Guidance For Podiatrists - Halton and St Helens PCT

Clinical Guideline
GUIDELINES FOR NAIL SURGERY
Guidance for Podiatrists
For use in:
All areas of the Trust
For use by:
All PCT staff
Used for:
All PCT staff
Document Owner:
Podiatry department
Board approved:
Approved Clinical Governance Workstream
Policy Indexed
ClinPol10
Controlled Document No
HSHPCT/Clinpol/10
Version Number 3
Status:
Clinical Guideline
Statutory and legal requirements
Implementation Lead
Implementation Process
Healthcare Commission Standards for Better
Health
Regulations (1992) Handling Home Care HSE
(2001)
Head of Podiatry
Policy to be circulated to all staff
Training programme to support clinical and
non-clinical staff
The Trust is committed to an environment that promotes equality and embraces diversity
both within our workforce and in service delivery. The document should be implemented
with due regard to this commitment
This document seeks to uphold the duties and principles contained within the Mental
Capacity Act. All Staff within the PCT should be aware of its implications
This Guidance is due for review in Aug 2009
After this date, guidance and process documents may become invalid. Guidance users
should ensure that they are consulting the current version of this document.
Issue Date: Aug 07 Author: Author: Head of Podiatry
Review Date: Aug 09 Lead Director: Lead Director: Director Provider Services Page1of 6

Contents
Page No
1 Rationale 3
1.1 Related Trust Policies 3
1.2 List of Equipment 3
1.3 Risk Assessment and COSHH 4
1.4 Training 4
2 General principles – Procedure for Nail Surgery 5
2.1 Referrals 5
2.2 History and Pre-operative assessment 5
2.3 Consent 6
2.4 Preparation of Area 6
2.5 Decontamination of Instruments 7
2.6 Decontaminating Hands and Protective Clothing 7
2.7 Procedure 8
2.8 Dressings and Post op Information 9
2.9 Operation Report 9
3 Audit 10
4 Management of Guidelines and 10
5 References 10
Appendices
1. Rationale
Issue Date: Aug 07 Author: Author: Head of Podiatry
Review Date: Aug 09 Lead Director: Lead Director: Director Provider Services Page2 of 10

The condition of in-growing toenail (onychocryptosis) usually affects the hallux nail,
and is most commonly seen between the ages of fifteen and forty years, with a male
to female predominance of about 3:1 ( Davies C S 1993). Since the introduction of
Local Anaesthesia (LA) into Podiatry practice in 1972, the principle management for
onychocryptosis has been the ablation of the nail matrix using Liquefied Phenol B.P.
either partially or total (McCourt F J. 1999).
This guidance is intended to ensure that podiatry staff undertaking nail surgery
employed by Halton and St Helen’s PCT do so safely for both patients and
themselves meeting the objectives listed in the policy statement.
Halton and St Helens PCT podiatry department is committed in offering patients this
specialist nail surgery in a community setting. The objective of nail surgery is to
permanently resolve the condition of onychocryptosis by either total or partial nail
avulsion with nail matrix ablation.
1.1 Related trust Policies
Record Keeping Policy (2006)
Consent Policy (2007)
Clinical Guidelines for use of Scandonest 3% in Children plus LA for adults (2005)
PGD for Adrenaline (2005)
Latex Policy (2005)
Infection Control Policy
Policy on use of Sterilizers
1.2 List of Equipment
Thwaites Nippers, Blacks file, McKay Nail elevator, Spencer-wells Forceps, Mosquito
forceps, Locke elevator, No 3
Scalpel handle, small and large tube gauze applicators, scissors, beaver handle, dental
cartridge syringe tourniquets.
Issue Date: Aug 07 Author: Author: Head of Podiatry
Review Date: Aug 09 Lead Director: Lead Director: Director Provider Services Page3 of 10

1.3 Risk assessment and COSHH (1988)
• The North West Regional Sub-group and infection control nurses support the use
of a disposable pastette for applying the phenol to the sulcus. It is imperative that
they are discarded in yellow bag.
• For staff that use the dropper bottle, this is still acceptable as the risk of cross
infection is very low.
• A full risk assessment
•
1.4 Training
• Newly qualified staff should not work alone with a podiatry assistant for a period
of 12 months/20 procedures without being supervised by a senior podiatrist with
sufficient nail surgery experience. During this period all types of nail surgery
should be undertaken.
• All clinicians performing N/S to undertake 10 nail op procedures each year.
Retraining to be offered if this is not met.
• All staff to undertake retraining each year in resuscitation, dealing with
anaphylaxis and administration of adrenalin.
Issue Date: Aug 07 Author: Author: Head of Podiatry
Review Date: Aug 09 Lead Director: Lead Director: Director Provider Services Page4 of 10

General Principles
PROCEDURE FOR NAIL SURGERY
ACTION
2.1 Referrals
All referrals from trust podiatry staff can be
booked into nail surgery clinics directly via the
podiatry office at Victoria House.
All referrals from other sources i.e. self/primary
health care team should be provisionally
assessed for suitability for nail surgery in the
emergency clinics at HCRC or Hallwood. If nail
surgery is required, the patients can be booked
into nail surgery clinics via the podiatry office at
Victoria House.
2.2 History
ACTION
Basic pre-op information, including what happens
during the procedure, re-growth rate (1% @ last
audit), healing time, time off work/school, not to
drive after the procedure, should be given
verbally and in writing by means of a patient
information leaflet
Record name, address, Date of birth, telephone
number, General Practitioner and presenting
condition.
Undertake primary assessment.
Pulses – if absent test with Doppler – if still
absent or weak monophasic, then nail surgery is
not advisable.
Undertake medical history including blood
disorders, sickle cell, hepatitis, infection not
responded to antibiotics, diabetes, neurological,
heart disease, Raynaulds, Epilepsy, respiratory
condition, pregnancy, kidney problems, allergies,
arthritis, skin conditions, previous Local
Anaesthetic.
Current medication including over the counter,
herbal steroids/anticoagulants in the last 6
months. Smoker.
Indicate what procedure is indicated.
RATIONALE
RATIONALE
To ensure patient is properly informed.
To comply with good record keeping
practice.
To ensure patient is suitable for surgery.
To ensure patient is suitable for surgery
Minimising any risk
To inform patient
Issue Date: Aug 07 Author: Author: Head of Podiatry
Review Date: Aug 09 Lead Director: Lead Director: Director Provider Services Page5 of 10

2.3 Consent
Full informed consent in writing should be
obtained from the patient (parent or guardian if
under 16) for the administration of the local
anaesthetic and operative procedure.
ACTION
Consent should include what procedure is to be
carried out, a statement which conveys that the
procedure has been explained in terms that the
operator judges the patient/parent or guardian
have understood, a space for the operator to sign
and date this statement, a statement that states
the patient/parent or guardian has had the
procedure explained and that they agree to it,
and a space for the signature of the
patient/parent or guardian.
High-risk patients should not have nail surgery
performed on a Friday, while the service runs
Monday to Friday hours.
High-risk patients should have their medical
circumstances checked out via letter to their
consultant/GP. Patients taking Warfarin, their
INR’s should be around 2.
Consultants/GPs should have notification of the
problems that may occur from a high-risk patient
having nail surgery – LA/phenol/tourniquet/post
op bleeding/healing/immune problem.
Adrenalin should be available during procedure.
2.4 Preparation of Area
ACTION
The general area where nail surgery is carried out
should be dust free, have good ventilation, and
have a minimal amount of people entering during
a session.
The room to be used is made ‘clean’, i.e. the
chair, lamp, unit, and any other surfaces such as
window ledges are swabbed thoroughly. A
general-purpose detergent (Hospec) and hot
water (5ml per 5 litres hot water) is adequate for
general environmental cleaning.
Prepare the trolley and patient chair with blue
paper roll.
To ensure that the patient/parent or
guardian is aware of what the procedure
involves, its risks, side effects of LA,
outcome and average healing time.
Patients/parents or guardian should be
issued with a patient information sheet on
nail surgery on their initial assessment
appointment.
RATIONALE
To comply with Trust Consent Policy.
As weekend cover not available.
In order to ascertain their suitability for nail
surgery.
So that any necessary counter measures
can be taken
In case of emergency
RATIONALE
To minimise risk of infection.
To minimise risk of infection.
Issue Date: Aug 07 Author: Author: Head of Podiatry
Review Date: Aug 09 Lead Director: Lead Director: Director Provider Services Page6 of 10

Between each patient the chair and unit should
be cleaned with a detergent (Hospec) and hot
water.
Use one dedicated sink only for cleaning
instruments.
2.5 Decontamination of Instruments
ACTION
Instruments must be washed in hot water and a
detergent (Hospec). A dedicated scrubbing brush
can be used for scrubbing the instruments under
the surface of the water. Instruments must not be
scrubbed in running water or above the surface of
water as this can create an aerosol.
All instruments used should be autoclaved prior
to use. Instruments must be placed on trays
provided without overloading. Instruments must
not touch each other. Hinged instruments must
be opened out, while instruments with a lumen,
i.e. beaver handle should be fully undone.
Remove sterile instruments on their tray to a
clean area prior to use. Do not place by the sink
as this area may be contaminated by the water
used in cleaning the instruments and hand
washing.
2.6 Decontaminating Hands and Protective
Clothing – Decontamination of hands is the
single most important factor in preventing cross
infection. Both operator and assistant should
“scrub up” before and after procedure
Decontaminate hands in accordance with
the PCT Hand Decontamination Policy
Use one of the sinks only for hand- washing.
A disposable plastic apron should be worn.
The operator should wear sterile surgical gloves
during the nail surgery procedure, however the
assistant’s gloves need not be sterile.
Eye protection should be available to staff
carrying out nail surgery.
Surgical face masks do not protect staff from
phenol fumes, but should be made available
should staff wish to use them
To prevent cross infection.
To prevent contamination from other
sources.
RATIONALE
May be a vector of cross infection to staff.
To comply with Trust policy for use of
sterilizers
To minimise risk of infection.
In order to reduce the risk of cross
infection.
To prevent hand contamination from used
instruments.
To protect clothing.
To ensure sterile procedure.
To protect eyes.
In order to reduce the risk of cross infection.
Issue Date: Aug 07 Author: Author: Head of Podiatry
Review Date: Aug 09 Lead Director: Lead Director: Director Provider Services Page7 of 10

2.7 Procedure in case of emergency.
Adrenalin should be to hand before LA is
administered.
Explain to the patient that an injection is given to
both sides of the toe.
Check the name, form, strength, batch No, and
expiry date of the LA. Check the needle seal has
not been broken.
The patient should be reclined for the LA and
procedure, unless medically unfit (i.e. angina).
Administer the LA warning the patient when the
needle is to be inserted, and that they need to
keep still. Non-sterile gloves should be worn for
this procedure.
Aspirate to check the needle has not been
inserted into a blood vessel if continuous
administration has not been used. Keep fingers
clear of the posterior aspect of the toe – use skin
blanch as a guide.
At the end of the procedure remove the needle
and discard into sharps bin along with the used
cartridge.
Allow sufficient time for the toe to become
anaesthetized. Test this by using a probe/neuro
tip over the area to be treated. If achieved,
discard gloves, put on apron, and protective
eyewear, if using.
Decontaminate hands, dry on clean paper towels
and put on sterile surgical gloves.
The forefoot should be swabbed with a pre-op
alcohol based solution working distally to
proximally.
De-vascularise the toe using a tourniquet. The
assistant should time how long this is applied,
which should not exceed 15 minutes.
Carry out the Partial Nail Avulsion/Total Nail
Avulsion, and check for completeness.
The assistant applies phenol to the area of matrix
to be cauterised, using the smallest amount in a
pastette.
The phenol should be applied for a total of 3
minutes using a blacks file. The area should then
be dried with sterile gauze.
Phenol is washed out with Isopropyl Alcohol.
Tourniquet is removed and the toe checked for
re-vascularisation and bleeding. The total time of
de-vascularisation is noted.
To anaesthetize the whole toe.
To ensure correct drug has been selected,
and not been tampered with, and to ensure
expiry date has not been exceeded.
To ensure patient comfort.
To ensure patient comfort and to prevent a
needle stick injury to staff.
To prevent local anaesthetic being
administered into a blood vessel
intravenously. To prevent needle stick
injury.
For safety reasons.
To ensure procedure can be carried out as
painless as possible.
To undertake sterile procedure.
To clean area.
To minimise bleeding during procedure.
To prevent tissue necrosis
To complete procedure.
To cauterise nail matrix
To ensure nail matrix is cauterised.
To remove Phenol.
To ensure blood supply has returned to the
toe.
Issue Date: Aug 07 Author: Author: Head of Podiatry
Review Date: Aug 09 Lead Director: Lead Director: Director Provider Services Page8 of 10

2.8
All debris and clinical waste should be disposed
of in a clinical waste yellow bag, which is tied at
end of session.
Dressings and Post op Information
ACTION
The dressing immediately following the nail op
should be Atrauman/ Inadine and
Melolin/Release (Sorbsan/Kaltostat as well if
heavy bleeding). “Release” for subsequent
dressings is the preference. If there are signs of
infection, or if the patient has poor personal
hygiene standards, or the patient is at risk i.e.
diabetic, Inadine and Release should be used.
Patient should be told what their toe will look like
post op.
Patient should be advised of the possibility of
post op pain, and to take an appropriate painkiller
if they experience any.
Patient should be given a post op advice sheet
with the type of procedure, LA strength and
amount used, dressing applied, contact
telephone No and out of hours advice.
The patient should be seen within 5 days
maximum for re dressing, sooner if high-risk. The
patient should also be advised to rest, with the
foot elevated and moving it around for the rest of
the day. To keep the dressing clean and dry and
refrain from sporting activity.
After the first dressing low risk patients may be
discharged. High-risk patients should be seen
until wound heals.
Salt-water footbaths (hypertonic solution) may be
advised and spare dressings given.
Operation report
Care pathway.
Operation report – to include: -
Patients name, DOB, address, telephone No,
patient No, date of op.
Type of anaesthetic used, amount, strength,
plain, batch No, Exp date.
Tourniquet time. Box to show re-vascularisation.
Health and Safety
RATIONALE
To follow best practice in preventing postoperative
infection.
To enable to decide whether they need to
seek help if something isn’t right.
To inform patient
To inform patient and to inform other Health
Care Professionals in case Out of Hours
help is required.
To reduce risk of post-operative infection.
To minimise disruption to patients life. To
monitor high-risk patients in case of
complication.
Can help clean wound.
Issue Date: Aug 07 Author: Author: Head of Podiatry
Review Date: Aug 09 Lead Director: Lead Director: Director Provider Services Page9 of 10

3. Audit
• To monitor and evaluate re-growth rates.
• To monitor and evaluate children who have received local anaesthesia for the
purpose of nail surgery procedures.
4. Management of Clinical Guidelines
Written By:
Date:
Andrew Lythgoe/ Julie Griffiths
1 st Sept 2006
Ratified by:
Review Date: Jan 2008
5. References:
McCourt F J (1999). Safety in the use of phenol for nail matrix ablation. Podiatry Now.
The Society of Chiropodists & Podiatrists.410-412.
Davies C S (1993). A clinical study comparing post-operative healing times following
chemical nail cautery using phenol and sodium hydroxide. The Journal of British
Podiatric Medicine. 101-103.
Acknowledgements:
Nail Surgery Clinical Supervision Group.
Issue Date: Aug 07 Author: Author: Head of Podiatry
Review Date: Aug 09 Lead Director: Lead Director: Director Provider Services Page10 of 10

Appendix 1
Consent Form 2
PODIATRY DEPARTMENT
Parental agreement to investigate or treatment for a child or young person
Patient details
Patient’s surname/family name..…………………………..
Patient’s first names .……………………………………….
Date of birth ………………………………………………….
Age…………………………………………………………….
Childs primary carer………………………………………….
Parents occupation…………………………………………..
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

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
Serious or frequently occurring risks
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 has been provided
Name (PRINT) ________________________
Signature _________________________ Date __________________
Job title
_________________________________________________
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.
Name (PRINT) ________________________
Signature _________________________ Date ___________________

Statement of patient
Please read this form carefully. If your treatment has been planned in advance, you
should already have your own copy of page 2 of the consent form, 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
Name (PRINT) ________________________
Signature _________________________ Date ___________________
Child’s agreement to treatment (if child wishes to sign)
I agree to the treatment I have been told about
Name (PRINT) ________________________
Signature _________________________ Date ___________________
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.
Name (PRINT) ________________________
Signature _________________________ 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)
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.
Who can give consent
Everyone aged 16 or more is presumed to be competent to give consent for themselves,
unless the opposite is demonstrated. The courts have stated that 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. If children are not able to give consent for themselves, some one with parental
responsibility may do so on their behalf.
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).
Information
Information about what the treatment will involve, its benefits and risks (including sideeffects
and 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).

Appendix 2
Consent Form 3
PODIATRY DEPARTMENT
Patient/parental agreement to investigation or treatment
(procedures where consciousness not impaired)
Patients Name………………………………………………………………………….
Podiatry Number………………………………………………………………………
D.O.B………………………………………………………………………………………
.
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: Resolution of painful/infected toenail.
Serious or frequently occurring risks: A 1% chance of re-growth of toenail.
Infection. Slower healing. Localised reaction to phenol. A rare, but serious
allergic reaction following the injection of a local anaesthetic. A partial nail
avulsion may loosen the whole nail resulting in total, permanent nail loss.
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 those involved.
The following leaflet has been provided: Nail surgery patient information.
Signed:
Name (PRINT)
Date
Job title
Statement of patient/person with parental responsibility for patient
I agree to the procedure described above.

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 the procedure will involve local anaesthesia.
Signature
Date
Name (PRINT)
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:
Name (PRINT)
Date
Job title.
Top copy accepted by patient: yes/no (please circle)
Statement of interpreter (where appropriate)
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) _______________________________

Guidance to health professionals (to be read in conjunction with consent policy)
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.
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, 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.
Information
Information about what the treatment will involve, its benefits and risks (including sideeffects
and 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).