FOI/2025/26/413

Your request:

Please provide the following information on NHS chaperone policies, training and reporting:

 

1) Current chaperone policy or policies relating the use of formal and informal chaperones.

 

2) Associated procedures & guidelines including:

a) Guidance on how the offer, acceptance, or refusal of a chaperone must be recorded in patient notes.

b) Guidance on how the sex of the chaperone is recorded.

 

3) If your policy/procedures/guidelines have been withdrawn, please provide:

a) the most recent version.

b) the date it was placed under review or withdrawn.

c) the communications with staff when it was put under review or withdrawn.

d) the timetable for development and approval of any replacement policy

e) details of internal and external consultation lists.

 

4) If not included in the policy/procedures/guidelines, please also disclose:

a) training and competency standards for staff acting as formal chaperones.

b) training description and provision for chaperones (eg online, in person, what organisations delivers the training and outline).

 

5) Audit reports, quality assurance reviews, compliance monitoring, and management and/or board reports relating to chaperoning 2024 to date.

 

6) Related equality impact assessments (EIAs) if separate

 

7) Datix reports:

a) Number of Datix reports raised related to chaperoning in 2024, 2025 and 2026 Jan & Feb, by sex of patient and chaperone & definition of sex field in Datix.

b) If you record this data by gender, please disclose the Number of Datix reports raised related to chaperoning in 2024, 2025 and 2026 Jan & Feb, by gender of patient and chaperone and definition of gender field in Datix.

 

8) Concerns:

a) Number of concerns raised by chaperones, if not recorded via Datix,  in 2024, 2025 and 2026 Jan & Feb, by sex of patient and chaperone & definition of sex field.

b) If you record this data by gender, please disclose the number of concerns raised by chaperones in 2024, 2025 and 2026 Jan & Feb, by gender of patient and chaperone and definition of gender field.

 

9) Complaints:

a) Number of complaints raised related to chaperoning in 2024, 2025 and 2026 Jan & Feb, by sex of patient and chaperone & definition of sex field in your complaints system.

b) If you record this data by gender, please disclose the number of complaints raised related to chaperoning in 2024, 2025 and 2026 Jan & Feb, by gender of patient and chaperone and definition of gender field in your complaints system.

c) Number of Freedom to Speak Up reports related to chaperones in 2024, 2025 and 2026 Jan & Feb by sex of the reporter.

d) If you record this data by gender, please disclose the number of cFTSU reports related to chaperoning in 2024, 2025 and 2026 Jan & Feb, by gender of the reporter.

 

 

 

Our response:

 

Please provide the following information on NHS chaperone policies, training and reporting:

 

1) Current chaperone policy or policies relating the use of formal and informal chaperones.

The Trust’s current chaperone policy is attached.

This outlines the use of formal and informal chaperones across services.

 

 

 

2) Associated procedures & guidelines including:

The Trust’s chaperone policy includes guidance on:

• Recording the offer, acceptance or refusal of a chaperone within patient records
• Recording relevant details of the chaperone where applicable

Please refer to the attached policy for full details.

 

 

 

3) If your policy/procedures/guidelines have been withdrawn, please provide:

The Trust does not hold any additional information within scope of this request.

 

 

4) If not included in the policy/procedures/guidelines, please also disclose:

Training and competency requirements for staff acting as chaperones are outlined within the Trust’s policy.

This includes expectations regarding staff suitability, training provision, and responsibilities when acting as a chaperone.

Please refer to the attached policy for further detail.

 

5) Audit reports, quality assurance reviews, compliance monitoring, and management and/or board reports relating to chaperoning 2024 to date.

The Trust does not hold centrally collated audit reports, quality assurance reviews, or board-level reports specifically relating to chaperoning for the period requested.

Where monitoring takes place, this is managed at a local service level.

 

 

6) Related equality impact assessments (EIAs) if separate

The Trust does not hold a separate Equality Impact Assessment within scope of this request.

 

 

7) Datix reports:

a) Number of Datix reports raised related to chaperoning in 2024, 2025 and 2026 Jan & Feb, by sex of patient and chaperone & definition of sex field in Datix.

b) If you record this data by gender, please disclose the Number of Datix reports raised related to chaperoning in 2024, 2025 and 2026 Jan & Feb, by gender of patient and chaperone and definition of gender field in Datix.

The Trust does not hold a specific reporting category for “chaperone” incidents within Datix. However, using the keyword search term “chaperone”, three incidents were identified.

Details are as follows:

• W154602 – Consultation ended due to no chaperone being available
• W166339 – Delay in obtaining a chaperone for an intimate examination
• W194675 – Patient requested a chaperone which had not been arranged

Please also refer to the attached spreadsheet for further detail.

 

 

8) Concerns:

The Trust does not hold centrally recorded data on concerns raised by chaperones outside of the Datix incident reporting system.

Any such concerns would be managed locally and are not held in a reportable format.

 

9) Complaints:

a) Number of complaints raised related to chaperoning in 2024, 2025 and 2026 Jan & Feb, by sex of patient and chaperone & definition of sex field in your complaints system.

b) If you record this data by gender, please disclose the number of complaints raised related to chaperoning in 2024, 2025 and 2026 Jan & Feb, by gender of patient and chaperone and definition of gender field in your complaints system.

c) Number of Freedom to Speak Up reports related to chaperones in 2024, 2025 and 2026 Jan & Feb by sex of the reporter.

d) If you record this data by gender, please disclose the number of cFTSU reports related to chaperoning in 2024, 2025 and 2026 Jan & Feb, by gender of the reporter.

The Trust does not hold complaint data specifically categorised under “chaperone”.

Any relevant complaints would not be identifiable without undertaking a manual review of records, which would exceed the appropriate cost limit under Section 12 of the Freedom of Information Act 2000.

Freedom to Speak Up (FTSU) data relating specifically to chaperoning is not held in a reportable format.