COVID-19: when parents refuse to comply with guidance

NOTE: The information within this article was correct at the time of publishing. However due to the fast-evolving nature of the pandemic, we strongly advise you to check all governmental and regulatory guidance for the latest updates.

Medical Protection has received a number of calls from members asking how they should respond to parents of children with COVID-19 symptoms who are openly refusing to comply with government guidance on testing and self-isolation. Dr Clare Devlin, Medicolegal Consultant at Medical Protection, provides detailed advice

The dilemma

A nurse practitioner sees two children with suspected COVID-19 and informs the families of each about the need for testing and self-isolation. One family take her advice on board and agree to follow it, but the other child’s parents are openly resistant, saying they won’t be getting their child tested and he will be continuing to attend his primary school.

The nurse practitioner discusses the matter with a GP, who arranges a consultation with the parents in the afternoon to again stress the reason for testing and self-isolation, and remind them of the government guidance. The GP calls Medical Protection before her afternoon consultation, wondering if she can let the school know that the child will be continuing to attend with symptoms of suspected COVID-19 if she is not successful in changing the parents’ position.

Medical Protection advice

As the GP has already recognised, an appropriate first step in this situation is to meet with the parents directly, and emphasise the reasons for testing and self-isolation and the risks to others of not doing so. You may wish to highlight the likelihood of children or teachers with underlying health conditions being at increased risk of severe disease if they contract COVID-19, and explain that these children and staff will be attending school on the understanding that pupils with suspected COVID-19 will be tested and self-isolate.

It may also be possible to explore whether there are specific beliefs or concerns underlying the parents’ non-compliance – such as concerns about test availability, distance to the test centre, delayed test results or beliefs around COVID-19 transmission – and you may be able to address some of these issues. You may be faced with the challenging situation of empathising with the particular difficulties the parents are facing, but also seeking to protect the health of the public according to current public health guidance.

You could consider gently explaining to the parents that regardless of the challenges they are facing, if they refuse to test and self-isolate you may need to disclose information about their child’s illness to the appropriate authority, for the protection of public safety.

Following this discussion, you will be able to weigh up whether or not you still have significant concerns about non-compliance.

What are the legal requirements on COVID-19?

As COVID-19 is a notifiable disease, there is a straightforward legal requirement to notify Public Health England of cases. NHS England guidance advises that suspected COVID-19 cases should be reported to Public Health England by the practice, while positive test results will be notified by the laboratory.

However, in this case there is the additional question of how to respond to the parents’ non-compliance. The GMC’s guidance Confidentiality: Good practice in handling patient information states in paragraphs 63-64:

“Confidential medical care is recognised in law as being in the public interest. The fact that people are encouraged to seek advice and treatment benefits society as a whole as well as the individual. But there can be a public interest in disclosing information to protect individuals or society from risks of serious harm, such as from serious communicable diseases or serious crime.

If it is not practicable or appropriate to seek consent, and in exceptional cases where a patient has refused consent, disclosing personal information may be justified in the public interest if failure to do so may expose others to a risk of death or serious harm. The benefits to an individual or to society of the disclosure must outweigh both the patient’s and the public interest in keeping the information confidential.”

The underlying decisions for you to make are if you believe the parents’ failure to test and  self-isolate puts others at risk of death or serious harm, and if the benefits to society of disclosure of this information outweigh the family’s and public interest in keeping medical information confidential.

If you come to the decision that you should make a disclosure in the public interest, then GMC guidance states in paragraph 67:

“…You should not ask for consent if you have already decided to disclose information in the public interest but you should tell the patient about your intention to disclose personal information, unless it is not safe or practicable to do so. If the patient objects to the disclosure you should consider any reasons they give for objecting.”

The GMC also provides further guidance in paragraph 68 to assist in the weighing up of the public and patient’s interest in making a disclosure.

Disclosing confidential information

If you do decide you should make a disclosure, then your next decision is which person or authority is the most appropriate to approach.  

As a starting point, you could contact your local health protection team – Public Health England – to discuss the best way forward. They may perform a risk assessment to decide whether further action should be taken.

When making a public interest disclosure, it is important to remember to disclose only the relevant information, and to carefully document what you have disclosed and to whom, together with the details of  your underlying decision-making process. If you have obtained advice from Public Health England, it would be appropriate to include it in your record. This will put you in a strong position should you ever have to explain and justify your actions in the future.

Conclusion

In this difficult scenario, it is helpful to discuss the need for testing and self-isolation again with the family, but you may still need to consider making a disclosure in the public interest.

For specific discussions on individual cases and medicolegal dilemmas, call the Medical Protection advice line on 0800 561 9090.