Scenario 1

Mrs N is 86 years old and has had a stroke. Her speech is unintelligible and she dozes much of the time. She suffers a fractured neck of femur in a fall. The staff on the ward explain what has happened and that she needs an operation. Because she is unable to speak, the staff watch her body language intently to gauge her understanding and give her a picture board to help her communicate. Mrs N is able, through these means, to convince the staff that she understands what has happened and that she wants them to carry out the operation.

Scenario 2

Mr M is 82 and usually very lively and alert. However, he has recently become very confused, probably due to a urinary tract infection. He is admitted to hospital where it is noted that he has an irreducible femoral hernia. The surgeons who are called to see him suggest immediate repair to avoid the risk of strangulation, but as Mr M is unable to consent and there is no imminent danger (the hernia is not strangulated), it is decided to wait, in the expectation that he will regain capacity, and then seek consent to surgical repair.

Scenario 3

Thirteen-year-old E is attending boarding school while his parents are in Africa working. One evening his house master, Mr G, brings him to the Emergency Department (ED); E has a raised temperature and is complaining of severe abdominal pain. A diagnosis of acute appendicitis is quickly made, and arrangements to take E down to theatre are put in motion. The doctor asks Mr G for E’s parents’ contact details, but is told that they are unavailable as they are currently in a locality with no communication infrastructure.

Mr G offers to sign the consent form on their behalf, explaining that he is acting in loco parentis* while Mr and Mrs S are away. The doctor, however, is unsure about this and contacts the trust’s solicitor. She tells him that it is likely that Mr G could consent on behalf of E’s parents, provided they assigned such rights to him, but suggests that the doctor first assess E’s capacity. 

Even if E had been deemed not competent to make a decision, the treatment could still have gone ahead as it was in E’s best interests

When his condition is explained to him in terms he can understand, E readily grasps the situation, his need for urgent surgery and the consequences of delay. He is therefore competent to consent to treatment on his own behalf, so parental consent is not necessary. However, even if E had been deemed not competent to make a decision, the treatment could still have gone ahead as it was in E’s best interests. The consequences of not operating in this case would be profound.

* “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 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.” DH, Reference Guide to Consent for Examination or Treatment (2nd edition) (2009), p37. 

Scenario 4

Mr H is a plasterer in his late 40s. He has been experiencing pain in his left knee, on and off, for several years, but this has been adequately managed with a combination of physiotherapy and NSAIDs. One day, he comes to see his GP, Dr J, complaining of intense pain and limited movement in his knee. Dr J, noting Mr H’s history and finding, on examination, that the knee is slightly swollen, recommends an intra-articular injection of steroid.

As he is aware that Mr H is self-employed and needs to be able to return to work as soon as possible, he suggests that he administer the injection there and then. Mr H is doubtful about having an injection straight into the joint, but Dr J brushes aside his doubts, saying that it will get him “up and running in no time”. He points out that it is unlikely he will get another appointment at the practice until the following week, which will only delay his recovery.

Mr H is doubtful about having an injection straight into the joint, but Dr J brushes aside his doubts

Mr H reluctantly acquiesces, and allows Dr J to administer the injection. Unfortunately, he subsequently develops septic arthritis in the joint. Although this is successfully treated with antibiotics, he loses several more weeks’ work and decides to sue Dr J. His claim alleges invalid consent, not only because he had not been warned about the small risk of infection, but because he had felt coerced into making a hasty decision.

Scenario 5

Mr S attends the ED of his local hospital with a severe allergic reaction thought to be from an insect bite. In addition to topical applications, he is given antihistamines. The following day he is involved in a road traffic accident, having failed to stop at a road junction.

The doctor at the hospital is adamant that appropriate warnings were given. However, these were not recorded in the notes

He claims that he was not informed that the medication could cause drowsiness and that it would be inadvisable for him to drive. But the doctor at the hospital is adamant that appropriate warnings were given. However, these were not recorded in the notes.

Mr S subsequently makes a claim and the trust’s solicitors advise settlement as they would be unable to prove that appropriate warnings were given.

Scenario 6

Mrs D is 42 and has recently discovered a lump in her breast. She is told that malignancy cannot be excluded and an urgent referral to a specialist is required. She asks the GP to defer the referral, explaining that her daughter is currently preparing for important exams in five weeks’ time and she does not want to cause her any anxiety. Dr F, her GP, cannot understand how she can take such a risk but it is clear on talking to her that she fully understands the implications of her decision. Dr F records his findings along with Mrs D’s reasons for not agreeing to an immediate referral.

Scenario 7

Dr T is an F1 doctor doing a rotation in gynaecology. Mrs V is admitted prior to a Uterine Artery Embolisation (UAE) and Dr T is asked to confirm her consent to the procedure, which she gave three weeks earlier in the outpatients’ department. Further questions and some concerns have occurred to Mrs V in the intervening weeks, and she particularly wants to know how the UAE will affect her chances of conceiving and carrying a baby to term. Dr T has only a sketchy, theoretical understanding of the procedure, which he has never seen performed. He is therefore not competent to obtain Mrs V’s consent and must refer her questions to the radiologist who will be carrying out the procedure.

Scenario 8

Mr D is admitted as a day case for colonoscopy for investigation of rectal bleeding. As he wants to be able to drive himself home after the procedure, he chooses not to have any sedation. He finds the colonoscopy extremely uncomfortable and insists that the procedure be stopped. This happens just when the surgeon identifies a suspicious-looking lesion in the transverse colon. The surgeon stops the procedure and then explains the situation to Mr D, who agrees to sedation being administered so the colonoscopy can be continued and the lesion biopsied. Arrangements are then made to contact a friend to collect Mr D after the procedure.