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Chester vs Afshar 2004
This is the Consent Form that has been introduced by Dartford & Gravesend NHS
Trust
(something similar has been introduced at the St Peters & Ashford Hospitals;
it is likely other NHS Trusts have done so however I have not, as yet, come across
them).

The
Chester vs Afshar case is mentioned (highlighted in green) however there is
minimal space to list the various warnings as demanded by the ruling of the
Chester vs Afshar case!
Last Updated 5th May 2016
Introduction

It is a general legal and ethical principle that valid consent must be obtained before
starting treatment or physical investigation or providing personal care for a person.

This principle reflects the right of patients to determine what happens to their own
bodies, and is a fundamental part of good practice.

A healthcare professional (or other healthcare staff) who does not respect this
principle may be liable both to legal action by the patient and to action by their
professional body.

If healthcare professionals (or other healthcare staff) fail to obtain proper consent
and the patient subsequently suffers harm as a result of treatment, this may be a
factor in a claim of negligence against the healthcare professional involved.

Poor handling of the consent process may also result in complaints from patients
through the
NHS complaints procedure or to professional bodies.


What is Consent?

In order for there to be an effective consent to treatment, it is not enough to show
that the patient said "
yes".  There must be genuine agreement to receive the
treatment.  It is necessary to show that:

  • The patient is competent
  • The patient is sufficiently informed &
  • The patient is not subject to coercion or undue influence


Chester vs. Afshar

This case involved a patient with lumbar disc protrusion who was operated on
electively 3 days after initial consultation by the surgeon.

The patient ultimately ended up with
cauda equina syndrome and proceeded to
sue the surgeon on grounds of negligence.

Cauda equina syndrome was considered as a recognised risk of the surgery but
the patient was not informed of this risk pre-operatively.  The patient admitted that,
having known of this, she would still have undergone surgery.  However, she
claimed that she would have sought a second opinion had she had more time to do
so.  After an involved legal process, the award of compensation to the patient was
finally ordered in the House of Lords.

In a majority judgment (3:2), it was held that
patients should be told of any
possible serious risks associated with their proposed medical treatment
.

Crucially, the Law Lords ruled that
to succeed in a claim for negligence, the
patient did not have to prove that they would have rejected the treatment
that had been inadequately explained to them, only that they might have
sought further advice or time to reflect further before making a decision
.


The judge held that
the operation was not negligently performed but that Mr
Afshar was negligent in not properly informing Ms Chester of the risks
.  Had
he done so, she would have sought second or even third opinions and would not
have had the surgery when she did.  Therefore, he was responsible for her injuries.

The House of Lords concluded that,
though the failure to warn was not a direct
cause of injury, it did result in negligence
.


Chester vs Afshar Consequences

General Medical Council.  In the wake of this judgment, the General Medical
Council
issued revised guidance.  It emphasises the duty of doctors to act in
partnership with their patients with respect to obtaining their consent to medical
treatment.

Doctors are advised to
disclose risks arising from treatment that may result in
common but minor side effects, as well as rare but serious adverse outcomes that
may result in permanent disability or death
.   The guidance specifically states that
where risks are beyond the minor or routine, the patient’s written consent should
be obtained
.


NHS Litigation Authority 2004.

Recommendations

  • Extreme care in the taking of consent is even more crucial than ever.
  • Careful & comprehensible warnings about all significant possible adverse
    outcomes must be given.
  • These warnings must be properly recorded in the notes.
  • The patient should be invited to sign the relevant entry to confirm that he / she
    has been given the warnings, has understood it and accepts the risk.
  • It is equally important to make a full entry in the notes, preferably signed by
    the claimant, if treatment is refused, including the reason when given.
  • Whenever possible, the clinician who discussed and is able to perform the
    treatment should be the one who obtains the consent.


Hempsons Solicitors 2005.

The advice after
Chester was that surgeons should carefully record in the patient’s
notes the risks of which they have warned the patient and ask the patient to sign
that record.  The implication of
Chester applying to other medical treatment is that
all doctors might have to follow this advice when prescribing any drug with
potentially serious side effects ...and this in itself would be a serious side effect of
Chester.


Medical Protection Society 2008.

The
Chester case established on policy grounds that the patient’s autonomy and
dignity required that
she be allowed the time to make an informed decision.  So, in
the wake of
Chester v Afshar, it is imperative that care is taken to warn patients
about all risks material to their decision and, when time permits, that they are
encouraged to consider their options over time before deciding whether or not to
undergo treatment
.


Department of Health, Reference guide to consent for examination or treatment.  
2nd Edition.  2009
.

Chester v Afshar.  The House of Lords judgment held that a failure to warn a
patient of a risk of injury inherent in surgery, however small the probability of the
risk occurring, denies the patient the chance to make a fully informed decision.  The
judgment held that
it is advisable that health practitioners give information about
all significant possible adverse outcomes and make a record of the information
given
.
In Practice

Chester vs Afshar boils down to 2 principles:

  1. All risks (no matter how small) and information must be given to the patient.
  2. The patient has to have time to digest and think on the information given
    regarding the risks attendant on the operation.

Thus, information has to be provided and this can be in the form of information
sheets, websites, DVD's etc.

Enough time to digest and think through the information means that the patient is
not given all this information just prior to the procedure. This is inappropriate as:

  1. There is a lack of time to permit a considered decision
  2. It is in an inappropriate environment for sympathetic and considerate discussion
  3. There is a perceived lack of any alternative to acquiescence on the part of the
    patient.
  4. There is a placing of a definitive decision at the culmination of a preparation
    process rather than closer to the outset

The confirmation of consent is best obtained outside of the procedure room and
would be reflective of an ethos of good patient centred practice with regard for
timeliness and unpressured decision making.

Also, “
If a person is not asked to signify their consent until just before the
procedure is due to start, at a time when they may be feeling particularly
vulnerable, there may be real doubt as to its validity.
”  DOH Model Policy
Useful Articles:

Medical Law Review 2002.  Clinical Negligence - Informed Consent & Causation.  
Chester v. Afshar

Hempsons Solicitors.  Issue_16_Healthcare_Summer_2005

Ann R Coll Surg Engl 2008.  Written consent – a prospective audit of practices for
ENT patients.

Ortho Update 2008.  Informed Consent & Orthodontic Treatment

MPS Guide to Consent in the UK.  2008

Department of Health.  Reference guide to consent for examination or treatment.  
2nd Edition.  2009

New Law Journal 2010.  Personal Injury - Medical Negligence.  A Moving Target

Chester v Afshar & Causation in the House of Lords.  C J Lewis

Informed Consent Through The Back Door.  Case Note - Chester v Afshar 2004.  
Rob Heywood

BDJ 2015.  The Changing Face of Informed Consent

BDJ 2015.  Risk Communication in the Dental Practice

BMJ 2015.  New Rules of Consent - The Patient Decides


Useful Websites:

Wikipedia

LexisWeb