Lesson 5 - Documentation, Confidentiality, Consent and Capacity
1. Introduction
Good mental health care depends not only on what practitioners do, but also on how their work is recorded, how information is protected and whether the person has understood and agreed to what is being proposed.
Documentation, confidentiality, consent and capacity are closely connected. A well-written clinical record demonstrates what information was obtained, what decisions were made, what the person understood, what they agreed to and why information was shared. Poor documentation can create clinical risk, disrupt continuity of care and make it difficult to explain or defend a decision later.
Confidentiality is central to a trusting therapeutic relationship, but it is not absolute. There are circumstances in which information may need to be shared to protect the person or somebody else from harm. Practitioners must understand when consent should be sought, when information can be shared without consent and when senior or safeguarding advice is required.
Capacity concerns whether a person can make a particular decision at the time it needs to be made. It must not be judged solely from a diagnosis, disability, appearance or a decision with which professionals disagree.
Case workers are not expected to resolve complex legal questions independently. They are, however, expected to recognise relevant concerns, communicate clearly, keep accurate records and escalate decisions beyond their competence.
2. Learning Outcomes
By the end of this lesson, learners should be able to:
Produce clear, accurate, respectful and clinically useful records.
Explain the principles of confidentiality and recognise when information may need to be shared.
Describe the requirements for valid consent and distinguish consent from compliance.
Explain the core principles of the Mental Capacity Act 2005.
Recognise possible concerns about a person’s ability to make a specific decision.
Apply appropriate principles when working with children, young people, parents and carers.
Record and escalate complex decisions concerning confidentiality, consent or capacity.
3. The Lecture
Why Good Documentation Matters
The clinical record is part of the person’s care. It enables other members of the team to understand what has happened, what risks have been identified and what needs to happen next.
A good record supports:
continuity and coordination of care;
communication between practitioners;
monitoring of progress and risk;
accountability and clinical governance;
safeguarding;
responses to complaints, incidents or legal proceedings;
the person’s right to understand information held about them.
Records should be written on the assumption that they may later be read by the person, their authorised representative, another professional, a regulator or a court. This does not mean avoiding important information. It means writing accurately, respectfully and professionally.
The purpose of documentation is not to prove that an appointment took place. It is to create a meaningful account of the contact and the clinical decisions arising from it.
What Should Be Documented?
The exact content will depend on the appointment, but a useful record will usually include:
the date, time and method of contact;
who was present and their relationship to the person;
the purpose of the contact;
relevant information provided by the person and others;
observations made during the appointment;
changes in presentation, functioning or circumstances;
relevant risks and protective factors;
interventions, advice or support provided;
the person’s views, wishes and preferences;
consent given, declined or withdrawn where relevant;
any concerns about understanding or decision-making;
information shared with others and the reason for sharing it;
decisions made and who made them;
agreed actions, responsibilities and timescales;
any escalation, supervision or senior advice sought;
arrangements for follow-up.
Records should contain enough information to help another practitioner understand both what happened and why decisions were made.
Recording Facts, Observations and Opinions
Practitioners should distinguish between:
what the person said;
what another person said;
what the practitioner directly observed;
the practitioner’s interpretation or professional opinion.
For example:
“Daniel stated that he had not slept for three nights and felt that people were watching his home.”
This records the person’s account without presenting it as independently established fact.
A direct observation might be:
“Daniel appeared restless and repeatedly walked around the room. His speech was rapid and difficult to interrupt.”
An interpretation might then be recorded cautiously:
“His presentation appeared significantly more activated than during the previous appointment. A possible deterioration in his mental state was discussed with the supervising clinician.”
Avoid language that is judgemental or vague. Statements such as “attention seeking”, “manipulative”, “difficult” or “non-compliant” rarely explain what actually happened.
Instead of writing:
“Sarah was manipulative and refused to cooperate.”
A more useful entry might be:
“Sarah repeatedly asked for the appointment to end and declined to answer further questions. She stated that she did not feel safe discussing the issue while her father was present.”
The second entry provides information that another practitioner can understand and act upon.
Accuracy, Relevance and Proportionality
Clinical records should be accurate, relevant and limited to information needed for care, safety, governance or another legitimate purpose.
Do not include gossip, speculation or unnecessary personal details. At the same time, do not omit relevant information merely because it is sensitive or uncomfortable to record.
Names, dates, medication doses, contact details and agreed actions should be checked carefully. Copying information from an earlier entry can reproduce outdated or incorrect information. Templates can support consistency, but they should not replace individual clinical thinking.
If there is uncertainty, record it honestly. For example:
“James was unsure whether the incident occurred on Monday or Tuesday.”
A practitioner should not alter a record in a way that hides the original entry. If an error is discovered, follow the organisation’s procedure for making a dated and transparent correction or addendum.
Record Decisions, Not Only Events
One of the most common documentation problems is recording what happened without recording the reasoning behind the response.
For example:
“Discussed with senior clinician. No safeguarding referral made.”
This does not explain the decision. A more useful record would state:
“Discussed with the supervising clinician because the young person described historical physical punishment. There was no indication of current contact with the alleged perpetrator or ongoing risk. The agreed plan was to obtain further information at the next appointment and review the safeguarding decision. The rationale and follow-up plan were explained to the young person.”
When a significant decision is made, record:
the information considered;
the views of the person;
relevant risks and protective factors;
who contributed to the decision;
the decision reached;
the reasons for it;
the agreed review or follow-up arrangements.
Timeliness
Records should normally be completed as soon as practicable after the contact. Delayed documentation increases the risk of forgotten details, unclear decisions and missed actions.
If an urgent risk is identified, completing the record must not delay immediate action. The practitioner should make the person safe, contact the relevant clinician or emergency service and then document what occurred as soon as possible.
If documentation is completed later, it should be clear when the contact occurred and when the entry was written.
Confidentiality
Confidentiality means protecting information entrusted to the service and using or sharing it appropriately. It applies to information disclosed directly by a person as well as information obtained from relatives, schools, professionals, records and observations.
Confidentiality applies in all forms of communication, including:
spoken conversations;
written notes and reports;
telephone calls and voicemail;
emails and text messages;
photographs and recordings;
electronic clinical systems;
video appointments;
supervision and multidisciplinary discussions.
Confidential information should only be accessed when there is a legitimate reason connected with the practitioner’s role. Being employed by a service does not give somebody permission to browse any record held by that service.
Everyday Confidentiality
Many confidentiality breaches occur through ordinary habits rather than deliberate misconduct. Examples include:
discussing a person in a public area;
leaving a record visible on a screen;
sending an email to the wrong recipient;
using an unapproved personal account or device;
disclosing information to a relative without checking consent;
including unnecessary clinical information in an email subject line;
leaving detailed voicemail messages without confirming that it is safe;
discussing an identifiable case on social media;
accessing a record out of curiosity.
Before sharing or sending information, pause and check:
Is this the correct person or organisation?
Have I verified the recipient’s identity and contact details?
Is there a legitimate reason to share this information?
Do I have consent, or another appropriate justification?
Am I sharing only what is necessary?
Am I using an approved and secure method?
Have I recorded the decision where appropriate?
If information is accidentally disclosed, do not try to conceal the error. Inform the appropriate senior person or data protection lead promptly and follow the incident-reporting procedure.
Confidentiality Is Important but Not Absolute
People should normally be told how their information will be used and who may receive it. Where appropriate, their consent should be obtained before information is shared.
However, confidential information may sometimes be shared without consent. Examples may include situations in which:
a child or adult may be at risk of abuse or neglect;
there is a risk of serious harm to the person or someone else;
disclosure is required by law or a court order;
information is required for certain statutory functions;
sharing is necessary in the public interest;
the person lacks capacity for the relevant decision and sharing is necessary and proportionate in their best interests.
A practitioner should not promise complete secrecy. A more accurate explanation is:
“What you tell me is private within the clinical team. If I become worried that you or someone else may be at serious risk, I may need to share relevant information with people who can help. Wherever it is safe to do so, I will explain this to you first.”
Consent is not always the legal basis used to process or share health information under data protection law. Practitioners should therefore avoid assuming that information can never be shared simply because consent has been refused. Complex decisions should be discussed with a senior clinician, safeguarding lead or data protection lead.
Sharing Information Without Consent
When considering disclosure without consent, ask:
What is the nature and seriousness of the concern?
Who may be at risk?
What information is relevant?
What is the purpose of sharing it?
Who needs to receive it?
Is the disclosure necessary and proportionate?
Can the person be informed before the disclosure?
Would informing them increase risk or obstruct a safeguarding response?
Has appropriate senior advice been obtained?
Has the decision and its rationale been recorded?
Only the information required for the purpose should be shared. A safeguarding concern does not automatically justify disclosing the entire clinical record.
If a decision is made not to share information, that decision may also need to be documented, particularly when a possible risk has been considered.
Information From Relatives and Other Third Parties
Relatives, partners, schools and other professionals may provide important information. A practitioner can usually listen to information without disclosing confidential information in return.
For example, a parent may telephone to describe a young adult’s recent deterioration. The practitioner can receive and record the concern even if the young adult has not agreed to information being shared with the parent. The practitioner should not then disclose the young adult’s treatment details merely because the parent has provided information.
It is usually helpful to explain that:
the information can be received;
confidentiality may limit what can be discussed in return;
the information may need to be recorded;
it may not be possible to guarantee that the person will never become aware of its source.
Promises that information will be kept “off the record” should not be made.
Consent
Consent is the person’s agreement to an examination, intervention, treatment or other proposed action.
For consent to be valid, it should generally be:
voluntary;
informed;
given by a person with capacity or competence for the decision;
specific enough for the proposed action;
current and continuing.
Consent is a process rather than a signature. A signed form may provide evidence that a discussion occurred, but it does not by itself demonstrate that the person understood the information or agreed freely.
Supporting Informed Consent
Information should be provided in a way the person can understand. Depending on their needs, this may involve:
using plain language;
avoiding unnecessary jargon;
breaking information into manageable sections;
providing written or visual information;
using an interpreter;
addressing communication, sensory or literacy needs;
allowing additional processing time;
offering more than one discussion;
checking understanding rather than simply asking, “Do you understand?”
A useful check is to invite the person to explain the decision in their own words:
“Just so I can check that I explained it clearly, can you tell me what you understand the appointment will involve?”
The practitioner should explain relevant benefits, risks, alternatives and what may happen if the person declines. The amount of information required will depend on the nature and significance of the decision.
Voluntary Consent
Consent must be given without inappropriate pressure, coercion or undue influence.
A person may agree because they genuinely choose to do so. Alternatively, they may appear to agree because they are frightened, feel unable to disagree with a parent or professional, or believe that services will be withdrawn if they refuse.
A person’s cooperation does not automatically demonstrate consent. Similarly, reluctance or anxiety does not necessarily mean that consent is absent. The practitioner should explore the person’s understanding and wishes.
Consent can also be withdrawn. If this happens, the practitioner should clarify what the person no longer agrees to, respond appropriately and document the discussion.
Consent in Ongoing Work
Consent should not be treated as a one-time administrative exercise completed at the beginning of care.
In ongoing case work, consent may be relevant to:
involving family members;
contacting a school or employer;
sharing information with another service;
recording or photographing something;
carrying out questionnaires or interventions;
changing the purpose or nature of the work;
discussing the person in teaching or supervision beyond routine care arrangements.
If the proposed action changes substantially, consent should be revisited.
Children and Young People
Consent and confidentiality involving children and young people require careful consideration of age, maturity, understanding, parental responsibility, risk and the nature of the decision.
A young person aged 16 or 17 is generally presumed able to consent to their own treatment, although concerns about capacity must be considered in accordance with the relevant legal framework.
A child under 16 may be able to consent if they have sufficient maturity and understanding to comprehend the nature and implications of the particular decision. This is commonly described as Gillick competence.
Gillick competence is:
specific to the particular decision;
dependent on the child’s understanding and maturity;
not determined by age alone;
capable of changing as the decision or circumstances change.
A child might be competent to agree to a relatively straightforward intervention but not to a more complex decision involving significant or long-term consequences.
When assessing whether a child can make a decision, the responsible clinician may consider whether the child can understand:
the nature and purpose of the proposed intervention;
the likely benefits and risks;
the available alternatives;
the possible consequences of accepting or refusing;
how the decision may affect them now and in the future.
Case workers should not make complex determinations about Gillick competence independently. They should identify concerns, record the child’s views and understanding, and discuss the matter with the responsible clinician.
Even when a parent can legally make a decision, the child should still be involved as much as possible. Their wishes, feelings and assent are clinically and ethically important.
Parental Responsibility and Confidentiality
Do not assume that every adult accompanying a child has parental responsibility or automatic access to all information. Family relationships can be complex, particularly following separation, fostering arrangements, adoption or local authority involvement.
If there is uncertainty about who holds parental responsibility, or whether information can be shared with a particular adult, pause and seek advice.
A competent child or young person may be entitled to confidential care. Parents do not automatically have access to every detail disclosed by a child simply because they are the parent.
At the beginning of work, it is helpful to explain to both the young person and the parent:
how confidentiality works;
what information will normally be shared;
how the young person will be involved in decisions;
circumstances in which information may be shared for safety;
that concerns will normally be discussed before disclosure when it is safe to do so.
Capacity
Capacity concerns a person’s ability to make a specific decision at the time it needs to be made.
It is not an overall judgement about whether someone is “capable” or “incapable”. A person may have capacity to make one decision but not another. Capacity may also fluctuate because of changes in mental state, physical health, medication, intoxication, distress, fatigue or the complexity of the decision.
The Mental Capacity Act 2005 applies to people aged 16 and over in England and Wales. It establishes five important principles:
A person must be presumed to have capacity unless it is established otherwise.
A person must be given all practicable support to make the decision before being treated as unable to do so.
A person is not to be treated as lacking capacity merely because they make an unwise decision.
Any act or decision made for a person who lacks capacity must be in their best interests.
Before acting, consideration must be given to whether the purpose can be achieved in a less restrictive way.
These principles protect autonomy while also providing a framework for decisions when a person is genuinely unable to decide for themselves.
The Functional Elements of Capacity
To make a particular decision, a person must be able to:
understand the information relevant to the decision;
retain that information long enough to make the decision;
use or weigh that information as part of the decision-making process;
communicate their decision by any means.
A formal assessment under the Mental Capacity Act also requires consideration of whether any inability to decide is because of an impairment of, or disturbance in the functioning of, the mind or brain.
Mental illness, learning disability, dementia, brain injury, neurodevelopmental differences, substance use or communication difficulties do not automatically mean that a person lacks capacity.
Similarly, agreeing with professionals does not prove capacity, and disagreeing with them does not prove incapacity.
Decision-Specific and Time-Specific Assessment
The question is not:
“Does this person have capacity?”
The correct question is:
“Can this person make this particular decision at the time it needs to be made?”
For example, someone may be able to decide what to eat and whether to attend an appointment but be unable, during an acute episode, to weigh the complex risks and benefits of a major treatment decision.
If the decision can safely wait and the person’s capacity is likely to improve, it may be appropriate for the responsible clinician to delay the decision. This might apply when the person is temporarily intoxicated, severely distressed, exhausted or experiencing a short-lived deterioration.
Supporting the Person Before Questioning Capacity
Before concluding that someone may be unable to decide, reasonable steps should be taken to support them. This might include:
choosing a quieter environment;
arranging an interpreter or communication support;
using accessible language;
offering information in writing;
using pictures or demonstrations;
discussing one issue at a time;
treating pain or physical discomfort;
choosing a time when the person is most alert;
involving a trusted supporter, with permission where appropriate;
allowing more time;
repeating or rephrasing information.
Difficulty communicating should not be mistaken for inability to decide. A person may communicate through speech, writing, gestures, signs, assistive technology or another reliable method.
Unwise Decisions
People with capacity are entitled to make decisions that professionals or relatives consider unwise.
For example, an adult may understand that stopping a medication is likely to result in deterioration but still decide that the side effects are unacceptable. The practitioner may strongly disagree, but disagreement alone does not establish incapacity.
The relevant question is whether the person can understand, retain, use or weigh the relevant information and communicate a choice—not whether the practitioner considers the final choice sensible.
However, a sudden or markedly out-of-character decision may justify careful exploration. It could reflect coercion, impaired decision-making, misunderstanding or a change in mental state.
Best-Interests Decisions
If a person aged 16 or over is assessed by the appropriate practitioner as lacking capacity for a specific decision, any decision made on their behalf must be in their best interests.
Best interests are not simply what professionals think is clinically preferable. Consideration may include:
the person’s past and present wishes and feelings;
their beliefs and values;
any relevant written statements;
the views of people involved in their care or interested in their welfare;
all relevant circumstances;
whether capacity may return;
available alternatives;
the least restrictive option.
The person should remain involved as fully as possible.
Case workers may provide valuable information about the person’s wishes, routines, communication and previous preferences. However, they should not independently make significant best-interests decisions unless this clearly falls within their role, competence and authority.
Consent and Capacity Are Not the Same
Consent is the person’s agreement to a proposed action. Capacity concerns whether they can make that particular decision.
A person may have capacity and refuse consent. That refusal must not be relabelled as incapacity simply because it is inconvenient or concerning.
A person may appear to agree but lack capacity to make the decision. Their apparent agreement does not remove the need for an appropriate capacity assessment and lawful decision-making process.
A person may also have capacity but not be giving voluntary consent because they are being coerced.
These concepts must therefore be considered separately.
Mental Capacity and Mental Health Law
The Mental Capacity Act and the Mental Health Act are different legal frameworks. The fact that someone lacks capacity does not automatically mean that treatment can be imposed under the Mental Health Act. Similarly, detention under the Mental Health Act does not mean that the person lacks capacity for every decision.
Questions about compulsory assessment, treatment, significant restrictions, deprivation of liberty or conflict between legal frameworks must be escalated to an appropriately qualified senior clinician.
The Case Worker’s Role
The case worker’s role is to support safe and lawful practice within agreed boundaries. This includes:
explaining routine confidentiality arrangements clearly;
obtaining and recording consent for actions within their role;
checking rather than assuming who can receive information;
noticing when a person appears not to understand a decision;
adapting communication to support understanding;
recording the person’s own views;
protecting records and communications;
escalating safeguarding and serious-risk concerns;
seeking advice when consent or capacity is uncertain;
following the agreed clinical plan;
documenting decisions and advice accurately.
The case worker should not:
promise absolute secrecy;
conduct complex capacity assessments without appropriate training and authority;
decide independently to override a person’s refusal;
disclose information to relatives merely because they ask;
assume a diagnosis means incapacity;
make major best-interests decisions alone;
delay urgent safeguarding action while trying to obtain consent;
use personal accounts, devices or unapproved systems for clinical information.
Clinical Example: Request for Secrecy
A 15-year-old tells a case worker that she has recently self-harmed but says, “You must promise not to tell anybody.”
The case worker should not make that promise. They should listen, clarify the nature and immediacy of the risk and explain that relevant information may need to be shared to help keep her safe.
The case worker should involve the supervising clinician promptly. Wherever safe and appropriate, the young person should be involved in deciding how information is shared and what support is arranged. The discussion, risk information, consultation and actions should all be recorded.
Clinical Example: A Relative Requests Information
The mother of a 22-year-old telephones and asks whether her son is taking his medication. She states that he has become increasingly withdrawn.
The case worker can listen to and record the mother’s concerns. Unless the patient has agreed to information being shared, or there is another lawful justification, the case worker should not confirm medication or treatment details.
The concern about possible deterioration should be passed to the appropriate clinician. The practitioner might say:
“Thank you for letting us know. I can receive information from you, but I may not be able to discuss his care without his agreement. I will make sure your concerns are passed to the clinical team.”
Clinical Example: Possible Difficulty Making a Decision
An adult with severe depression repeatedly says, “Do whatever you want—I don’t care.” When asked about a proposed intervention, he cannot explain its purpose or possible consequences.
The case worker should not assume that this is valid consent. They should try to explain the information in an accessible way and check whether factors such as fatigue, distress or concentration are affecting the discussion.
If concerns remain, the matter should be escalated to the responsible clinician for a decision-specific capacity assessment. The case worker should document what was explained, the person’s responses, the support offered and the escalation.
Clinical Example: An Apparently Unwise Choice
A person understands the risks and benefits of continuing therapy but chooses to stop because attending appointments conflicts with work.
The decision may concern the practitioner, but it does not by itself demonstrate a lack of capacity. The practitioner should explore alternatives, check understanding and ensure that the decision is voluntary. If the person can understand, retain, use or weigh the relevant information and communicate the decision, their choice should generally be respected.
4. Clinical Perspective
Clinical Pearls
A good clinical record allows somebody who was not present to understand what happened, what mattered and what needs to happen next.
Record the person’s own words when they are particularly important, especially when documenting risk, consent, refusal or unusual experiences.
Confidentiality does not mean keeping information within one conversation at all costs. It means using information responsibly and sharing it only when there is an appropriate justification.
Never promise secrecy before hearing what the person wants to disclose.
Consent should be revisited when the proposed action, purpose or recipient of information changes.
Capacity is about the decision, not the diagnosis.
A decision that appears unwise may still be capacitous.
Apparent agreement is not necessarily informed or voluntary consent.
When sharing without consent, disclose the minimum necessary information to the appropriate person and record why.
If you are uncertain whether information should be shared, seek prompt senior advice. Do not allow uncertainty to cause dangerous delay where there is an immediate safeguarding or serious-risk concern.
Practical Documentation Tips
Complete records promptly and use clear, ordinary language.
Document significant telephone calls, messages, attempted contacts and advice from supervisors.
Do not write with the intention of making yourself appear faultless. Write an accurate account of the situation and the reasoning at the time.
Avoid copying large sections of previous entries unless the information has been reviewed and remains relevant.
Record unanswered questions and uncertainty. Clinical records do not need to create false certainty.
If a person disagrees with your account, record their view respectfully and inform the responsible clinician if the disagreement is significant.
Document actions with ownership and timescales. “Follow up” is less useful than “Case worker to telephone the patient by 4 pm on 24 September.”
Common Pitfalls
A frequent mistake is assuming that consent must always be obtained before information can be shared. Consent is important, but information may sometimes need to be shared without it for safeguarding, serious-risk or legal reasons.
Another mistake is treating parental involvement as automatic. The child’s age, competence, confidentiality, welfare and the adult’s parental responsibility must all be considered.
Practitioners sometimes describe a person as lacking capacity because the person refuses advice. Refusal and incapacity are not the same.
Another pitfall is writing conclusions without evidence. “No risk” is rarely adequate. The record should describe what was asked, what was disclosed and which protective factors or concerns informed the assessment.
Practitioners may also record that someone “consented” without documenting what was explained. For significant decisions, the record should show the information provided and the person’s response.
Situations Requiring Escalation
Seek immediate or prompt advice from a senior clinician, safeguarding lead or appropriate manager when:
there is a risk of serious harm to the person or someone else;
abuse, neglect, exploitation or domestic abuse is suspected;
a child asks for serious risk information to remain secret;
consent to share information is refused despite significant safety concerns;
the person appears unable to understand or weigh an important decision;
there is disagreement about a child’s competence or parental consent;
there is uncertainty about parental responsibility;
family members disagree about disclosure or treatment;
coercion or undue influence is suspected;
a significant best-interests decision may be required;
compulsory intervention or substantial restriction is being considered;
a court order, police request or legal demand for information is received;
confidential information has been sent to the wrong person;
the practitioner is unsure whether a disclosure is lawful or proportionate.
5. Summary
Clinical documentation is an essential part of care. Records should be accurate, timely, relevant, respectful and sufficiently detailed to explain important decisions and actions.
Confidential information must be protected, but confidentiality is not absolute. Relevant information may sometimes need to be shared without consent to protect a child or adult from harm, fulfil a legal requirement or serve an overriding public interest. Any disclosure should be necessary, proportionate and appropriately documented.
Valid consent should be informed, voluntary and given by someone able to make the relevant decision. It is an ongoing process rather than a signature.
Capacity is specific to a particular decision and time. A person should be presumed to have capacity and given practicable support to decide. A diagnosis, disability or apparently unwise decision does not by itself demonstrate incapacity.
Children and young people should be involved in decisions according to their maturity and understanding. Questions about Gillick competence, parental responsibility, serious risk or conflicting views should be escalated.
Case workers play an important role in recognising concerns, supporting communication, protecting information, documenting accurately and seeking senior advice when decisions fall outside their competence.
6. Further Reading
Mental Capacity Act 2005, section 1: the statutory principles
GMC: Confidentiality—good practice in handling patient information
Department for Education: Information sharing to safeguard children and young people
British Medical Association. Medical Ethics Today: The BMA’s Handbook of Ethics and Law.
Mental Capacity Act Code of Practice guidance and local organisational policies on documentation, confidentiality, safeguarding, information governance and consent.
7. Knowledge Check
Question 1
Which is the most appropriate clinical record?
A. “Patient was manipulative and difficult throughout.”
B. “Patient was non-compliant with questioning.”
C. “Patient declined to answer further questions and stated that she did not feel safe speaking while her father was present.”
D. “Patient behaved badly and would not engage.”
Correct answer: C.
Explanation:
C describes what happened and includes the person’s explanation. It avoids judgemental labels and gives the clinical team information that may influence how future appointments are arranged.
A is incorrect because “manipulative” is an interpretation presented as fact and does not describe the behaviour.
B is incorrect because “non-compliant” is vague and does not explain which questions were declined or why.
D is incorrect because “behaved badly” and “would not engage” are subjective and provide little clinically useful information.
Question 2
A patient’s sister telephones to report that the patient has stopped eating and has been talking about death. There is no recorded consent to discuss care with the sister. What should the case worker do?
A. Refuse to listen because there is no consent.
B. Listen to the concerns, avoid disclosing confidential information, and escalate the risk information promptly.
C. Confirm the patient’s diagnosis and medication to reassure the sister.
D. Ask the sister to telephone again after obtaining written consent from the patient.
Correct answer: B.
Explanation:
B is correct because a practitioner can receive relevant information from a relative without disclosing confidential information in return. The concerns suggest possible significant risk and require prompt escalation.
A is incorrect because refusing to receive the information could result in important risk information being missed.
C is incorrect because providing treatment details would usually be a disclosure requiring consent or another appropriate justification.
D is incorrect because waiting for written consent could cause dangerous delay. The immediate priority is to receive and escalate the concern.
Question 3
Which statement about confidentiality is most accurate?
A. Confidential information must never be shared without consent.
B. Information can be shared with any healthcare worker employed by the same organisation.
C. Confidentiality is important, but relevant information may sometimes be shared without consent when there is an appropriate legal, safeguarding or public-interest justification.
D. Parents are always entitled to all information about a person under 18.
Correct answer: C.
Explanation:
C correctly recognises that confidentiality is a fundamental duty but is not absolute. Any disclosure without consent should be necessary, proportionate and limited to relevant information.
A is incorrect because there are circumstances in which disclosure without consent may be justified or required.
B is incorrect because access depends on a legitimate need connected with the person’s care or another authorised purpose, not simply employment by the organisation.
D is incorrect because a child or young person may have rights to confidential care. Age, competence, welfare, parental responsibility and risk must be considered.
Question 4
Which statement best describes valid consent?
A. A signature on a consent form is always sufficient.
B. Consent is valid whenever the person cooperates with the practitioner.
C. Consent should be voluntary, informed and given by somebody able to make the relevant decision.
D. Consent cannot be withdrawn once an intervention has started.
Correct answer: C.
Explanation:
C identifies the central features of valid consent.
A is incorrect because a signature does not prove that the person understood the information or made a voluntary decision.
B is incorrect because cooperation may arise from fear, misunderstanding, pressure or passivity and does not necessarily demonstrate consent.
D is incorrect because a person may withdraw consent. The practitioner must then clarify what is being withdrawn and respond appropriately.
Question 5
An adult with bipolar disorder refuses a recommended support programme. The person accurately explains its purpose, benefits, risks and alternatives. What is the correct response?
A. Conclude that the person lacks capacity because bipolar disorder is present.
B. Conclude that the person lacks capacity because refusing support is unwise.
C. Respect the decision unless there is other evidence that the person cannot make it.
D. Ask a relative to provide consent instead.
Correct answer: C.
Explanation:
C is correct because capacity is decision-specific and cannot be determined from diagnosis or disagreement alone. A person with capacity may refuse a recommended intervention.
A is incorrect because a diagnosis does not automatically remove capacity.
B is incorrect because the Mental Capacity Act protects the right to make an unwise decision.
D is incorrect because a relative cannot simply replace the decision of an adult who has capacity. Even when capacity is lacking, relatives do not automatically become substitute decision-makers.
Question 6
Which set of abilities is relevant when considering whether a person can make a decision?
A. Reading, writing, calculating and remembering their medical history.
B. Understanding, retaining, using or weighing relevant information, and communicating a decision.
C. Agreeing with the clinician and selecting the safest option.
D. Remaining calm, maintaining eye contact and answering quickly.
Correct answer: B.
Explanation:
B describes the functional elements relevant to decision-making capacity.
A is incorrect because literacy, numeracy and detailed memory are not universal requirements for capacity.
C is incorrect because capacity does not depend on agreeing with the clinician or choosing the option professionals prefer.
D is incorrect because anxiety, differences in eye contact or slower processing do not establish incapacity.
Question 7
A person with a learning disability appears confused by a proposed intervention. What should happen first?
A. Assume that the person lacks capacity.
B. Ask a relative to decide immediately.
C. Take practicable steps to support understanding and decision-making.
D. Cancel the intervention permanently.
Correct answer: C.
Explanation:
C reflects the requirement to support the person before concluding that they cannot decide. Information might need to be simplified, presented visually, repeated or discussed with communication support.
A is incorrect because a learning disability does not automatically mean that the person lacks capacity.
B is incorrect because relatives do not automatically have authority to make decisions for an adult.
D is incorrect because the person may be able to decide with appropriate support or at a different time.
Question 8
A 15-year-old asks to receive support without their parent being told. What is the best response?
A. State that anyone under 16 can never consent independently.
B. Agree immediately and promise that no information will ever be shared.
C. Consider the young person’s maturity and understanding, explain confidentiality and its limits, and seek senior clinical advice where required.
D. Inform the parent before listening to the young person.
Correct answer: C.
Explanation:
C is correct because a child under 16 may be able to consent if they have sufficient maturity and understanding for the particular decision. Confidentiality and risk must also be considered.
A is incorrect because some children under 16 may be Gillick competent.
B is incorrect because absolute secrecy should not be promised, particularly where safeguarding or serious-risk concerns might arise.
D is incorrect because automatically informing the parent may undermine the young person’s rights, trust and safety. The individual circumstances must be considered first.
Question 9
A case worker accidentally emails clinical information to the wrong recipient. What should they do?
A. Delete the sent email and take no further action.
B. Wait to see whether the recipient opens it.
C. Promptly inform the appropriate senior person or data protection lead and follow the incident procedure.
D. Alter the clinical record so that the email is not mentioned.
Correct answer: C.
Explanation:
C is correct because prompt reporting allows the organisation to assess the risk, contain the breach and take any required action.
A is incorrect because deleting an item from the sender’s mailbox does not retrieve it from the recipient and does not address the breach.
B is incorrect because delay may increase the consequences and prevent timely containment.
D is incorrect because concealing or altering records would compound the incident and undermine professional accountability.
Question 10
Which documentation is most appropriate after information is shared without consent because of an immediate safeguarding concern?
A. “Confidentiality breached due to safeguarding.”
B. “Information shared.”
C. No entry should be made because the disclosure was confidential.
D. Record the concern, information considered, recipient, information disclosed, reason for sharing without consent, advice obtained and actions agreed.
Correct answer: D.
Explanation:
D provides a clear and accountable record of what was shared and why. It demonstrates that the disclosure was considered, purposeful and proportionate.
A is incorrect because “breached” may inaccurately imply wrongdoing, and the entry does not explain the decision.
B is incorrect because it does not identify what was shared, with whom or why.
C is incorrect because significant information-sharing decisions should be documented. Failing to record the disclosure could compromise continuity, accountability and future risk management.
