Army Suicide Prevention Policy
Guidelines for medical officers—confidentiality
and consent
REFERENCES:[16]
A. JSP 346. PULHHEEMS—A Joint Service
System of Medical Classification.
B. Confidentiality: Protecting and Providing
Information. General Medical Council September 2000.
C. Guidance on Ethics for Occupational Physicians,
5th Edition, May 1999. The Faculty of Occupational Physicians.
D. JSP 400. Disclosure of Information.
E. Queen's Regulations for the Army 1975.
F. LANDSO 3203. Discipline—Reporting
to the Police and Investigation of Crime and Serious Incidents.
G. D/AMD/31/33/1 dated 27 February 2003
(DGPL 65/03).
INTRODUCTION
1. The immediate clinical management of
attempted suicide and self-harm in the Army is the same as in
routine medical practice. Subsequently the occupational demands
of military service mean that many of these patients will need
to be medically downgraded and have their employability restricted,
in accordance with Reference A. The detailed management of cases
is normally the province of mental health professionals, and welfare
and chaplaincy services are regularly involved. Nevertheless,
the increased availability of the means of suicide (notably firearms)
in the military requires particular care in managing those who
may be at risk. The possibility that such events may be manifestations
of underlying problems, such as bullying, also calls for special
considerations in dealing with patients, and the possibility of
threats to life or of serious injury to others in the military
and civilian community should also be considered.
2. Medical officers may feel that the need
to provide relevant information to appropriate agencies threatens
their duties as a doctor in respect of confidentiality and consent.
This DGAMS Policy Letter provides guidelines within which medical
officers may provide such information. All references to the masculine
gender are to be interpreted as applying equally to the feminine.
CURRENT GUIDANCE
3. Detailed guidance on confidentiality
for doctors (extract enclosed), with which all medical officers
should be familiar, and amplified in Reference C for occupational
physicians. In essence, the principle of confidentiality of medical
information is paramount, except where overridden by specified
exceptions, of which the need to protect the patient or others
from the risk of death or serious harm is most relevant in attempted
suicide and self-harm. MoD policy on disclosure of medical information
is contained in Chapter 4 of Reference D.
4. The medical officer is the adviser to
the unit commanding officer on all matters pertaining to the prevention
of sickness and the maintenance of health of all personnel, as
described in Chapter 5 of Reference E.
AIM
5. The aim of this Policy Letter is to highlight
areas of concern over confidentiality which may arise for medical
officers dealing with attempted suicide and self-harm, to inform
medical officers of their role in this part of the Army's suicide
prevention strategy, and to guide them in decision making. It
should be read in conjunction with the detailed guidance on confidentiality
for doctors contained in Reference B.
ROLE OF
OTHER AGENCIES
6. The commanding officer of a unit has
responsibility for the safety and health of the troops under his
command, as described in Chapter 3 of Reference E. He has detailed
knowledge of his unit and its tasks and responsibilities, which
makes him able to assess the wider implications of the health
of personnel under his command. His powers of authority and access
to other agencies enable him to act to support individuals and
ensure the safety and health of all those for whom he is responsible.
He is the first point of contact for employment matters as described
below.
7. Medical officers should be aware that
the Royal Military Police (RMP) have a role in the investigation
of attempted suicide and self-harm, described in Reference F.
The Special Investigation Branch of the RMP will investigate cases
that are notified to them by the commanding officer or RMP. The
rationale underlying the requirement to report incidents is to
expose bullying and other serious offences, and any possibility
that the injury may not have been self-inflicted, but caused by
a third party: without compulsion to report the matter, there
might be temptation to avoid embarrassing revelations. The RMP
may approach the medical officer for information, in which case
he will be guided by Reference B.
MEDICAL ISSUES
8. Many cases of attempted or contemplated
suicide will present to a medical officer alone, and they will
deal with each case on clinical grounds. There are, however, issues
of particular relevance to military medical practice, which may
arise and present a challenge to the principle of confidentiality.
9. The medical officer has a dual responsibility
to the patient and to the Army, particularly to safeguard the
health of members of the Armed Forces and others who may be affected
by their actions. To meet this responsibility, he must evaluate
the risk to the patient and to others, as described below. To
achieve this he should ensure that he has as much information
about the case as possible, including knowledge of the military
employment of the individual. It will usually be necessary to
consult commanding officers or their staff to obtain information
to inform this evaluation.
DISCLOSURE
10. The following should be considered in
all cases of attempted suicide and self harm.
(a) Is there a risk of death or serious harm
to the patient? In particular might he be at risk given access
to lethal means, such as a loaded firearm or explosive material?
If so, then the commanding officer or other authority must be
informed, at once if necessary, of employment restrictions such
as unfitness to handle live weapons, to work in an armoury, or
to handle hazardous material. Such employment restrictions should
be phrased in such a way as to avoid disclosure of clinical diagnosis.
Limited medical disclosure to the commanding officer may be justified
to protect the patient as described in paragraph 36 of Reference
B.
(b) Is there a direct risk of death or serious
harm to others? The need to limit access to the means to cause
harm to others, through employment restrictions, may arise in
the same way as described above, and disclosure may be justified
under the same paragraph.
(c) Is there an indirect risk of death or
serious harm to others? Bullying may be a precipitating cause
of attempted or contemplated suicide, and thus the possibility
that others are similarly at personal risk should be considered.
In these circumstances, consent for disclosure should be actively
sought, but even if this is withheld, the medical officer should
consider disclosure since failure to do so might expose others
to unacceptable risk. This is permissible in accordance with the
GMC's guidelines at Paragraphs 36 and 37c of Reference B.
(d) Is there a possibility that the cause
of injury is not self-inflicted, but inflicted by others? Disclosure
(with consent if possible) may also be required to assist in the
prevention or detection of a serious crime.
11. Wherever possible (in accordance with
the guidance in Reference B) every attempt should be made to secure
consent for any disclosure of information. Ideally consent should
be given in writing, but in all circumstances it must be fully
documented in the clinical notes. Disclosure of medical information,
whether with consent or not, should be made in private to the
commanding officer, who must be made aware of the confidential
nature of the disclosure. Even if consent has been withheld, the
patient should normally be informed of the disclosure unless there
are over-riding reasons (which must be fully documented).
12. If there is no evidence that the patient
or others are at continued risk, or that a crime has been committed,
there is no absolute requirement for the medical officer to proactively
report the detail of the case to the commanding officer or RMP.
If the medical officer is questioned directly by the commanding
officer, he should be guided by his knowledge of the case and
professional judgement in formulating his response, and if necessary
should seek the advice of a senior colleague.
FURTHER ADVICE
13. In difficult circumstances a medical
officer is advised to discuss the matter with a senior medical
officer, a mental health professional, AMD Medico-Legal Department,
or with their medical protection organisation. There will be rare
occasions when there is an immediate need to take action, in advance
of seeking such advice, and the medical officer should then act
in the public interest in accordance with the principles in Reference
B. Clear and contemporaneous records should always be kept. These
will assist should the medical officer be called to account for
his actions by the General Medical Council or in a Court of Law.
FOLLOW UP
14. In accordance with Reference G, every
episode of suicide, attempted suicide and self harm should subsequently
be the subject of significant event analysis in primary care,
as part of the implementation of clinical governance guidelines.
DISCLOSURES TO
PROTECT THE
PATIENT OR
OTHERS
15. Disclosure of personal information without
consent may be justified where failure to do so may expose the
patient or others to risk or death or serious harm. Where third
parties are exposed to a risk so serious that it outweighs the
patient's privacy interest, you should seek consent to disclosure
where practicable. If it is not practicable, you should disclose
information promptly to an appropriate person or authority. You
should generally inform the patient before disclosing the information.
16. Such circumstances may arise, for example:
(a) Where a colleague, who is also a patient,
is placing patients at risk as a result of illness or other medical
condition. If you are in doubt about whether disclosure is justified
you should consult an experienced colleague, or seek advice from
a professional organisation. The safety of patients must come
first at all times. (Our booklet Serious Communicable Diseases
gives further guidance on this issue.)
(b) Where a patient continues to drive, against
medical advice, when unfit to do so. In such circumstances you
should disclose relevant information to the medical adviser of
the Driver and Vehicle Licensing Agency without delay.
(c) Where a disclosure may assist in the prevention
or detection of a serious crime. Serious crimes, in this context,
will put someone at risk of death or serious harm, and will usually
be crimes against the person, such as abuse of children.
16 Not printed. Back
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