Unexpected findings

During a consultation, a practitioner may identify an unexpected factor such as the possibility of a significant undiagnosed medical condition. When this happens, a practitioner has a responsibility to complete an ‘Unexpected Information’ report with information on what was said during the consultation. As well as sharing this with the client as part of their determination, this will be shared with someone involved in the care of the client, such as their GP too. The practitioner should seek the consent of the client before informing a GP of the finding.

If the finding is of a life-threatening nature, the practitioner should seek the client’s consent to telephone the GP or call an ambulance if appropriate. This telephone call should be followed up with a written notification to the GP. The practitioner should seek the client’s consent to telephone their GP and inform them of the finding.

If the client does not give consent for the practitioner to contact their GP, the practitioner should judge whether the situation is serious enough to break confidentiality by telling the GP without the client’s consent. This should always be shared with the client where appropriate.