the procedure: i.e. in out-patients, at 

a pre-admission clinic, or when they arrive for treatment. If a form is signed before patients 

arrive for treatment, however, a member of the healthcare team must check with the patient 

at this point whether they have any further concerns and whether their condition has 

changed. This is particularly important where:


• there has been a significant lapse of time between the form being signed and the 

proposed procedure being undertaken; 

• new information becomes available regarding the proposed intervention (for 

example, new evidence of risks or new treatment options); 

• the patient’s condition has changed significantly in the intervening period between 

the time when consent was sought and when the intervention is undertaken. 

11.6 When confirming the patient’s consent and understanding, it is advisable to use a form of 

words which requires more than a yes/no answer from the patient: For example beginning 

with “tell me what you’re expecting to happen”, rather than “is everything all right?” 

11.7 While administrative arrangements will vary, it should always be remembered that for 

consent to be valid, the patient must feel that it would have been possible for them to refuse, 

or change their mind. It will rarely be appropriate to ask a patient to sign a consent form after 

they have begun to be prepared for treatment (for example, by changing into a hospital 

gown), unless this is unavoidable because of the urgency of the patient’s condition. 

11.8 The patient’s consent may be obtained by post and this gives the patient time to read and 

reflect on the consent form and information provided. However, any person carrying out a 

procedure on a patient must ensure that, immediately before the procedure, the patient has 

understood the information and that they still give their consent. If the patient has queries or 

concerns he or she must be given time to consider any additional information. 

11.9 Whatever the context in which medical decisions are made, you must work in partnership 

with your patient to ensure good care. In so doing, you must: 

• listen to patients and respect their views about their health 

• discuss with patients what their diagnosis, prognosis, treatment and care involve 

• share with patients the information they want or need in order to make decisions 

• maximize patients’ opportunities, and their ability, to make decisions for themselves 

• respect patients’ decisions 

12.0 PROCEDURE TO FOLLOW WHEN PATIENTS LACK CAPACITY TO GIVE OR 

WITHHOLD CONSENT 

12.1 The Mental Capacity Act 2005 provides a statutory framework to empower and protect 

vulnerable people who may not be able to make their own decisions. It applies to persons 

over the age of 16 (with some exceptions relating to creation of Advance Decisions and 

Lasting Powers of Attorney as outlined in the Trust Policy: Advance Care Planning to 

Include Advance Decisions to Refuse Treatment, Statements of Wishes & Feelings & 

Lasting Powers of Attorney. The Act defines ‘lack of capacity’ as an inability to make a 

particular decision at a particular time due to “an impairment of or disturbance in the 

functioning of the mind or brain”. The Act introduces the following key elements when 

defining capacity: 

• Time specific – the issue is whether a person can make a decision at a particular time. 

• Decision specific- capacity relates to a specific decision not a general ability to make 

decisions. 

• Diagnostic threshold – must have permanent or temporary impairment of or 

disturbance in the functioning of the mind or brain. 

• Not based on appearance and behaviour – i.e. not assuming someone lacks capacity 

just because they have a learning disability. 

• Balance of probabilities – lack of capacity must be decided on the balance of 

probabilities of what is more likely than not. 



12.2 The Act states that a person cannot make a decision if they cannot do one any of the 

following four things: 

• Understand information given to them relevant to the decision. 

• Retain that information long enough to be able to make the decision. 

• Use or weigh up the information available to make the decision as part of the decision – 

making process. 

• Communicate their decision in any way. 

12.3 Lack of capacity can be due to (amongst other things): 

• A stroke or brain injury. 

• A mental health problem. 

• Dementia. 

• A learning disability. 

• Confusion, drowsiness or unconsciousness because of an illness or the treatment of it. 

• A neurological disorder. 

• Substance misuse. 

12.4 A disturbance in the functioning of the mind or brain can be permanent or temporary. No-one 

can be deemed ‘incapable’ by reference simply to a particular diagnosis or mental condition 

nor by reference to a person’s age or appearance or aspect of their behaviour that might 

lead to an unjustified assumption about their lack of capacity. 

12.5 Those assessing capacity must also consider whether a person who lacks capacity may 

regain capacity to make the relevant decision at a later date. If the patient may regain 

capacity the decision maker must decide whether the decision in question can wait until such 

time as the service user may regain capacity or if the service user’s best interests require 

that a decision is taken before they regain capacity (for example because there is a medical 

emergency). 

12.6 Any restraint used in connection with the care or treatment of a service user who lacks 

capacity must be a proportionate response to the likelihood of the service user suffering 

harm and the seriousness of that harm. 

13.0 SEEKING CONSENT FOR ANAESTHESIA 

13.1 Where an anaesthetist is involved in a patient’s care, it is their responsibility (not that of a 

surgeon) to seek consent for anaesthesia, having discussed the benefits and risks. 

However, in elective treatment it is not acceptable for the patient to receive no information 

about anaesthesia until their pre-operative visit from the anaesthetist: at such a late stage 

the patient will not be in a position genuinely to make a decision about whether or not to 

undergo anaesthesia. Patients should therefore either receive a general leaflet about 

anaesthesia in out-patients, or have the opportunity to discuss anaesthesia in a preassessment 

clinic. 

13.2 The anaesthetist must ensure that the discussion with the patient and their consent is 

documented in the anaesthetic record, in the patient’s notes or on the consent form. Where 

the clinician providing the care is personally responsible for anaesthesia (e.g. where local 

anaesthesia or sedation is being used), then he or she will also be responsible for ensuring 

that the patient has given consent to that form of anaesthesia. 

13.3 In addition, where general anaesthesia or sedation is being provided as part of dental 

treatment, the General Dental Council currently holds dentists responsible for ensuring that 

the patient has all the necessary information. 



14.0 EMERGENCIES 

14.1 Clearly in emergencies, the two stages (discussion of options and confirmation that the 

patient wishes to go ahead) will follow straight on from each other, and it may often be 

appropriate to use the patient’s notes to document any discussion and the patient’s consent, 

rather than using a form. The urgency of the patient’s situation may limit the quantity of 

information that they can be given, but should not affect its quality. 

15.0 YOUNG PEOPLE AGED 16–17 

15.1 People aged 16 or 17 are presumed to be capable of consenting to their own medical 

treatment, and any ancillary procedures involved in that treatment, such as an anaesthetic 

(Family Law Reform Act 1969). The consent of young people will be valid if it is given 

voluntarily by an appropriately informed young person capable of consenting to the particular 

intervention. However, unlike adults, the refusal of a competent person aged 16–17 may in 

certain circumstances be overridden by either a person with parental responsibility or a 

court. 

15.2 The Family Law Reform Act 1969 applies only to the young person’s own treatment. It does 

not apply to an intervention that is not potentially of direct health benefit to the young person, 

such as blood donation or non-therapeutic research on the causes of a disorder. However, a 

young person may be able to consent to such an intervention under the standard of Gillick 

competence, considered below. 

15.3 In order to establish whether a young person aged 16 or 17 has capacity to consent to the 

proposed intervention, the same criteria as for adults should be used. If a young person 

lacks capacity to consent because of an impairment of, or a disturbance in the functioning of, 

the mind or brain then the Mental Capacity Act 2005 will apply in the same way as it does to 

those who are 18 and over. If however they are unable to make the decision for some other 

reason, for example because they are overwhelmed by the implications of the decision, then 

the Act will not apply to them and the legality of any treatment should be assessed under 

common law principles. It may be unclear whether a young person lacks capacity within the 

meaning of the Act. In those circumstances, it would be prudent to seek a declaration from 

the court. 

15.4 If the 16/17-year-old is capable of giving valid consent, it is not legally necessary to obtain 

consent from a person with parental responsibility for the young person in addition to the 

consent of the young person. It is, however, good practice to involve the young person’s 

family in the decision-making process – unless the young person specifically wishes to 

exclude them – if the young person consents to their information being shared. 

16.0 CHILDREN UNDER 16 – THE CONCEPT OF GILLICK COMPETENCE 

16.1 Children under 16 who have sufficient understanding and intelligence to enable them to 

understand fully what is involved in a proposed intervention will also have the capacity to 

consent to that intervention. This is sometimes described as being ‘Gillick competent.’ A 

child of under 16 may be Gillick competent to consent to medical treatment, research, 

donation or any other activity that requires their consent. 

16.2 The concept of Gillick competence is said to reflect a child’s increasing development to 

maturity. The understanding required for different interventions will vary considerably. A child 

under 16 may have the capacity to consent to some interventions but not to others. The 

child’s capacity to consent should be assessed carefully in relation to each decision that 

needs to be made. 



16.3 In some cases, for example because of a mental disorder, a child’s mental state may 

fluctuate significantly, so that on some occasions the child appears Gillick competent in 

respect of a particular decision and on other occasions does not. In cases such as these, 

careful consideration should be given as to whether the child is truly Gillick competent at the 

time that they need to take a relevant decision. 

16.4 If the child is Gillick competent and is able to give voluntary consent after receiving 

appropriate information, that consent will be valid and additional consent by a person with 

parental responsibility will not be required. It is, however, good practice to involve the child’s 

family in the decision-making process, if the child consents to their information being shared. 

16.5 Where advice or treatment relates to contraception, or the child’s sexual or reproductive 

health, the healthcare professional should try to persuade the child to inform his or her 

parent(s), or allow the medical professional to do so. If however the child cannot be 

persuaded, advice and/or treatment should still be given if the healthcare professional 

considers that the child is very likely to begin or continue to have sexual intercourse with or 

without advice or treatment, and that unless they receive the advice or treatment then the 

child’s physical or mental health is likely to suffer. 

16.6 If the child seeks advice or treatment in relation to abortion and cannot be persuaded to 

inform her parent(s), every effort should be made to help the child find another adult (such 

as another family member or a specialist youth worker) to provide support to the child. 

17.0 THE REQUIREMENT OF VOLUNTARINESS 

17.1 Although a child or young person may have the capacity to give consent, this is only valid if it 

is given voluntarily. This requirement must be considered carefully. Children and young 

people may be subject to undue influence by their parent(s), other carers or a sexual partner 

(current or potential), and it is important to establish that the decision is that of the individual 

him or herself. 

18.0 CHILD OR YOUNG PERSON WITH CAPACITY REFUSING TREATMENT 

18.1 Where a young person of 16 or 17 who could consent to treatment in accordance with the 

Family Law Reform Act 1969, or a child under 16 but Gillick competent, refuses treatment, it 

is possible that such a refusal could be overruled if it would in all probability lead to the death 

of the child/young person or to severe permanent injury. 

18.2 The courts have stated that they have jurisdiction to override a refusal of a child/young 

person, at least where they seek to refuse treatment in circumstances that will, in all 

probability, lead to the death of the child/young person or to severe permanent injury; or 

where there is a serious and imminent risk that the child/young person will suffer grave and 

irreversible mental or physical harm. 

18.3 The courts have, in the past, also found that parents can consent to their competent child 

being treated even where the child/young person is refusing treatment. However, as at 2012, 

there is no post-Human Rights Act 1998 authority for this proposition, and it would therefore 

be prudent to obtain a court declaration or decision if faced with a competent child or young 

person who is refusing to consent to treatment, to determine whether it is lawful to treat the 

child. 

18.4 Where the treatment involved is for mental disorder, consideration should be given to using 

mental health legislation. 



18.5 Section 131 of the Mental Health Act 1983 means that when a young person of 16 or 17 has 

capacity (as defined in the Mental Capacity Act 2005) and does not consent to admission for 

treatment for mental disorder (either because they are overwhelmed, do not want to consent 

or refuse to consent), they cannot then be admitted informally on the basis of the consent of 

a person with parental responsibility (see chapter 36 of the Code of Practice to the Mental 

Health Act 1983. 

18.6 A life-threatening emergency may arise when consultation with either a person with parental 

responsibility or the court is impossible, or the person with parental responsibility refuses 

consent despite such emergency treatment appearing to be in the best interests of the child. 

In such cases the courts have stated that doubt should be resolved in favour of the 

preservation of life, and it will be acceptable to undertake treatment to preserve life or 

prevent serious damage to health. 

19.0 CHILD LACKING CAPACITY 

19.1 Where a child under the age of 16 lacks capacity to consent (i.e. is not Gillick competent), 

consent can be given on their behalf by any one person with parental responsibility (if the 

matter is within the ‘zone of parental control’ or by the court. A decision is within the zone of 

parental control if it is a decision one would expect a parent to make, taking account of 

societal conventions and human rights law; and there is nothing to suggest that the parent 

may not be acting in the child’s or young person’s best interests. 

The greater the invasiveness or restrictiveness, the more likely to be outside the zone. 

The less confident a professional is that they can answer ‘yes’ to both questions, the more 

likely it will be that the decision in question falls outside the zone. 

The parameters of the zone will vary from case to case. The following factors can be 

considered: 

19.2 Are there no indications that the parent might not act in the best interests of the child or 

young person? 

The less confident a professional is that they can answer ‘yes’ to both questions, the more 

likely it will be that the decision in question falls outside the zone. 

The parameters of the zone will vary from case to case. The following factors can be 

considered: 

• The nature and invasiveness of what is to be done to the patient. The more extreme it is, 

the more likely it will be that it falls outside the zone. 

• Whether the patient is resisting. Treatment in these circumstances may require more 

justification. 

• The general social standards in force at the time. Anything which goes beyond the kind 

of decisions parents routinely make will be more suspect 

• The age, maturity and understanding of the child or young person. The greater these 

are, the more likely it is that the child/young person should take the decision. 

• The extent to which a parent’s interests may conflict with those of the child or young 

person. A conflict may suggest that the parent will not act in the child/young person’s 

best interests. 



19.3 As is the case where patients are giving consent for themselves, those giving consent on 

behalf of child patients must have the capacity to consent to the intervention in question, be 

acting voluntarily and be appropriately informed. The power to consent must be exercised 

according to the ‘welfare principle’: that the child’s ‘welfare’ or ‘best interests’ must be 

paramount. Even where a child lacks capacity to consent on their own behalf, it is good 

practice to involve the child as much as possible in the decision-making process. 

19.4 Where necessary, the courts can overrule a refusal by a person with parental responsibility. 

It is recommended that certain important decisions, such as sterilisation for contraceptive 

purposes, should be referred to the courts for guidance, even if those with parental 

responsibility consent to the operation going ahead. 

19.5 Failure to refer such cases to the court is not only a breach of professional guidance but also 

potentially a breach of the European Convention on Human Rights. In situations where there 

is continuing disagreement or conflict between those with parental responsibility and doctors, 

and where the child is not competent to provide consent, the court should be involved to 

clarify whether a proposed treatment, or withholding of treatment, is in the child’s best 

interests. Parental refusal can only be overridden in an emergency. 

19.6 The Children Act 1989 sets out persons who may have parental responsibility. These 

include: 

• the child’s mother 

• the child’s father, if he was married to the mother at the time of birth 

• unmarried fathers, who can acquire parental responsibility in several different ways: 

For children born before 1 December 2003, unmarried fathers will have parental 

responsibility if they: marry the mother of their child or obtain a parental responsibility order 

from the court 

register a parental responsibility agreement with the court or by an application to court 

For children born after 1 December 2003, unmarried fathers will have parental responsibility 

if they: register the child’s birth jointly with the mother at the time of birth re-register the birth 

if they are the natural father marry the mother of their child or obtain a parental responsibility 

order 

from the court register with the court for parental responsibility 

• the child’s legally appointed guardian 

• a person in whose favour the court has made a residence order concerning the child 

• a local authority designated in a care order in respect of the child 

• a local authority or other authorised person who holds an emergency protection order in 

respect of the child. 

19.7 Section 2(9) of the Children Act 1989 states that a person who has parental responsibility for 

a child ‘may arrange for some or all of it to be met by one or more persons acting on his or 

her behalf’. Such a person might choose to do this, for example, if a childminder or the staff 

of a boarding school have regular care of their child. As only a person exercising parental 

responsibility can give valid consent, in the event of any doubt then specific enquiry should 

be made. Foster parents do not automatically have parental responsibility. 

19.8 Consent given by one person with parental responsibility is valid, even if another person with 

parental responsibility withholds consent. However, the courts have stated that a ‘small 

group of important decisions’ should not be taken by one person with parental responsibility 

against the wishes of another, citing in particular non-therapeutic male circumcision and 

immunisation. 




Where persons with parental responsibility disagree as to whether these procedures are in 

the child’s best interests, it is advisable to refer the decision to the courts. It is possible that 

major experimental treatment, where opinion is divided as to the benefits it may bring the 

child, might also fall into this category of important decisions, although such a case has not 

yet been considered in the English courts. 

19.9 Where there is doubt about whether a parent is acting in the interest of the child or young 

person, then the healthcare practitioner would be unwise to rely on the parent’s consent, for 

example if a child alleges abuse and the parent supports psychiatric treatment for the child. 

The Government’s guidance Working Together to Safeguard Children covers situations 

involving parental consent where abuse or neglect is suspected. 

19.10 In order to consent on behalf of a child, the person with parental responsibility must 

themselves have capacity. Where the person with parental responsibility for a child are 

themselves under 18, they will only be able to give valid consent for the child’s treatment if 

they themselves are Gillick competent (see paragraphs 6–11 above). Whether or not they 

have capacity may vary, depending on the seriousness of the decision to be taken. 

19.11 There are situations where refusal or withdrawal of prescribed medical and therapeutic 

treatment for children (0 – 18 years) may constitute neglect, and it is important for staff to be 

aware of the following: 

Where parents, the child or others refuse, withdraw or actively withhold commonly available 

food or fluids, or fail to co-operate with prescribed medical or therapeutic treatment such that 

a child suffers, or is likely to suffer significant harm or in extreme circumstances, may die, 

this is neglect. A referral should be make immediately to LSA Children’s Social Car under 

the local Safeguarding Board Child Protection procedures. 

Attempts to justify the above neglect on some basis may be misguided believed to be in the 

child’s best interest, such as: 

• The religion of the child / parent / carer 

• Cultural expectations 

• Disability of the child including learning disability 

19.12 Such reason or conviction may be advanced by a parent the child or a practitioner, including 

a medical practitioner or any combination of these. 

Such information and reasons however, do not change the legal duties of the Local 

Safeguarding Children’s Board agencies to safeguard the child’s best interest; this may 

result in LA Children’s Social Care taking legal advice. 

19.13 Where a child is a ward of court, no important step may be taken in the life of the child 

without the prior consent of the court. This is likely to include more significant medical 

interventions but not treatment for minor injuries or common diseases of childhood. 

19.14 In an emergency, it is justifiable to treat a child who lacks capacity without the consent of a 

person with parental responsibility, if it is impossible to obtain consent in time and if the 

treatment is vital to the survival or health of the child. 

20.0 PROVISION OF INFORMATION 

20.1 The provision of information is central to the consent process. Before patients can come to a 

decision about treatment, they need comprehensible information about their condition and 

about possible treatments/investigations and their risks and benefits (including the 

risks/benefits of doing nothing). Drawings, diagrams and models may be used to facilitate 

this process where appropriate.


Patients also need to know the scope of the intended treatment and whether additional 

procedures are likely to be necessary as part of the procedure, for example a blood 

transfusion, or the removal of particular tissue. Once a decision to have a particular 

treatment/investigation has been made, patients need information about what will happen: 

where to go, how long they will be in hospital, how they will feel afterwards and so on. 

20.2 Patients and those close to them will vary in how much information they want: from those 

who want as much detail as possible, including details of rare risks, to those who ask health 

professionals to make decisions for them. The patient must always be encouraged to make 

the decision for him or herself although there will always be an element of clinical judgement 

in determining what information should be given. 

20.3 However, the presumption must be that the patient wishes to be well informed about the 

risks and benefits of the various options. Staff will make a written entry in the patient’s 

healthcare record when the information is provided, what information is provided and any 

discussions related to this including the risks, benefits and alternatives. Where the patient 

makes clear (verbally or non-verbally) that they do not wish to be given this level of 

information, this should be clearly documented within the patient’s healthcare record. 

20.4 The following sources of patient information are available in this Trust: 

The Trust provides a range of information leaflets on specific treatments, for example drug 

treatments, Electro-Convulsive Therapy (ECT), acupuncture, auricular acupuncture and 

dental treatment and podiatry 

20.5 It is important that information is provided in a form which is easy to understand. The 

necessary arrangements should be made for the patient to have access to an independent 

source to help them consider their options. This could, for example, be in the form of an 

advocacy service. 

20.6 This Trust is committed to ensuring that patients whose first language is not English receive 

the information they need and are able to communicate appropriately with healthcare staff. 

In order to safeguard the consent process, unless the health professional is fluent in the 

patient’s language, an interpreter should always be used when seeking consent from the 

patient. It is not appropriate to use children to interpret for family members who do not 

speak English. 

20.7 Details of Trust-wide access to interpreters is available on the Trust Intranet site. 

20.8 Consideration should be given to other communication barriers which could be assisted with 

specialist services and/ or equipment (i.e. signing, speech & language therapists). 

20.9 Patients may sometimes request more detailed information about their condition or about a 

proposed treatment than can be provided in general leaflets. This should always be provided 

whenever practicable by the appropriate practitioner. 

20.10 After an appointment with a health professional in primary care or in out-patients, patients 

will often think of further questions which they would like answered before they take their 

decision. Where possible, it will be much quicker and easier for the patient to contact the 

healthcare team by phone than to make another appointment or to wait until the date of an 

elective procedure. 

20.11 Where patients access clinics directly, it should not be assumed that their presence at the 

clinic implies consent to particular treatment. You should ensure that they have the 

information they need before proceeding with an investigation or treatment. 

20.12 Archiving arrangements for any information given to patients to support their decision 

making. (Please refer to Policy 4.02 Development of Service User and Carer Information). 



21.0 COMPLETING CONSENT FORMS 

21.1 The standard consent form provides space for a health professional to provide information to 

patients and to sign confirming that they have done so. The health professional providing the 

information must be competent to do so: either because they themselves carry out the 

procedure, or because they have received specialist training in advising patients about this 

procedure, have been assessed, are aware of their own knowledge limitations and are 

subject to audit. Inappropriate delegation (e.g. where the health care professional seeking 

consent has inadequate knowledge of the procedure) may mean that the consent is not 

valid. 

21.2 If the patient signs the form in advance of the procedure (for example in out-patients or at a 

pre-assessment clinic), a health professional involved in their care on the day should sign 

the form to confirm that the patient still wishes to go ahead and has had any further 

questions answered. It will be appropriate for any member of the healthcare team (for 

example a nurse admitting the patient for an elective procedure) to provide the second 

signature, as long as they have access to appropriate colleagues to answer questions they 

cannot handle themselves. 

22.0 RESPONSIBILITIES FOR SEEKING CONSENT 

22.1 The health professional carrying out the procedure is ultimately responsible for ensuring that 

the patient is genuinely consenting to what is being done: it is they who will be held 

responsible in law if this is challenged later. 

22.2 Where oral or non-verbal consent is being sought at the point the procedure will be carried 

out, this will naturally be done by the health professional responsible. However, team work is 

a crucial part of the way the NHS operates, and where written consent is being sought it may 

be appropriate for other members of the team to participate in the process of seeking 

consent. 

22.3 It is a health professional’s own responsibility: 

• to ensure that when they require colleagues to seek consent on their behalf they are 

confident that the colleague is competent to do so; and 

• to work within their own competence, and not to agree to perform tasks that exceed that 

competence. 

• If you feel that you are being pressurised to seek consent when you do not feel 

competent to do so this should be addressed through line management. 

23.0 ATTENDANCE BY STUDENTS AND TRAINEES 

23.1 Where a student or trainee health professional is undertaking examination or treatment of 

the patient where the procedure will further the patient’s care – for example taking a blood 

sample for testing – then, assuming the student is appropriately trained in the procedure, the 

fact that it is carried out by a student does not alter the nature and purpose of the procedure. 

It is therefore not a legal requirement to tell the patient that the health professional is a 

student, although it would always be good practice to do so and consent in the usual way will 

still be required. 

23.2 In contrast, where a student proposes to conduct a physical examination which is not part of 

the patient’s care, then it is essential to explain that the purpose of the examination is to 

further the student’s training and to seek consent for that to take place. Again, consent 

should be recorded in the patient's notes. 



23.3 A patient's explicit consent should be obtained prior to any occasion when a student or 

trainee is going to be present during an examination or when treatment is to be given. 

Patients have the right to refuse consent in these circumstances without any detrimental 

effect on their treatment. Written consent must be obtained if students or trainees are going 

to be present during examination or treatment using sedation or anaesthetic. 

24.0 REFUSAL OF TREATMENT 

24.1 If the process of seeking consent is to be a meaningful one, refusal must be one of the 

patient’s options. An adult patient who has capacity can refuse any treatment, except in 

circumstances governed by the Mental Health Act 1983. The following paragraphs apply 

primarily to adults. In determining whether a patient has capacity to make this decision the 

test for capacity from the Mental Capacity Act 2005 (see section 7.2 above) must be applied. 

24.2 An adult with capacity may make a decision which is based on their religious belief (e.g. 

Jehovah’s Witnesses) or value system. Even if it is perceived by others that the decision is 

unwise or irrational, the patient may still make that decision if he or she has capacity to do 

so. 

24.3 If, after discussion of possible treatment options, a patient with capacity refuses all 

treatment, this fact should be clearly documented in their notes. If the patient has already 

signed a consent form, but then changes their mind, the health professional (and where 

possible the patient) should note this on the form. 

24.4 Where a patient has refused a particular intervention, the health professional must ensure 

that they continue to provide any other appropriate care to which they have consented. They 

should also ensure that the patient realises they are free to change their mind and accept 

treatment if they later wish to do so. Where delay may affect their treatment choices, they 

should be advised accordingly. 

24.5 If a patient consents to a particular procedure but refuses certain aspects of the intervention, 

the health professional must explain to the patient the possible consequences of their partial 

refusal. If the health professional genuinely believes that the procedure cannot be safely 

carried out under the patient’s stipulated conditions, he or she is not obliged to perform it. 

They must, however, continue to provide any other appropriate care. Where another health 

professional believes that the treatment can be safely carried out under the conditions 

specified by the patient, he or she must on request be prepared to transfer the patient’s care 

to that health professional. 

25.0 ADVANCE DECISIONS TO REFUSE TREATMENT 

25.1 For a full analysis on Advance Decisions please see the Trust’s Policy Advance Care 

Planning to Include Advance Decisions to Refuse Treatment, Statements of Wishes and 

Feelings and Lasting Powers of Attorney ( 8.11 ). An Advance Decision enables someone 

aged 18 and over, while still capable, to refuse specified medical treatment for a time in the 

future when they may lack the capacity to consent to or refuse that treatment. An Advance 

Decision enables individuals to refuse medical treatment. It does not enable individuals to 

demand treatment. 

25.2 An Advance Decision to refuse treatment must be valid and applicable to current 

circumstances. If it is, it has the same effect as a decision that is made by a person with 

capacity: It is binding on healthcare professionals who must follow the decision. 

25.3 An Advance Decision need not be in writing unless it refers to the refusal of life sustaining 

treatment. It must however be stated as clearly and unambiguously as possible in order to 

avoid misinterpretation, and therefore it would be better if it were in writing. It can be 

expressed in either medical terms or layman’s language. A clinician who is present when a 

patient makes a verbal Advance Decision should: 




• Make careful notes of the treatment to be refused & circumstances in which it applies. 

• Note who was present and their role. 

• Inform the lead clinician. 

• Encourage the person to put their decision in writing. 

(Mental Capacity Act Code of Practice 9.23). 

25.4 Refusal of life sustaining treatment 

If the Advance Decision refers to refusal of life sustaining treatment, it must be: 

1) In writing and signed in presence of witness. 

2) Witnessed & signed in presence of the person making the decision. 

3) Inclusive of a separate statement that the decision stands even if the person’s life is 

at risk. 

(Mental Capacity Act Code of Practice 9.24) 

25.5 Healthcare professional’s liability 

Health Care Professionals will be protected from liability if they: 

• Stop or withhold treatment because they reasonably believe that an Advance Decision 

exists, and that it is valid and applicable. 

• Treat a person because, having taken all practical and appropriate steps to find out if the 

person has made an Advance Decision to refuse treatment, they do not know or are not 

satisfied that a valid and applicable Advance Decision exists. 

25.6 In some cases, an application may be made to The Court of Protection for a decision where 

there is doubt or disagreement about a decision and validity/applicability. While the court 

decides, professionals can provide life sustaining treatment to stop deterioration in the 

person’s condition (Mental Capacity Act Code of Practice 9.69). 

25.7 Advance Decisions and the Mental Health Act 1983 

25.7.1 Non Detained patients: 

A person over 18 with capacity is entitled to make an Advance Decision which 

refuses treatment which may include treatment for a mental disorder. While a person 

is an informal patient, the decision, if valid & applicable, will be binding. 

25.7.2 Detained Patients: 

An Advance Decision that refers to refusal of treatment for a mental disorder may be 

overridden if the person is liable to be detained under the Mental Health Act 1983. 

Part 4 of the Mental Health Act enables the Responsible Clinician to treat a person 

for a mental disorder notwithstanding any prior Advance Decision that refuses that 

treatment. 

25.8 Electroconvulsive Therapy 

25.9 

• Electroconvulsive Therapy cannot be administered to a patient who lacks capacity unless 

a Second Opinion Appointed Doctor has certified that the treatment does not conflict with 

an Advance Decision that the Second Opinion Appointed Doctor (SOAD) is satisfied it is 

valid and applicable (s58A). The exception to this is emergency treatment under s62. 

This emergency treatment may only be given to either save the life of the patient, or 

prevent a serious deterioration in the patient’s condition (Mental Health Act s62).


25.9 Supervised Community Treatment 

• Supervised Community Treatment patients may not be given treatment if it conflicts with 

a valid and applicable Advance Decision (other than emergency treatment under Mental 

Health Act s 64G). 

26.0 ADVANCE STATEMENTS 

26.1 Advance statements are not binding on the health professionals but are indicative of the 

patient’s wishes and should not be ignored. If a patient has specified in an advance 

statement that they want a particular treatment, their wishes will be relevant in so far as it 

indicates the patient’s preferences, but the health professional is not bound to provide that 

treatment and may act in accordance with his or her clinical judgement. Advance statements 

will be very relevant in assessing best interests of the person. 

26.2 More details of advance decisions and statements is outlined in the Trust’s policy, Advance 

Care Planning to include Advance Decisions to Refuse Treatment, Statements of Wishes 

and Feelings and Lasting Powers of Attorney and the Mental Capacity Act 2005 Code of 

Practice 

27.0 TISSUE 

27.1 The removal, storage and use of human tissue is now regulated by the Human Tissue Act 

2004. Where human tissue which is defined as material which has come from a human body 

and consists of, or includes, human cells (but does not include cell lines or hair and nails 

from living people) is removed, the Act provides that certain specified activities (including 

research) as set out in Schedule 1 require the consent of the patient. Consent must be given 

by an appropriate person and penalties of up to three years imprisonment or a fine, or both, 

can be imposed for failure to obtain or misuse of consent. Live gametes and embryos are 

excluded as they are regulated under the Human Fertilisation and Embryology Act 1990. 

27.2 When dealing with tissue samples health professionals should be familiar with the Codes of 

Practice and guidance issued by the Human Tissue Authority. These are available on their 

website at www.hta.gov.uk. 

28.0 CLINICAL PHOTOGRAPHY AND CONVENTIONAL OR DIGITAL VIDEO RECORDINGS 

28.1 Video recordings of treatment may be used both as a medical record or treatment aid in 

themselves, and as a tool for teaching, audit or research. The purpose and possible future 

use of the video must be clearly explained to the person, before their consent is sought for 

the recording to be made. If the video is to be used for teaching, audit or research, patients 

must be aware that they can refuse without their care being compromised and that when 

required or appropriate the video can be anonymised. As a matter of good practice, the 

same principles should be applied to clinical photography. If patients do not have capacity to 

consent they cannot be used for teaching or research purposes, the Mental Capacity Act 

2005 has clear boundaries and guidance in this area. 

28.2 Occasionally, video recordings, clinical photography and/or radiographs may be required 

following injuries sustained as the result of an accident or an assault. Health professionals 

should be satisfied that the patient has been given sufficient information for valid consent, 

making it clear that the recording could be used during legal proceedings, as part of a 

medical record, or possibly as a tool for teaching, audit or research. The need to obtain 

consent applies equally if the patient has requested the recording, photograph or radiograph. 



28.3 The General Medical Council guidance (Making and Using Visual and Audio Records of 

Patients 2002) gives detailed advice in the use of recordings when treating or assessing 

patients. Further information can also be found in the Information Commissioners “Use and 

Disclosure of Health Data: Guidance on the Application of the Data Protection Act 1998” 

May 2002. See also Policy 7.06 Clinical Records Management. 

29.0 CONSENT AND THE MENTAL HEALTH ACT 1983 

29.1 As a provider of healthcare services it is crucial that all best practice guidelines and legal 

requirements in the services it provides. Consent should be sought for each aspect of the 

person’s treatment, as and when it arises. It is important to establish whether the person is 

able to consent to a particular treatment and whether they do consent to that treatment. 

29.2 The sections contained in Part IV of the Mental Health Act 1983 are concerned with the 

treatment of patients suffering from mental disorder. All persons involved with this process 

should be familiar with the following publications: 

• Mental Health Act 1983 (as amended 2007) (MHA) 

• Code of Practice to the MHA 1983 (2008) (CoP) 

• Reference Guide to the Mental Health Act 1983 (2008) 

29.3 It is the Approved Clinician (AC) who must ensure that there is compliance with the MHA 

provisions relating to medical treatment. This policy must be used in conjunction with the 

Mental Health Act Code of Practice. 

30.0 CAPACITY AND THE MENTAL HEALTH ACT 1983 

30.1 Capacity to consent continues to be applicable for those patients subject to the Mental 

Health Act. The Responsible Clinician should make an assessment of capacity to consent to 

the proposed treatment at the earliest opportunity; this should be recorded in the medical 

notes. 

30.2 Capacity should be re assessed ‘as appropriate’ and a clear record made each time there is 

requirement to complete a form T2 in compliance with Section 58. To assist with audit and 

scrutiny it is helpful to give the entry an underlined heading within the medical record. 

31.0 TREATMENT AND THE MENTAL HEALTH ACT 1983 

31.1 Part 4 of the Mental Health Act applies to all forms of medical treatment for mental disorder. 

However, certain types of treatment are subject to special rules set out in sections 57, 58, 

and 58A described below. 

31.2 Section 57 - Treatments requiring a patient's consent and a second opinion: 

• This section applies to both detained and informal patients. 

• It stipulates that no patient may be subject to psychosurgery or the implantation of 

female hormones into a man for the purpose of reducing sexual drive without the 

patient’s express consent and the opinions of two other people who have been 

professionally concerned with the patient’s medical treatment. 

• The second opinion is to be provided by a doctor appointed by the Care Quality 

Commission. 

• Treatments given under this section require careful consideration because of the ethical 

issues and possible long-term effects. 



• Advice should be sought from the Mental Health Act Department of the Trust if this 

section is being relied upon, as procedures for implementing this section must be agreed 

between the Care Quality Commission and the Trust. 

31.3 Section 58 – Treatments requiring the patient’s consent or a second opinion: 

• This section applies to all patients liable to be detained except for those detained under 

sections 4, 5(2) or 5(4), 35, 135, 136, 37(4),45A(5); conditionally discharged restricted 

patients, and SCT patients not recalled to hospital. 

• It covers the administration of medication for mental disorder (unless included in section 

57 or 58A treatment) if three months or more have elapsed since medication for mental 

disorder was first given to the patient during an unbroken period of compulsion 

(“medication after three months”). 

• If the above criteria apply then the RC must personally seek the consent of the patient in 

order to continue with the proposed treatment. 

• The patient must have the capacity to make the decision. 

31.4 Section 58A – Treatments requiring consent and / or a second opinion: 

• Electro-convulsive therapy (ECT) and any other treatment provided for in regulations 

made under this section may only be given to the patient if the patient either consents to 

the treatment, or if he or she is incapable of giving such consent. 

• It applies to patients aged 18 and over who are detained, asides from those who are the 

subject of Community Treatment Orders. It does not apply to a community patient if 

there is authority to give treatment and the section 62A certificate requirement is met. A 

patients consent to ECT must be certified by either the approved clinician or the SOAD. 

• It applies to all patients who are under the age of 18. The patients consent but be 

certified by a SOAD. 

• For patients who lack capacity, the SOAD must certify that the patient is not capable of 

understanding the nature, purpose and likely effects of the treatment. They must then 

certify that it is appropriate for the treatment to be given. 

• Before certificates are issued for any patient, the SOAD must consult with two people 

who have been professionally concerned with the patient’s medical treatment as follows: 

• A nurse; and 

• Someone who is neither a nurse nor a doctor nor the patient’s Responsible Clinician 

or Approved Clinician. 

• A SOAD should not sign a certificate/it will not be valid where there is: 

• A valid and applicable Advance Decision prohibiting the treatment; 

• A court order 

• A decision from the donee of a Lasting Power of Attorney or a Court Appointed 

Deputy who has authority to refuse treatment. 

• In accordance with the Mental Capacity Act 2005 

• Further guidance regarding ECT and its legal provisions can be found in the Mental 

Health Act 1983 Code of Practice specifically Chapters 24 and 36. 

31.5 Part 4A – applies to SCT patients not recalled to hospital. The rules differ depending on 

whether they have the capacity to consent to the treatment in question. 



Part 4A patients who have capacity to consent to a treatment may not be given that 

treatment unless they consent. There are no exceptions even in an emergency. The effect 

is that treatment can be given without their consent only if they are recalled to hospital. 

Part 4A patients who lack capacity to consent to a treatment may be given it if their 

Attorney or Deputy or the Court of Protection consents to such treatment. They may also be 

given it without anyone’s consent by or under the direction of the Approved Clinician in 

charge of the treatment unless: 

• The treatment would be contrary to a valid and applicable Advance decision (if the 

patient is over 18). 

• The treatment would be against the decision of someone with authority under the MCA 

2005 to refuse it on the patient’s behalf (if the patient is over 16). 

• Force needs to be used to administer the treatment and the patient objects to the 

treatment. Force means the actual use of physical force on the patient. The question to 

be asked is simply whether the patient objects. All relevant evidence should be taken 

into account, so far as reasonably can be. If there is reason to think that a patient would 

object if able to do so then the patient should be taken to be objecting. 

• Medical treatment for mental disorder may not be given (by anyone in any 

circumstances) to SCT patients who have not been recalled to hospital unless the 

requirements of Part 4A are met 

• Part 4A requires a certificate from a SOAD for: 

o Treatment which would require a certificate under section 58 if the patient were 

detained. 

• ECT and any other types of treatment to which section 58A applies. 

• A certificate is not required for a section 58 type treatment during the first month 

following a patient’s discharge from detention onto SCT (even if the 3 month period in 

section 58 has already expired or expires during that first month). 

• When giving Part 4A certificates SOADs do not have to certify whether a patient has or 

lacks capacity to consent not whether a patient with capacity is consenting or refusing. 

However they may make it a condition of their approval that particular treatments are 

given only in certain circumstances. For example, they might specify that a particular 

treatment is to be given only with the patient’s consent. 

• In an emergency, treatment can be given to Part 4A patients who lack capacity (and who 

have not been recalled) by anyone whether or not they are acting under the direction of 

an Approved Clinician. It is an emergency only if treatment is immediately necessary to: 

• Save the patient’s life; 

• Prevent a serious deterioration of the patient’s condition and the treatment does not 

have unfavorable physical or psychological consequence which cannot be reversed; 

• Alleviate serious suffering by the patient and the treatment does not have 

unfavorable physical or psychological consequences which cannot be reversed and 

does not entail significant physical hazard; 

• Prevent the patient behaving violently or being a danger to themselves or others and 

the treatment represents the minimum interference necessary for that purpose, does 

not have unfavorable physical or psychological consequences which cannot be 

reversed and does not entail significant physical hazard. 




• If the treatment is ECT, (or medication administered as a part of ECT) only the first 2 

categories apply. 

• In addition force may be used (whether or not the patient objects) provided that: 

• The treatment is necessary to prevent harm to the patient. 

• The force used is proportionate to the likelihood of the patient suffering harm and to 

the seriousness of that harm. 

• SCT patients recalled to hospital are subject to sections 58 and 58A in the same way as 

other detained patients. There are 3 exceptions: 

• A certificate under section 58 is not needed for medication if less than one month has 

passed since the patient was discharged from hospital and became an SCT patient. 

• A certificate is not needed under either section 58 or 58A if the treatment in question 

is already explicitly authorized on recall on the patient’s Part 4A certificate. 

• Treatment that was already being given on the basis of a Part 4A certificate may be 

continued even though it is not authorized for administration on recall if the AC in 

charge of the treatment considers that discontinuing it would cause the patient 

serious suffering. But it may only be continued pending compliance with section 58 

or 58A, i.e. whilst steps are being taken to obtain a new certificate. 

31.6 Section 63 - Treatments that do not require the patient’s consent are all medical treatments 

for mental disorder given by or under the direction of the patient’s RC and which are not 

referred to in sections 57, 58 and 58A. This is a wide definition and includes nursing, care, 

habilitation, and rehabilitation given under medical direction. It is however good practice to 

try and gain the patient’s consent to care in these categories. Examples of the application of 

this section include: Feeding by Nasogastric tube of an anorexic or PD patient and 

monitoring the bloods of patient’s prescribed Clozapine. 

31.7 Section 62 - Sections 57 and 58 do not apply if the treatment in question is: 

• immediately necessary to save the patient’s life; 

• a treatment which is not irreversible, but which is immediately necessary to prevent a 

serious deterioration of the patient’s condition; 

• a treatment which is not irreversible or hazardous, but which is immediately necessary to 

alleviate serious suffering by the patient; or 

• a treatment which is not irreversible or hazardous, but which is immediately necessary to 

prevent the patient from behaving violently or being a danger to himself or to others, and 

represents the minimum interference necessary to do so. 

31.8 Section 58A does not apply to ECT if ECT falls with the first two categories above. 

Regulations about other section 58A treatments can say which of the categories of 

immediate necessity above apply in each case. 

32.0 THE MENTAL HEALTH ACT 1983 THREE-MONTH RULE 

32.1 The three month rule legally authorises a doctor to prescribe and a nurse to administer 

medication for mental disorder to patients detained under the Mental Health Act 1983 if they 

refuse or are incapable of giving valid consent. The three month period commences with the 

date of the first dose of medication during any continuous period of detention, even if the 

medication has been changed or is not given continuously. This includes any medication



given under Section 2. During this period it remains good practice to try and gain the 

patient’s consent to treatment. 

32.2 Following the three month period, medicines for the treatment of mental disorder can be 

given to the patient either with the patient's consent as recorded by the patient's RC on Form 

T2 or, in the absence of the patient's consent, only if authorised under a Form T3 completed 

by a SOAD. It is the responsibility of the Responsible Clinician to contact the Care Quality 

Commission to gain the second opinion; this task will be undertaken by the Mental Health 

Act Department if requested by the Responsible Clinician. 

33.0 TRAINING 

33.1 Training on obtaining consent will be an integral part of the Trust’s Mental Capacity Act and 

Mental Health Act training. Scenarios will be used as part of this package to ensure staff 

understand the issues involved. Specific training must be given to members of staff 

undertaking this delegated task even if they are not authorised to carry out the procedure 

themselves. 

33.2 Managers will be responsible for identifying staff that need to obtain consent from patients 

who are not authorised to carry out the procedures for which consent is being sought . 

Directorates will undertake an annual training needs analysis within their area of 

responsibility to identify which staff require training and at what level. Reference can be 

made to the specific grids through General Managers/ Heads of Service. 

34.0 IMPLEMENTATION 

34.1 General Managers and Clinical Directors are responsible for ensuring that Consultant 

Psychiatrists, the Consultant in Palliative Care and Ward Managers are aware of the 

expectations of these principles that they understand the implications of their practice and 

that of their staff and for ensuring that all subordinate staff are aware of these principles 

35.0 EQUALITY IMPACT ASSESSMENT 

35.1 This policy has been assessed using the Equality Impact Assessment Screening Tool. The 

assessment concluded that the policy would have no adverse impact on, or result in the 

positive discrimination of, any other diverse groups detained. These include the strands of 

disability, ethnicity, gender, identify, age, sexual orientation, religion / belief, social inclusion 

and community cohesion. 

36.0. CONSULTATION 

36.1 Executive Leadership Council. 

37.0 MONITORING COMPLIANCE 

37.1 This policy will be audited annually by Health Partnerships, Local and Forensic Services 

Divisions using a ratified audit tool, this will include: 

37.2 Evidence of the discussions that have taken place within individual patients and the 

information provided as part of obtaining consent. 

37..3 How the discussion and provision of information is recorded. 

37..4 Evidence relating to the process for recording that consent has been given. 

37..5 The process for ensuring that sufficient numbers of staff are trained to obtain consent even if 

they are not authorised to conduct the procedure.



37..6 Evidence of the provision for procedure specific training and consent for clinical staff 

regardless of whether or not they are authorised to perform the procedure but are authorised 

to obtain consent for that procedure. 

37..7 Review of any incidents in which consent has been obtained by a member of staff not 

authorised to carry this out, confirming that processes have been followed, including 

notification to the GMC via the approved form. 

37..8 The findings of the audit will be considered by the Patient Safety Group and also within 

Health Partnerships, Local and Forensic Services Divisions that action plans are developed 

and implemented as necessary by individual Directorates. Ongoing monitoring will be 

undertaken by Local Governance Groups who will confirm that all agreed actions have been 

completed 

37..9 The Learning and Development Department will provide annual data showing staff who have 

attended generic training sessions throughout the year. This must include records of all staff 

identified to obtain consent, the training they have received relating to this, confirmation of 

their competence to obtain consent and evidence of periodic reaffirmation of this. 

38.0 TARGET AUDIENCE 

38.1 All clinical staff. 

39.0 CHAMPION AND EXPERT WRITERS 

39.1 The Champion of this policy is Dr Peter Miller, Executive Director: Clinical Governance and 

Medical Affairs. The Expert Writers are Jane Craig, Trust Risk Manager, Kieran Colton, 

Head of Governance, Community Services Division and Michael Sergeant, Mental Health 

Act/Mental Capacity Act Lead, (Local Services). 

40.0 REVIEW DATE 

40.1 The review of this policy will be undertaken in August 2015. 

41.0 LEGISLATION COMPLIANCE 

41.1 The Mental Capacity Act 2005 

41.2 Mental Health Act 1983 (as amended) 

41.3 The Mental Capacity Act 2005 Code of Practice 

41.4 Mental Health Act 1983 Code of Practice 

41.5 Mental Capacity Act Depravation Of Liberty Safeguards Code Of Practice 2008 

42.0 SOURCE DOCUMENTS 

42.1 The Mental Capacity Act 2005 

42.2 Mental Health Act 1983 (as amended) 

42.3 The Mental Capacity Act 2005 Code of Practice 

42.4 Mental Health Act 1983 Code of Practice 

42.5 Mental Capacity Act Deprivation Of Liberty Safeguards Code Of Practice 2008


42.6 Reference Guide to Consent for Examination or Treatment Second Edition DH October 2009 

42.7 Consent: Patients and Doctors Making Decisions Together General Medical Council June 

2008 

42.8 The Legal Aspects of the Care and Treatment of Children and Young People with Mental 

Disorder: A Guide for Professionals, National Institute for Mental Health in England, January 

2009 

42.9 NHSLA Risk Management Standards 2012 / 13 

42.10 Essential Standards of Quality and Safety. Outcome 2 – Consent to Care and Treatment 

Care Quality Commission March 2010. 



APPENDIX 1 

CONSENT FORM 1 

Patient agreement to investigation 

or treatment 

Patient details (or pre-printed label) 

Patient’s surname/family name..…………………………. 

Patient’s first names .………………………………………. 

Date of birth …………………………………………………. 

Responsible health professional.…………………………… 

Job title ………………………………………………………. 

NHS number (or other identifier)…………………………….. 

Male 

Female 

Special requirements ……………………………………… 

(eg other language/other communication method) 

To be retained in patient’s notes 



Patient identifier/label 

Name of proposed procedure or course of treatment (include brief explanation if medical term 

not clear) …………………………………………………. 

…………………………………………………………………………………………………………………… 

……………………………………………………………… 

Statement of health professional (to be filled in by health professional with appropriate knowledge 

of proposed procedure, as specified in consent policy) 

I have explained the procedure to the patient. In particular, I have explained: 

The intended benefits ……………………………………………………………..……….……… 

…………………………………………………………………………………………………………………… 

…………………………………………………..…………………………..……………… 

Significant, unavoidable or frequently occurring risks 

……………………………………………...………………...………………………………………………… 

……………………………………….…………… 

………………………………….………………………………………………..……………………. 

Any extra procedures which may become necessary during the procedure 

blood transfusion…………………………………..…….………………………………………. 

other procedure (please specify) ………………………………...……...…………….…..……. 

…………………………………………………………………………...………………….…..……. 

I have also discussed what the procedure is likely to involve, the benefits and risks of any available 

alternative treatments (including no treatment) and any particular concerns of this patient. 

The following leaflet/tape has been provided ……………….…………………………..… 

This procedure will involve: 

general and/or regional anaesthesia local anaesthesia sedation 

Signed:…….…………………………………… 

Name (PRINT) ………………………. ……… 

Date .. …………………….………. 

Job title …….. ………………….… 

Contact details (if patient wishes to discuss options later) …..……………….…………… 

Statement of interpreter (where appropriate) 

I have interpreted the information above to the patient to the best of my ability and in a way in which 

I believe s/he can understand. 

Signed ………………………….……………………. Date ………………..……………. 

Name (PRINT) …………………..……………………………………………………………… 

Statement of patient 

Top copy accepted by patient: yes/no (please ring) 


Please read this form carefully. If your treatment has been planned in advance, you should already 

have your own copy of page 2 which describes the benefits and risks of the proposed treatment. If 

not, you will be offered a copy now. If you have any further questions, do ask – we are here to help 

you. You have the right to change your mind at any time, including after you have signed this form. 


I agree to the procedure or course of treatment described on this form. 


I understand that you cannot give me a guarantee that a particular person will perform the 

procedure. The person will, however, have appropriate experience. 

I understand that I will have the opportunity to discuss the details of anaesthesia with an 

anaesthetist before the procedure, unless the urgency of my situation prevents this. (This 

only applies to patients having general or regional anaesthesia.) 

I understand that any procedure in addition to those described on this form will only be carried out 

if it is necessary to save my life or to prevent serious harm to my health. 

I have been told about additional procedures which may become necessary during my treatment. I 

have listed below any procedures which I do not wish to be carried out without further discussion. 

………………………………………………………………………… 

…………………………………………………………………………………………………………………… 

…………………………………………………………………………………………………………………… 

………………………………………………………………………………….. 

Patient’s signature ………………………………………….. Date………………………….. 

Name (PRINT) ……………………………………………………………………………………… 

A witness should sign below if the patient is unable to sign but has indicated his or her consent. 

Young people/children may also like a parent to sign here (see notes). 

Signature …………………………………………… Date ……………………..….……… 

Name (PRINT) ………………………………………………………………………………….… 

Confirmation of consent (to be completed by a health professional when the patient is admitted 

for the procedure, if the patient has signed the form in advance) 

On behalf of the team treating the patient, I have confirmed with the patient that s/he has no further 

questions and wishes the procedure to go ahead. 

Signed:…….…………………………………… 

Name (PRINT) ………………………. ……… 

Date .. …………………….………. 

Job title …….. ………………….… 

Important notes: (tick if applicable) 

See also advance directive/living will (eg Jehovah’s Witness form) 

Patient has withdrawn consent (ask patient to sign /date here) ……………...………. 



Guidance to health professionals (to be read in conjunction with consent policy) 

What a consent form is for 

This form documents the patient’s agreement to go ahead with the investigation or treatment you 

have proposed. It is not a legal waiver – if patients, for example, do not receive enough information 

on which to base their decision, then the consent may not be valid, even though the form has been 

signed. Patients are also entitled to change their mind after signing the form, if they retain capacity 

to do so. The form should act as an aide-memoire to health professionals and patients, by providing 

a check-list of the kind of information patients should be offered, and by enabling the patient to have 

a written record of the main points discussed. In no way, however, should the written information 

provided for the patient be regarded as a substitute for face-to-face discussions with the patient. 

The law on consent 

See the Department of Health’s Reference guide to consent for examination or treatment for a 

comprehensive summary of the law on consent (also available at www.doh.gov.uk/consent). 

Who can give consent 

Everyone aged 16 or more is presumed to be competent to give consent for themselves, unless the 

opposite is demonstrated. If a child under the age of 16 has “sufficient understanding and 

intelligence to enable him or her to understand fully what is proposed”, then he or she will be 

competent to give consent for himself or herself. Young people aged 16 and 17, and legally 

‘competent’ younger children, may therefore sign this form for themselves, but may like a parent to 

countersign as well. If the child is not able to give consent for himself or herself, some-one with 

parental responsibility may do so on their behalf and a separate form is available for this purpose. 

Even where a child is able to give consent for himself or herself, you should always involve those 

with parental responsibility in the child’s care, unless the child specifically asks you not to do so. If a 

patient is mentally competent to give consent but is physically unable to sign a form, you should 

complete this form as usual, and ask an independent witness to confirm that the patient has given 

consent orally or non-verbally. 

When NOT to use this form 

“When NOT to use this form 

If the patient is 18 or over and lacks the capacity to give consent, you should use form 4 (form for 

adults who lack the capacity to consent to investigation or treatment) instead of this form. A patient 

lacks capacity if they have an impairment of the mind or brain or disturbance affecting the way their 

mind or brain works and they cannot: 

• understand information about the decision to be made 

• retain that information in their mind 

• use or weigh that information as part of the decision-making process, or 

• communicate their decision (by talking, using sign language or any other means). 

You should always take all reasonable steps (for example involving more specialist colleagues) to 

support a patient in making their own decision, before concluding that they are unable to do so. 

Relatives cannot be asked to sign a form on behalf of an adult who lacks capacity to consent for 

themselves, unless they have been given the authority to so under a Lasting Power of Attorney or 

as a court appointed deputy.” 



Information 

Information about what the treatment will involve, its benefits and risks (including side-effects and 

complications) and the alternatives to the particular procedure proposed, is crucial for patients when 

making up their minds. The courts have stated that patients should be told about ‘significant risks 

which would affect the judgement of a reasonable patient’. ‘Significant’ has not been legally defined, 

but the GMC requires doctors to tell patients about ‘serious or frequently occurring’ risks. In addition 

if patients make clear they have particular concerns about certain kinds of risk, you should make 

sure they are informed about these risks, even if they are very small or rare. You should always 

answer questions honestly. Sometimes, patients may make it clear that they do not want to have 

any information about the options, but want you to decide on their behalf. In such circumstances, 

you should do your best to ensure that the patient receives at least very basic information about 

what is proposed. Where information is refused, you should document this on page 2 of the form or 

in the patient’s notes. 




Agreement of parent (or person who has parental responsibility) to investigation or 

treatment for a child or young person 




Date of birth …………………………………………………. 

Age ……………………………………………………………. 


Job title ………………………………………………………. 


Male 

Female 







Name of proposed procedure or course of treatment (include brief explanation if medical term 

not clear) …………………………………………………. 

…………………………………………………………………………………………………………………… 

……………………………………………………………… 

Statement of health professional (to be filled in by health professional with appropriate knowledge 

of proposed procedure, as specified in consent policy) 

I have explained the procedure to the child and his or her parent(s). In particular, I have explained: 

The intended benefits ……………………………………………………………..……….……… 

…………………………………………………………..…………………………..……………… 

Significant, unavoidable or frequently occurring risks 

……………………………………………...……………… 

...………………………………………………………………………………………….…………… 

………………………………….………………………………………………..……………………. 

Any extra procedures which may become necessary during the procedure 

blood transfusion…………………………………..…….………………………………………. 

other procedure (please specify) ………………………………...……...…………….…..……. 

…………………………………………………………………………...………………….…..……. 


alternative treatments (including no treatment) and any particular concerns of this patient and his or 

her parents. 

The following leaflet/tape has been provided ……………….…………………………..… 

This procedure will involve: 

general and/or regional anaesthesia 

sedation 

Signed:…….…………………………………… 

Name (PRINT) ………………………. ……… 

local anaesthesia 

Date .. …………………….………. 

Job title …….. ………………….… 

Contact details (if child/parent wish to discuss options later) ……………….…………… 


I have interpreted the information above to the child and his or her parents to the best of my ability 

and in a way in which I believe they can understand. 

Signed ………………………….……………………. Date ………………..……………. 

Name (PRINT) …………………..……………………………………………………………… 

Statement of parent 



Please read this form carefully. If the procedure has been planned in advance, you should already 

have your own copy of page 2 which describes the benefits and risks of the proposed treatment. If 

not, you will be offered a copy now. If you have any further questions, do ask – we are here to help 

you and your child. You have the right to change your mind at any time, including after you have 

signed this form. 



I agree to the procedure or course of treatment described on this form and I confirm that I have 

‘parental responsibility’ for this child. 



I understand that my child and I will have the opportunity to discuss the details of anaesthesia with 

an anaesthetist before the procedure, unless the urgency of the situation prevents this. (This only 

applies to children having general or regional anaesthesia.) 

I understand hat any procedure in addition to those described on this form will only be carried out if 

it is necessary to save the life of my child or to prevent serious harm to his or her health. 

I have been told about additional procedures which may become necessary during my child’s 

treatment. I have listed below any procedures which I do not wish to be carried out without 

further discussion. ……………………………………………………… 

…………………………………………………………………………………………………………………… 

…………………………………………………………………………………………………………………… 

………………………………………………………………………………….. 

Signature ………………………………………….. 

Name (PRINT) ………………………………… 

Date………………………….. 

Relationship to child…………………………… 

Child’s agreement to treatment (if child wishes to sign) 

I agree to have the treatment I have been told about. 

Name …………………………………………… Signature ……………………..….……… 

Date ………………………………………………………………………………….… 

Confirmation of consent (to be completed by a health professional when the child is admitted for 

the procedure, if the parent/child have signed the form in advance) 

On behalf of the team treating the patient, I have confirmed with the child and his or her parent(s) 

that they have no further questions and wish the procedure to go ahead. 

Signed:…….…………………………………… 

Name (PRINT) ………………………. ……… 

Date .. …………………….………. 

Job title …….. ………………….… 

Important notes: (tick if applicable) 

See also advance directive/living will (eg Jehovah’s Witness form) 

Parent has withdrawn consent (ask parent to sign /date here) ……………...………. 




This form 

This form should be used to document consent to a child’s treatment, where that consent is being 

given by a person with parental responsibility for the child. The term ‘parent’ has been used in this 

form as a shorthand for ‘person with parental responsibility’. Where children are legally competent 

to consent for themselves (see below), they may sign the standard ‘adult’ consent form (form 1). 

There is space on that form for a parent to countersign if a competent child wishes them to do so. 



opposite is demonstrated. 

“Where a young person of 16 or 17 or a Gillick competent child under 16, refuses treatment, it is 

possible that such a refusal could be over-ruled if it would in all probability lead to the death of the 

child or to severe permanent injury. It would be prudent, to obtain a court declaration or decision if 

faced with a competent child or young person who is refusing to consent to treatment, to determine 

whether it is lawful to treat the child.” 

Although children acquire rights to give consent for themselves as they grow older, people with 

‘parental responsibility’ for a child retain the right to give consent on the child’s behalf until the child 

reaches the age of 18. Therefore, for a number of years, both the child and a person with parental 

responsibility have the right to give consent to the child’s treatment. In law, health professionals 

only need the consent of one appropriate person before providing treatment. This means that in 

theory it is lawful to provide treatment to a child under 18 which a person with parental responsibility 

has authorised, even if the child refuses. As a matter of good practice, however, you should always 

seek a competent child’s consent before providing treatment unless any delay involved in doing so 

would put the child’s life or health at risk. Younger children should also be as involved as possible 

in decisions about their healthcare. Further advice is given in the Department’s guidance Seeking 

consent: working with children. Any differences of opinion between the child and their parents, or 

between parents, should be clearly documented in the patient’s notes. 

Parental responsibility 

The person(s) with parental responsibility will usually, but not invariably, be the child’s birth parents. 

People with parental responsibility for a child include: the child’s mother; the child’s father if married 

to the mother at the child’s conception, birth or later; a legally appointed guardian; the local authority 

if the child is on a care order; or a person named in a residence order in respect of the child. 

Fathers who have never been married to the child’s mother will only have parental responsibility if 

they have acquired it through a court order or parental responsibility agreement (although this may 

change in the future). 



complications) and the alternatives to the particular procedure proposed, is crucial for children and 

their parents when making up their minds about treatment. The courts have stated that patients 

should be told about ‘significant risks which would affect the judgement of a reasonable patient’. 

‘Significant’ has not been legally defined, but the GMC requires doctors to tell patients about 

‘serious or frequently occurring’ risks. In addition if patients make clear they have particular 

concerns about certain kinds of risk, you should make sure they are informed about these risks, 

even if they are very small or rare. You should always answer questions honestly. 

Guidance on the law on consent 

See the Department of Health publications Reference guide to consent for examination or treatment 

and Seeking consent: working with children for a comprehensive summary of the law on consent 

(also available at www.doh.gov.uk/consent). 





Agreement of patient or parent (or person who has parental responsibility) to investigation or 

treatment 

(procedures where consciousness not impaired) 

Name of procedure (include brief explanation if medical term not clear) 

…………………………………………………………………………………………………………………… 

………………………………………………………………………………………... 

Statement of health professional (to be filled in by health professional with appropriate 

knowledge of proposed procedure, as specified in consent policy) 

I have explained the procedure to the patient/parent. In particular, I have explained: 

The intended benefits …………………………………………………………………….…………… 

……………………………………………………………………………………………………………. 

……………………………………………………………………………………………………………. 

Significant, unavoidable or frequently occurring 

risks:……………………………………………………….……….. 

...…………………………………………………………………………………………………………. 

………………………………….………………………………………………………………………… 


alternative treatments (including no treatment) and any particular concerns of those involved. 

The following leaflet/tape has been provided …………………………………………….…….. 

Signed: .…………………………………… Date ……... …………………………………….. 

Name (PRINT) ………………………. ………. Job title …………………………………………. 


I have interpreted the information above to the patient/parent to the best of my ability and in a way in 

which I believe s/he/they can understand. 

Signed ……………….……….Date…….…………..Name (PRINT)…………….………………….. 

Statement of patient/person with parental responsibility for patient 

I agree to the procedure described above. 



I understand that the procedure will/will not involve local anaesthesia. 

Signature ………………………………………. 

Name (PRINT) ………………………………… 

Date ……………………………..……………… 

Relationship to patient ………………………… 



Confirmation of consent (to be completed by a health professional when the patient is admitted for 

the procedure, if the patient/parent has signed the form in advance) 

I have confirmed that the patient/parent has no further questions and wishes the procedure to go 

ahead. 

Signed: …………………………………… Date ……... ……………………………. 

Name (PRINT) ………………………..……….. 

Job title ………………………………… 





This form 

This form documents the patient’s agreement (or that of a person with parental responsibility for the 

patient) to go ahead with the investigation or treatment you have proposed. It is only designed for 

procedures where the patient is expected to remain alert throughout and where an 

anaesthetist is not involved in their care: for example for drug therapy where written consent 

is deemed appropriate. In other circumstances you should use either form 1 (for adults/competent 

children) or form 2 (parental consent for children/young people) as appropriate. 

Consent forms are not legal waivers – if patients, for example, do not receive enough information on 

which to base their decision, then the consent may not be valid, even though the form has been 

signed. Patients also have every right to change their mind after signing the form. 



opposite is demonstrated. If a child under the age of 16 has “sufficient understanding and 

intelligence to enable him or her to understand fully what is proposed”, then he or she will be 

competent to give consent for himself or herself. Young people aged 16 and 17, and legally 

‘competent’ younger children, may therefore sign this form for themselves, if they wish. If the child 

is not able to give consent for himself or herself, some-one with parental responsibility may do so on 

their behalf. Even where a child is able to give consent for himself or herself, you should always 

involve those with parental responsibility in the child’s care, unless the child specifically asks you not 

to do so. If a patient is mentally competent to give consent but is physically unable to sign a form, 

you should complete this form as usual, and ask an independent witness to confirm that the patient 

has given consent orally or non-verbally. 

When NOT to use this form (see also ‘This form’ above) 

If the patient is 18 or over and is not legally competent to give consent, you should use form 4 (form 

for adults who are unable to consent to investigation or treatment) instead of this form. A patient will 

not be legally competent to give consent if: 

• they are unable to comprehend and retain information material to the decision and/or 

• they are unable to weigh and use this information in coming to a decision. 

You should always take all reasonable steps (for example involving more specialist colleagues) to 

support a patient in making their own decision, before concluding that they are unable to do so. 

Relatives cannot be asked to sign this form on behalf of an adult who is not legally competent to 

consent for himself or herself. 



complications) and the alternatives to the particular procedure proposed, is crucial for patients when 

making up their minds about treatment. The courts have stated that patients should be told about 

‘significant risks which would affect the judgement of a reasonable patient’. ‘Significant’ has not 

been legally defined, but the GMC requires doctors to tell patients about ‘serious or frequently 

occurring’ risks. In addition if patients make clear they have particular concerns about certain kinds 

of risk, you should make sure they are informed about these risks, even if they are very small or 

rare. You should always answer questions honestly. Sometimes, patients may make it clear that 

they do not want to have any information about the options, but want you to decide on their behalf. 

In such circumstances, you should do your best to ensure that the patient receives at least very 

basic information about what is proposed. Where information is refused, you should document this 

overleaf or in the patient’s notes. 

The law on consent 

See the Department of Health’s Reference guide to consent for examination or treatment for a 

comprehensive summary of the law on consent (also available at www.doh.gov.uk/consent). 




Form for adults who lack the capacity to consent to investigation or treatment 




Date of birth …………………………………………………. 


Job title ………………………………………………………. 


Male 

Female 







All sections to be completed by health professional proposing the procedure 

A Details of procedure or course of treatment proposed 

(NB see guidance to health professionals overleaf for details of situations where court approval must first be sought) 

B Assessment of patient’s capacity (in accordance with the Mental Capacity Act) 

I confirm that the patient lacks capacity to give or withhold consent to this procedure or course of 

treatment because of an impairment of the mind or brain or disturbance affecting the way their mind or 

brain works (for example, a disability, condition or trauma, or the effect of drugs or alcohol) and they 

cannot do one or more of the following: 

understand information about the procedure or course of treatment 

retain that information in their mind 

use or weigh that information as part of the decision-making process, or 

communicate their decision (by talking, using sign language or any other means) 

Further details: for example how above judgements reached; which colleagues consulted; what attempts 

made to assist the patient make his or her own decision and why these were not successful.” 

C Assessment of patient’s best interests 

I am satisfied that the patient has not refused this procedure in a valid advance decision. As far as is 

reasonably possible, I have considered the person’s past and present wishes and feelings (in particular 

if they have been written down) any beliefs and values that would be likely to influence the decision in 

question. As far as possible, I have consulted other people (those involved in caring for the patient, 

interested in their welfare or the patient has said should be consulted) as appropriate. I have considered 

the patient’s best interests in accordance with the requirements of the Mental Capacity Act and believe 

the procedure to be in their best interests because: 

(Where the lack of capacity is likely to be temporary, for example the patient is unconscious, or 

where patient has fluctuating capacity) 

The treatment cannot wait until the patient recovers capacity because: 

ISSUE 6 – AUGUST 2012 

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D Involvement of the patient’s family and others close to the patient 

The final responsibility for determining whether a procedure is in an incapacitated patient’s best interest lies with the health professional 

performing the procedure. However, it is a legal requirement to consult with those close to the patient (eg spouse/partner, family and friends, 

carer, supporter or advocate) unless you have good reason to believe that the patient would not have wished particular individuals to be 

consulted, or unless the urgency of their situation prevents this. Where there is a Personal Welfare Lasting Power of Attorney this Attorney 

must be consulted about the decision. Where there is a Court Appointed Deputy this person must also be consulted. “Best interests” go far 

wider than “best medical interests”, and include factors such as the patient’s wishes and beliefs when competent, their current wishes, their 

general well-being and their spiritual and religious welfare. The Mental Capacity Act requires that any relevant written statement of wishes and 

feelings must be taken into account where practicable and appropriate to do so. 

Independent Mental Capacity Advocate (IMCA) 

For decisions about serious medical treatment, where there is no one appropriate to consult other than 

paid staff, has an Independent Mental Capacity Advocate (IMCA) been instructed? 

Yes 

No 

Details: 

Signature ………………………………………….. Date…………………………..” 

(to be signed by a person or persons close to the patient, if they wish) 

I/We have been involved in a discussion with the relevant health professionals over the treatment 

of……………………………(patient’s name). I/We understand that he/she is unable to give his/her own 

consent, based on the criteria set out in this form. I/We also understand that treatment can lawfully be 

provided if it is in his/her best interests to receive it. 

Any other comments (including any concerns about decision) 

Name ………………………………………Relationship to patient………………………………… 

Address (if not the same as patient…………………………………………………………………. 

……………………………………………………………………………………………………………... 

……………………………………………………………………………………………………………... 

Signature ………………………………………….. 

Date………………………….. 

If a person close to the patient was not available in person, has this matter been discussed in any other 

way (eg over the telephone?) 

Yes No 


42


Details: 

Signature of health professional proposing treatment 

The above procedure is, in my clinical judgement, in the best interests of the patient, who lacks capacity 

to consent for himself or herself. Where possible and appropriate I have discussed the patient’s 

condition with those close to him or her, and taken their knowledge of the patient’s views and beliefs into 

account in determining his or her best interests. 

I have/have not sought a second opinion. 

Signature:…….…………………………………… 

Name (PRINT) ………………………. ……… 

Date .. …………………….………. 

Job title …….. ………………….… 

Where second opinion sought, s/he should sign below to confirm agreement: 

Signature:…….…………………………………… 

Name (PRINT) ………………………. ……… 

Date .. …………………….………. 

Job title …….. ………………….… 

E The patient has an attorney or deputy 

Where the patient has authorised an attorney to make decisions about the procedure in question under a Lasting Power of Attorney or a Court 

Appointed Deputy has been authorised to make decisions about the procedure in question, the attorney or deputy will have the final 

responsibility for determining whether a procedure is in the patient’s best interests. 

Signature of attorney or deputy 

I have been authorised to make decisions about the procedure in question under a Personal Welfare 

Lasting Power of Attorney / as a Court Appointed Deputy (delete as appropriate). I have considered the 

relevant circumstances relating to the decision in question (see section C) and believe the procedure to 

be in the patient’s best interests. Any other comments (including the circumstances considered in 

assessing the patient’s best interests) 

Signature:…….…………………………………… etc 


43



This form should only be used where it would be usual to seek written consent but an adult patient (16 

or over) lacks capacity to give or withhold consent to treatment. If an adult has capacity to accept or 

refuse treatment, you should use the standard consent form and respect any refusal. Where treatment is 

very urgent (for example if the patient is critically ill), it may not be feasible to fill in a form at the time, but 

you should document your clinical decisions appropriately afterwards. If treatment is being provided 

under the authority of Part IV of the Mental Health Act 1983, different legal provisions apply and you are 

required to fill in more specialised forms (although in some circumstances you may find it helpful to use 

this form as well). If the adult now lacks capacity, but has made a valid advance decision to refuse 

treatment that is applicable to the proposed treatment then you must abide by that refusal. For further 

information on the law on consent, see the Department of Health’s Reference guide to consent for 

examination or treatment 

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_103 

643.) 

When treatment can be given to a patient who lacks the capacity to consent 

All decisions made on behalf of a patient who lacks capacity must be made in accordance with the 

Mental Capacity Act 2005. More information about the Act is given in the Code of Practice 1 . Treatment 

can be given to a patient who is unable to consent, only if : 

• the patient lacks the capacity to give or withhold consent to this procedure AND 

• the procedure is in the patient’s best interests. 

Capacity 

A person lacks capacity if they have an impairment or disturbance (for example, a disability, condition or 

trauma, or the effect of drugs or alcohol) that affects the way their mind or brain works which means that 

they are unable to make a specific decision at the time it needs to be made. It does not matter if the 

impairment or disturbance is permanent or temporary. A person is unable to make a decision if they 

cannot do one or more of the following things: 

• Understand the information given to them that is relevant to the decision. 

• Retain that information long enough to be able to make the decision. 

• Use or weigh up the information as part of the decision- making process. 

1 

Mental Capacity Act 2005 Code of Practice - www.publicguardian.gov.uk/mca/code-of-practice.htm 

• Communicate their decision - this could be by talking or using sign language and includes simple 

muscle movements such as blinking an eye or squeezing a hand. 

You must take all steps reasonable in the circumstances to assist the patient in taking their own 

decisions. This may involve explaining what is involved in very simple language, using pictures and 

communication and decision-aids as appropriate. People close to the patient (spouse/partner, family, 

friends and carers) may often be able to help, as may specialist colleagues such as speech and 

language therapists or learning disability teams, and independent advocates (as distinct from an IMCA 

as set out below) or supporters. Sometimes it may be necessary for a formal assessment to be carried 

out by a suitably qualified professional. 

Capacity is ‘decision-specific’: a patient may lack capacity to take a particular complex decision, but be 

able to take other more straight-forward decisions or parts of decisions. Capacity can also fluctuate over 

time and you should consider whether the person is likely to regain capacity and if so whether the 

decision can wait until they regain capacity. 


44


Best interests 

The Mental Capacity Act requires that a health professional must consider all the relevant 

circumstances relating to the decision in question, including, as far as possible considering: 

• the person’s past and present wishes and feelings (in particular if they have been written down) 

• any beliefs and values (e.g. religious, cultural or moral) that would be likely to influence the decision in 

question and any other relevant factors 

• the other factors that the person would be likely to consider if they were able to do so. 

When determining what is in a person’s best interests” a health professional must not make 

assumptions about someone’s best interests merely on the basis of the person’s age or appearance, 

condition or any aspect of their behaviour. If the decision concerns the provision or withdrawal of lifesustaining 

treatment the health professional must not be motivated by a desire to bring about the 

person’s death. 

The Act also requires that, as far as possible, health professionals must consult other people, if it is 

appropriate to do so, and take into account of their views as to what would be in the best interests of the 

person lacking capacity, especially anyone previously named by the person lacking capacity as 

someone to be consulted and anyone engaging in caring for patient and their family and friends. 

Independent Mental Capacity Advocate (IMCA) 

The Mental Capacity Act introduced a duty on the NHS to instruct an independent mental capacity 

advocate (IMCA) in serious medical treatment decisions when a person who lacks capacity to make a 

decision has no one who can speak for them, other than paid staff. IMCAs are not decision makers for 

the person who lacks capacity. They are there to support and represent that person and to ensure that 

decision making for people who lack capacity is done appropriately and in accordance with the Act. 

Lasting Power of Attorney and Court Appointed Deputy 

A person over the age of 18 can appoint an attorney to look after their health and welfare decisions, if 

they lack the capacity to make such decisions in the future. Under a Lasting Power of Attorney (LPA) the 

attorney can make decisions that are as valid as those made by the person themselves. The LPA may 

specify limits to the attorney’s authority and the LPA must specify whether or not the attorney has the 

authority to make decisions about life-sustaining treatment. The attorney can only, therefore, make 

decisions as authorised in the LPA and must make decisions in the person’s best interests. 

The Court of Protection can appoint a deputy to make decisions on behalf of a person who lacks 

capacity. Deputies for personal welfare decisions will only be required in the most difficult cases where 

important and necessary actions cannot be carried out without the court’s authority or where there is no 

other way of settling the matter in the best interests of the person who lacks capacity. If a deputy has 

been appointed to make treatment decisions on behalf of a person who lacks capacity then it is the 

deputy rather than the health professional who makes the treatment decision and the deputy must make 

decisions in the patient’s best interests. 

Second opinions and court involvement 

Where treatment is complex and/or people close to the patient express doubts about the proposed 

treatment, a second opinion should be sought, unless the urgency of the patient’s condition prevents 

this. The Court of Protection deals with serious decisions affecting personal welfare matters, including 

healthcare, which were previously dealt with by the High Court. Cases involving: 

• decisions about the proposed withholding or withdrawal of artificial nutrition and hydration (ANH) from 

patients in a permanent vegetative state (PVS) 


45


• cases involving organ, bone marrow or peripheral blood stem cell (PBSC) donation by an adult who 

lacks capacity to consent 

• cases involving the proposed non-therapeutic sterilisation of a person who lacks capacity to consent to 

this (e.g. for contraceptive purposes) and 

• all other cases where there is a doubt or dispute about whether a particular treatment will be in a 

person’s best interests (include cases involving ethical dilemmas in untested areas) should be referred 

to the Court for approval. The Court can be asked to make a decision in cases where there are doubts 

about the patient’s capacity and also about the validity or applicability of an advance decision to refuse 

treatment. 


46


Policy/Procedure for: 

Consent to Examination or Treatment 

APPENDIX 2 

Issue: 06 

Status: 

Author Name and Title: 

APPROVED 

Jane Craig, Trust Risk Manager, Kieran Colton, Head of Governance, 

Community Services Division and Michael Sergeant, Mental Capacity 

Act/ Mental Health Act Lead (Local Services) 

Issue Date: AUGUST 2012 

Review Date: AUGUST 2015 

Approved by: 

Distribution/Access: 

EXECUTIVE LEADERSHIP TEAM 

NORMAL 

RECORD OF CHANGES 

DATE 

AUTHOR 

POLICY/ 

PROCEDURE 

DETAILS OF CHANGE 

08/05 J Craig CL/CP/02 Revised to include the Forensic Directorate 

03/07 J Craig CL/CP/02 Revised to meet “house “style 

09/07 J Craig CL/CP/02 

09/08 J Craig CL/CP/02 

06/10 J Craig 1.03 Revised throughout 

07/11 J Craig 1.03 

01/12 

J Craig, 

K Colton 

M Sergeant 

1.03 

Revised to meet the requirements of the NHSLA and 

links to the relevant sections of the Mental Capacity Act 

2005. 

Revised to meet the requirements of the NHSLA and 

links to the relevant sections of the Mental Capacity Act 

2005 and the Mental Capacity Act Code of Practice 

Para 25.2 - ref T1 changed to T2 & T2 changed to T3 

Removal of Consent Form 1: Patient Agreement to 

Electroconvulsive Therapy (ECT) (Millbrook ECT 

Pathway and Queen’s Medical Centre Pathway from 

Appendix 1 

Additions: Section 6, 8, 9, 10, 12, 15, 16, 17, 18, 19, 

33.1, 33.2, and 37 


47


EMPLOYEE RECORD OF HAVING READ THE POLICY/PROCEDURE 

APPENDIX 3 

Title of Policy/Procedure: 

CONSENT TO EXAMINATION OR TREATMENT 

I have read and understand the principles contained in the named policy/procedure. 

PRINT FULL NAME SIGNATURE DATE 


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Consent to Examination or Treatment Policy - Nottinghamshire ...

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