Section 2: Medico-legal aspects

Error in a legal context

So far, we have discussed medical error in general, non-legal terms. Now we shall consider it from a strictly legal point of view. We shall look at issues surrounding consent and confidentiality, but in a legal context, as soon as one mentions error, the word negligence immediately springs to mind.

If a doctor makes a mistake in the treatment of a patient, then he or in the case of a child, his family, may decide to pursue the hospital Trust (or the doctor himself, if he provided the treatment in a private capacity) for compensation. Generally speaking, in order to win compensation, the family will have to prove that the Trust or doctor were negligent. It is important to remember that negligence as a legal concept is all about financial compensation and that the law has defined negligence in specific terms and not all errors will be considered negligent.

Negligence

Before looking in detail at what is relevant to this book, medical negligence, we need to know the basics that lie behind what is called the tort of negligence. (Tort is simply the old French word for wrong. In modern legal terms, it forms a branch of legal study.)

In principle, a person is liable in negligence if he breaches a duty owed to another in such a way as to cause damage to that person. What does this mean? In practical terms, in order to decide whether an act is negligent, a lawyer will break this formula down, looking at each of its constituent parts, phrase by phrase, word by word. For example, he will ask himself whether a duty of care exists between the injured person and the alleged defendant.

It may not always be clear whether a duty exists in a given set of circumstances, but as far as medical treatment is concerned, it is assumed that a doctor owes such a duty to his patient. The key questions in any medical negligence case are whether that duty to take care has been breached and then if it has, whether any damage has been caused as a result of that breach.

Medical negligence

Has there been a breach of duty?

When the treatment of a patient comes under scrutiny in a potential negligence claim, the first question that will be asked is: was that treatment in accordance with the standards of a body of reasonable or responsible paediatricians? If it was, then the doctor or the hospital will not have breached their duty of care; but if the treatment does not accord with the standards of a reasonable body of paediatricians, then they will have breached that duty.

This test was first formulated by the House of Lords in the case of Bolam v Friern Hospital Management Committee in 1957. Hence the Bolam test.

Over the years, a body of cases has built up that indicates how this Bolam test should be applied. How, for instance, should we look on a case where, in a given set of circumstances, one set of paediatricians may treat a child in a certain fashion while others would adopt a different approach? Answer: it is enshrined in case law that so long as both bodies of paediatricians are reasonable/responsible, then it would not matter which of the two approaches the doctor adopted. In other words, it is possible to have more than one correct approach to treatment.

But this begs the question: who determines whether you have breached your duty of care?

If the hospital has received a letter of claim from the solicitors representing the family concerning the treatment of a child, this should indicate that the family have investigated the case and gone to medical experts who have written reports critical of the care provided. At first blush, there is a case for the Trust to answer.

In response, the lawyers for the Trust will instruct experts to look at the allegations made against it. The experts will be asked to consider both breach of duty and causation. So in the first instance, the answer to the question is that the opinions of the experts, as interpreted by the lawyers, will determine the progress of the case. If both experts, the expert for the family and the expert for the Trust believe that the care was substandard (it did not accord with the standards of a reasonable body of paediatricians), then it is likely that the Trust will concede that the treating doctors and, therefore, the Trust have breached their duty of care. But what happens, if the expert for the Trust concludes that the treating clinicians have not breached their duty of care?

At this point one may say that the difference in the two opinions, that of the family’s expert and that of the Trust’s expert, simply reflects two different approaches. Have we not just said that a doctor will not breach his duty of care, so long as he acts in accordance with a reasonable body of opinion? Has not the trust’s expert supported the clinicians’ care? Is this not enough?

The short answer is that it may be, but not necessarily. The Bolam test has been qualified or rather refined by the case of Bolitho v City and Hackney Health Authority. The judges in this 1993 case stated that although one group of so-called reasonable practitioners may adopt a certain approach to treatment, if that approach does not stand up to logical analysis, then a doctor cannot expect his treatment of the patient to be endorsed, if he adopted that apparently ‘reasonable’, but illogical approach to treatment. This is just one way in which the competing views of experts may be resolved. But it may come down to something less tangible: merely that one expert is more believable than another.

At the end of the day, if the case cannot be determined by other means, it will come before a judge, who will hear all the evidence, listen to the experts and decide which of them he prefers. It is, of course, he who will be the final arbiter. But before then, depending upon where in the United Kingdom the case is brought (the procedural rules differ from jurisdiction to jurisdiction), evidence will have been disclosed, meetings will be held and views will crystalize. The experts for the opposing sides will have met and their opinions may shift one way or the other. The reality is that few cases will go before a judge. They will either be settled out of court or the family will decide to drop the case.

Causation

But let us assume that the family prove that the doctor or Trust has breached their duty of care to the child. This does not automatically mean that they will be awarded any money. In order to obtain compensation, they must clear the causation hurdle. They must demonstrate that the breach of duty caused some injury or damage to their child, that it changed the outcome for the worse.

In some cases, causation is uncomplicated and straightforward. In others, it can be fiendishly complex. In the context of this book, we shall not delve too deeply into its intricacies, but hope to give you some idea of its basic concepts.

As an example of straightforward causation, take the case of a young child with a slipped upper femoral epiphysis. The doctor knows that if the operation is performed appropriately, there will be a good outcome. The doctor undertakes the procedure, but he performs it in a substandard fashion. The child is left with a bad limp. The family will easily prove causation: the poor performance of the procedure has caused the child’s injury.

Causation will be far less easy to prove in a case of septicaemia. A child is admitted to the ward with a rash which the doctor should have diagnosed as being evidence of meningococcal septicaemia. Within a matter of hours, the child’s condition deteriorates. The child dies. The causation question to address is: would the child’s life have been saved if appropriate antibiotics and fluids had been administered, when the child presented? This question may prove difficult to resolve. Its answer will depend on a careful analysis by the experts of the medical and nursing notes to see how the child’s condition deteriorated during his time in hospital and a judgement on how effective earlier treatment would have been.

Damages

The purpose of a claim in negligence is to provide the child and family with compensation for any harm done to him through substandard care. Once it is established that the Trust has breached its duty of care to the child and that that breach has caused injury, the court will move on to determine how much the child should be awarded in damages.

Clearly, it is impossible to adequately compensate someone in monetary terms for the physical disabilities they may suffer as a result of negligence, but the idea behind compensation is to put the child in the same position as he would have been, if the error had not been made.

The child will be given a sum of money which is designed to compensate him for his pain and suffering. He will also receive a sum to compensate him for any monetary expense arising from the negligence which he has incurred in the past: for example, the costs of physiotherapy.

Finally, he will be compensated for the future losses that he will incur as a result of the negligence. The sorts of loss will depend on the severity of the child’s injury. In the most severe cases of brain damage, the compensation for future loss could include sums for loss of earnings, the cost of buying and adapting a suitable home, the costs of nursing care, physiotherapy, occupational therapy, speech therapy and computer technology to aid in communication. Over the lifetime of a brain-damaged child the loss that he will suffer as a result of negligence could easily be several million pounds, depending on his life expectancy.

The child may receive the damages as a one-off lump sum payment. Alternatively, he may receive periodical payments spread over his lifetime.

If, however, a child dies as a result of negligence, then the damages will be very limited. His estate will be awarded a sum for his pain and suffering and his funeral expenses. The parents will also receive a statutory sum for bereavement damages that is currently set at £11,800.

The limitation period

An adult injured through medical negligence has three years to start his claim formally in the courts. (This three-year period runs essentially from the time when the negligence occurred, but is more accurately defined by when the person harmed knew of the negligence.) Although the court can extend this limitation period in certain circumstances, if he fails to start court proceedings within these three years, he can no longer pursue his claim.

The rules concerning children are different. Children are not considered to have legal capacity until they are eighteen. Before then, a child’s case will be brought on his behalf by his parents, standing in the child’s legal shoes. The ‘limitation clock’ does not start to tick until the 18th birthday. Therefore, a child who has suffered injury has until he is 21 to bring a claim.

However, if a person lacks mental capacity beyond the age of 18, the limitation clock may never start to run. He can then bring a case at any point in his life. ‘Mental capacity’ in this context means the ability to run one’s own financial affairs; it is different from the test for capacity in Consent cases (see below).

The most expensive cases, the ones that cost millions of pounds, are often those that concern brain-damaged infants from the most severe cases to those suffering some form of developmental delay (e.g. through an alleged delay in diagnosing and treating meningitis). It is not unusual for these cases to be litigated 20, 30 or more years after the date of the alleged negligence. This may seem strange. There are several reasons why this may be so. But the family often only discover the true difficulties of looking after a brain-damaged child when the child grows older and his lack of mobility becomes a problem and it may be only then that their thoughts turn to suing the clinical team that treated their child. Or it may be that the family’s lawyer will advise them to delay the claim until the impact of the injury on the child and family can be fully assessed.

When a patient dies, whether a child or an adult, his personal representatives will have three years to start proceedings. This three years runs from the date of death or when it was known that there had been a mistake, if this is later.

Jurisdictions

The United Kingdom is divided into a number of different legal jurisdictions. In certain areas of law, England and Wales, Scotland and Northern Ireland have their own, different set of rules, as do also the Channel Islands and the Isle of Man. However, what we have said above about medical negligence applies to all jurisdictions. (The Scottish word for tort is delict, but the principles are the same.) However, these jurisdictions do have their own rules for procedure, that affect how a case is litigated.

The defence of the NHS trusts in medical negligence cases is also organized in different ways. Thus the NHSLA is responsible for cases in England, whereas Welsh Health Legal Services is responsible in Wales. In essence, however, defence of such cases is financed out of central funds, no matter where in the United Kingdom NHS hospital cases are litigated.

Issues around consent

Consent to treatment is the foundation of patient autonomy and is fundamental to the trust that should exist between the doctor/nurse and the patient. It is required for all aspects of treatment, from the administration of routine antibiotics to the most complicated and demanding of surgical procedures. (It forms an important aspect of research projects. However, consent in research is beyond the scope of this book and is not dealt with here.)

From the standpoint of the paediatrician confronted with an ill child to treat, his wish is to help that child and his parents by applying his medical knowledge to cure and alleviate suffering. That said, the general rule is that a patient, no matter what his age, a child or adult, cannot be made to accept treatment that he does not want. It is does not matter how painless, beneficial and risk-free that treatment would be; the patient is fully within his rights to refuse what he is offered. It is irrelevant that the consequences of refusal may be dire or fatal.

To put it bluntly, in legal terms, if the doctor treats without the patient’s consent, he is liable in the tort of battery. In layman’s terms, he commits an assault.

That is the general rule. But there are exceptions to this rule, some of which may apply to patients whatever their age and some of which apply only to children and are, therefore, of special concern to the paediatrician. These exceptions will be discussed below. But we must first describe the framework within which consent operates.

Validity of consent

A patient’s consent is valid, if it is given voluntarily, and if the patient has the mental capacity to understand the nature of the treatment and has been given sufficient information about the procedure to understand its nature. In the context of errors, we are, therefore, interested in failures on the part of the paediatrician to provide sufficient information and failures to respect the autonomy of the patient, that is, ignoring his wishes. Before looking at these error types, we wish to focus on the issue of capacity to consent.

Capacity

As a paediatrician, a doctor will deal on a day-to-day basis with issues of capacity that differ markedly from those that confront clinicians in other branches of medicine. This arises out of the nature of the speciality, because the patient is a child. This feature of the paediatrician’s work will have become second nature to him and need not be problematic, provided that he keeps in mind the basic rules of capacity as far as they concern children. They are:

• Children aged 16 and over are presumed to have the same capacity as an adult to consent to medical treatment (Family Law Reform Act 1969).
  
• Except in emergencies, the consent of a parent or, more accurately, someone with parental responsibility will be required for those children who lack the capacity to understand the nature of the treatment being offered.
  
• A child under the age of 16 may have capacity, provided he is capable of understanding the nature of the proposed course of treatment and is capable of expressing that wish. Such a child is referred to as Fraser competent. (Such children were known as Gillick competent. The two terms can be used interchangeably, though strictly speaking Fraser competent is how such children are referred to nowadays.) There is no fixed age at which a child becomes Fraser competent. It depends on the maturity of each individual child. Usually, the Fraser test will cause few difficulties, as both parent and child will agree on the treatment and be involved in the decision-making process. The problem typically arises when a young girl turns up at the hospital asking for a termination of pregnancy, determined to keep her condition from her parents. Then the doctor will have to carefully assess the capacity of this child, to determine whether she is competent to understand.

The above points constitute the basic special rules for a child’s capacity to consent. However, a doctor should not assume that just because a child is over 16, he is competent to consent; the child may lack capacity because he suffers from some mental condition. Thus the doctor should still assess whether he has capacity by applying the general rules for competency. They are in reality an extended form of the Fraser test. Under these, a person is competent, if he can:

• understand and retain information pertinent to the decision about his care, that is, the nature, purpose and possible consequences of the proposed investigations or treatment, as well as the consequences of not having treatment;
  
• use this information to consider whether or not he should consent to the intervention offered;
  
• communicate his wishes.

Sometimes, the very condition from which the child is suffering may affect their ability to make decisions about the treatment of their condition and deny them the capacity to make effective treatment decisions. Take the case that appeared before the court of a 16-year-old girl suffering from anorexia nervosa, who refused treatment for her condition. Although she had the capacity to consent to treatment under the Family Law Reform Act, the Court of Appeal doubted whether she had sufficient understanding to refuse treatment, because it is a feature of anorexia nervosa that patients have a distorted view of what is a normal body image and this renders them incapable of making an informed decision. In circumstances such as this, a doctor should contact the Trust’s solicitors for advice and, if appropriate, make an application to the court for directions on what treatment, if any, is to be provided.

Parental responsibility

We have explained that someone with ‘parental responsibility’ must give consent, where the child lacks competence.

The Children Act 1989 outlines who has parental responsibility. Under the provisions of this Act, the following have parental responsibility:

• a mother – she will always have parental responsibility for her child;
  
• a father – but he will only have this responsibility if he was married to the mother when the child was born or has acquired legal responsibility for his child by one of the following processes:
  
  
  
  • (from 1 December 2003) by jointly registering the birth of the child with the mother;
    
  • by a parental responsibility agreement with the mother;
    
  • by a parental responsibility order, made by a court;
  
  
• the child’s legally appointed guardian;
  
• a local authority designated in a care order over the child;
  
• a local authority or other authorized person who holds an emergency protection order for the child.

Children who are wards of court will need to have their ‘important steps’ approved by the court. A doctor should have a copy of the ward papers with the medical records, so that he can see what routine treatment can be offered without reference to the court.

Foster parents and grandparents do not automatically have parental responsibility. Nor do parents under the age of 16. If the parents are themselves under 16, then they can only give consent to treatment of their child, if they themselves are Fraser competent.

Grandparents and foster parents will only be able to give consent if authority to give consent has been devolved to them. But where there is no specific agreement between parents and someone else, that other person can give consent providing that it is in the best interests of the child. For example, if a child is injured in the playground at school and his parents cannot be contacted then it may be a teacher that brings him into the ED for treatment. That teacher can give valid consent for any treatment that is required.

For the rest of this section on Consent, when we refer to ‘parents’, this should be taken as meaning those with parental responsibility, where it is appropriate from the context.

Respecting patient autonomy

As a rule and just like any other patient, a child and/or his parents have the right to refuse treatment for any reason whatsoever. However, this general rule does have exceptions.

Parents refusing treatment

Parents must exercise their power to give or withhold consent for the treatment of their child in his best interests, not their own. They may withhold consent for any number of reasons. If their child suffers from a terminal condition, they may decide that he would not benefit from further painful treatment which only has a slim chance of prolonging life. Whether that decision is the right one must be judged from the standpoint of what is best for the child.

So what happens when a parents for whatever reason refuses the treatment suggested for their child against the doctor’s advice? The common example is that of Jehovah’s Witnesses refusing to allow a doctor to administer to their child potentially life-saving blood products. If he is confronted with this situation, through the Trust’s solicitors, the doctor should apply to court for a decision on whether the blood products can be administered. In making its decision, the court will look at the best interests of the child; his welfare will be of paramount concern. Such decisions can be made surprisingly quickly. If this scenario arises on a doctor’s watch, then he should contact the Trust’s solicitors immediately. They should be able to make an application to the court and obtain a decision within a matter of hours.

Child refusing treatment

A competent adult can refuse any treatment for himself, no matter how vital. But this rule may not apply to the Fraser competent child. So in the case of a 15-year-old Jehovah’s Witness, the court ordered that a life-saving transfusion be administered to him, despite both the child and his parents objecting. The order was made because it was in the best interests of the child. The lesson that we can draw from this is that although Fraser competence allows the child to consent to treatment, such competence does not mean that their refusal to accept treatment is final.

The issue is best determined by the court if there is time to make an application to a judge.

Emergency treatment

In an emergency, a doctor will be within his rights to treat a child who lacks capacity to consent without the authority of the parents or the court. The situation is similar to the treatment of patients who are temporarily incapacitated. Everyday, patients are brought to the ED unconscious after an accident. They are attended to immediately despite the fact that they cannot give consent. Such treatment is justified by the legal doctrine of necessity.

Information to be provided

Consent to treatment should be an expression of patient choice. But if a doctor does not give the child and their parents sufficient relevant information concerning the proposed treatment, then the choice they make will not be properly informed. This will invalidate any ‘consent’ or agreement to treatment and lay the doctor open to legal criticism and a potential claim. Such an error will surface, as far as the law is concerned, when the treatment for which ‘consent’ was given ends in a poor outcome. It is at that point that the family will complain.

In terms of the information to be given, a doctor’s duty is defined by the terms of the Bolam test for negligence. In other words, he is to give the information regarding risks, side effects and consequences that is thought appropriate in the circumstances by a reasonable or responsible body of fellow paediatricians. Doctors commonly think that there is no need to warn of risks that have a less than 1% chance of occurring. In some cases, this may be good practical advice, but it is not an accurate reflection of the law. A doctor should always assess the parents, the child and the condition and gauge what information they require.

Child protection cases

Child protection cases often involve very young children who are not competent or able to give consent themselves. In such cases, a doctor may wish to investigate or treat the child, in circumstances where the parents will not give their consent. For example, he may want to perform a skeletal survey for new or old fractures in a child. In deciding whether he can proceed, a distinction should be drawn between treatment, on the one hand, and investigation, on the other.

If a doctor wishes to investigate the condition of the child, then he should not proceed without parental consent, especially if the investigation entails an intimate examination. If the parents do not give their consent, then he will need a court order before examining the child. But if the doctor wants to treat the child, then he would be justified in proceeding without the parent’s consent, providing that he can satisfy himself that the treatment is in the child’s best interests. Of course, there may be times, when treatment and investigation become one and the same thing. If this occurs, the doctor should primarily think of the child’s best interests and act on this basis.

GMC booklet

As a general comment, the issue of consent is a complex area of law. The GMC has published guidance in the form of a booklet entitled Consent: Patients and Doctors Making Decisions Together.

Confidentiality (Case 8)

‘Whatever I see or hear, professionally or privately, which ought not to be divulged, I will keep secret and tell no one’: The words are those of Hippocrates. They form part of his oath and are still an important article of the doctor/patient relationship. Hippocrates simply gives voice to the fact that a full history is an essential requirement for diagnosis and treatment and the patient must feel able to tell his doctor everything relevant to his condition, even the most embarrassing and personal details, without fear that those details will be divulged to others. Updating the words of Hippocrates and putting them in legal terms, a doctor owes a duty of confidence regarding information about his patient or others acquired in his capacity as a doctor. This duty applies whether the information comes from other people or from the patient himself.

If a doctor breaches this duty of confidence then he could be sued for damages, but more likely he will be reported to the GMC. As far as it affects clinicians, the law concerning confidentiality is fashioned from a number of different sources. Primarily, there is the common law duty of confidence (constructed from court judgements). In the last few decades, this has been supplemented by a number of Acts of Parliament: namely, The Access to Health Records Act (1990), The Data Protection Act (1998) and The Human Rights Act (1998). These different elements combine to create a more or less coherent whole. What we have set out below represents a basic outline of this legal framework.

Starting with the basics, a doctor can disclose information to others if he has consent of the patient, that is, the child or, if he lacks capacity (is under 16 and is not Fraser competent), his parents. But consent can be implied. Most patients understand that a doctor will share information about them with other members of the health team. In other words, the doctor can assume that he has the patient’s implied consent to do this.

This may seem obvious, but a doctor should, where appropriate, consider just how far this implied consent extends for any given course of treatment. It may not extend to highly personal details about the child and his family that he has learned in treating some other, previous illness. The doctor in charge of the team should consider what information it is necessary to disclose when treating the child. If he discloses information of a highly personal nature to the members of his team, then he should make it clear that the information is disclosed to them in confidence. He should also tell the family and/or the child that the information has been shared with other members of the team.

Confidentiality issues particular to paediatrics

Unlike clinicians in other specialties, paediatricians will often receive information from people other than their immediate patient, the child. Frequently, it is the parents who will provide much of the relevant history. This should not cause a problem in itself, but a doctor could find that the parents divulge information about themselves or each other that is of a highly personal nature. Though the doctor’s primary duty is to the child, he also owes a duty of confidence to the parents in relation to any information that they may have divulged about themselves.

If the doctor records that information concerning the parent in the child’s medical records, then what should he do when someone asks for disclosure of the child’s records? It would depend on why the notes were to be disclosed. But in order to protect the confidentiality of the parent, he should ensure that the information is removed or blanked out (in legal terminology, redacted) in the copying of the notes. Alternatively, he may disclose the records in their unedited form, providing he has obtained the parent’s consent.

Although the general rule is that a doctor should not disclose information without the patient’s consent, there may be circumstances where he would be justified in disclosing information about a child without consent, on the basis that it would be in the child’s medical interest.

For example, a doctor may be presented with a child who is seeking a termination of pregnancy but is not Fraser competent. Having decided that he cannot go ahead with the termination that the child seeks, because she lacks capacity, the clinician should try to persuade her that her parents should be involved in the consultation. If she cannot be persuaded, but the doctor is convinced that the disclosure of the pregnancy would be in the child’s best medical interests, then he would be justified in informing an appropriate person of the consultation and what he has learnt from it: that the child is pregnant. That appropriate person may be the child’s GP or her parents. But the doctor should still inform her of his decision and that he will be informing others of her condition.

Obviously, if the child is Fraser competent and has sufficient understanding of her condition and the treatment options and risks, then he must respect the duty of confidentiality that exists between himself and her.

Data Protection Act 1998

Generally speaking, patients seek disclosure of their records under the Data Protection Act. It is most frequently ‘used’ for this purpose. However, disclosure of records represents only a small part of its purpose.

To comply with the Act, each Trust should have in place a number of protocols to safeguard the confidentiality of patient information. For example, the physical paper records should be carefully stored in a secure environment. Any electronic data (e.g. radiographs) should be protected with access only allowed to those with passwords.

There are any number of ‘obvious’ things that a doctor can do to ensure compliance, like marking letters with confidential information ‘private and confidential’; taking care over typed handover sheets, making sure that they are not left in the canteen; and not leaving computer screens on to be read by prying eyes.

Disclosure without consent

There are a number of other circumstances in which a doctor can legitimately disclose patient information to another without the consent of the child or his parents:

• Abuse or neglect: Where the doctor believes that the child may be the victim of abuse or neglect and the child is unable to give or withhold consent for disclosure, then the child’s health is of paramount importance and he may disclose his belief to an appropriate, responsible person.
  
• Statutory obligation: A doctor is required to notify the appropriate authorities, if he attends upon someone suffering from an infectious disease or someone who is known or suspected to be addicted to controlled drugs.
  
• Public interest: A doctor may disclose patient information, if he believes that the patient presents a real risk of danger or serious harm to the public. Given that the patients of a paediatrician are children, it is unlikely that a paediatrician will be confronted with such instances often, if ever. But he may come across an older child who presents as mentally unstable. If he believes this instability could manifest itself in extreme violence to others, then he may disclose this belief to the proper authorities.
  
• When ordered by the court to do so: A doctor should not assume that simply because a lawyer or some figure of authority, such as a police officer, asks for disclosure of the child’s records, they are entitled to see the medical records. He should only disclose the records, if the child or his parents have consented or the court has ordered disclosure.

Caldicott Guardians

Each Trust and health service body should employ a Caldicott Guardian. Much of the work of the Caldicott Guardian relates to compliance with statutory obligations. His role is to ensure that patient information is dealt with in an appropriate fashion and that there are systems in place to ensure that all clinicians and the Trust generally respect the duty of confidentiality that exists between them and the patients that they serve. Therefore, he should be a first port of call, if an issue arises concerning the use of confidential information.

References and further reading

Department of Health (2000) An Organisation with a Memory: The Report of an Expert Group on Learning from Adverse Events in the NHS, Chaired by the Chief Medical Officer. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/Browsable/DH_4098184

GMC (2006) Good Medical Practice. www.gmc-uk.org/guidance/good_medical_practice.asp

GMC (2008) Consent: Patients and Doctors making decisions together. http://www.gmc-uk.org/guidance/ethical_guidance/consent_guidance_index.asp