This policy is designed to protect both patients and staff from abuse or allegations of abuse and to assist patients to make an informed choice about their examinations and consultations. Broadly, it follows guidance issued by the General Medical Council.
Clinicians (male and female) where an intimate or personal examination of the patient (either male or female) is justified should;
- Give the patient a clear explanation of what the examination will involve and give the opportunity to ask questions.
- Adopt a professional and considerate manner
- Offer the chaperone service if required
- Always ensure that the patient is provided with adequate privacy to undress and dress and keep the patient covered as much as possible to maintain their dignity
- Not assist the patient in removing clothing unless the patient has advised specifically that assistance is required.
Patients who request a chaperone should never be examined without a chaperone being present. If necessary, where a chaperone is not available, the consultation / examination should be rearranged for a mutually convenient time when a chaperone can be present. There may be rare occasions when a chaperone is needed for a home visit. The same procedure should still be followed.
WHO CAN ACT AS A CHAPERONE?
A chaperone does not have to be medically qualified but will
- Be trained as a Chaperone and familiar with the procedures involved in a routine intimate examination
- Be sensitive, and respectful of the patient’s dignity and confidentiality
- Be prepared to reassure the patient if they show signs of distress or discomfort
- Be prepared to raise concerns about a Clinician where appropriate
- The chaperone should only be present for the examination itself, and most discussion with the patient should take place while the chaperone is not present
- Patients should be reassured that all practice staff understand their responsibility not to divulge confidential information.
- The clinician will contact Reception to request a chaperone.
- The clinician will record in the notes that the chaperone is present, and identify the chaperone.
- Where no chaperone is available the examination will not take place – the patient should not normally be permitted to dispense with the chaperone once a desire to have one present has been expressed.
- The chaperone will enter the room discreetly and remain in room until the clinician has finished the examination.
- The chaperone will normally attend inside the curtain at the head of the examination couch and watch the procedure.
- To prevent embarrassment, the chaperone should not enter into conversation with the patient or GP unless requested to do so, or make any mention of the consultation afterwards.
- The chaperone will make a record in the patient’s notes after examination. The record will state that there were no problems, or give details of any concerns or incidents that occurred.
- The patient can refuse a chaperone, and if so this must be recorded in the patient’s medical record.
We do our utmost to provide the best possible service for our Patients however, sometimes things do go wrong.
We fully comply with the NHS Complaints procedures including “Listening, Responding and Learning”, keeping you fully informed and supporting you in how to complain or have your complaint reviewed by the Parliamentary & Healthcare Ombudsman.
We have a process for handling complaints – please click HERE for a leaflet about this. Whilst we hope this won’t be necessary we will respond to complaints however made;
- Verbally, face to face or, on the telephone
- In writing – please address your complaint to the “Complaints Manager”, Fraser Cherry, Practice Manager.
- Via email
If you have a disability or language difficulty, please let us know so we can help you – additional support is available as detailed on this leaflet
Our “Responsible Person” is Dr Siobhan Brennan, Partner.
Unless we know about problems, we can’t put them right – so, please tell us!
Consent for Treatment
The purpose of this protocol is to set out the Practice’s approach to consent and the way in which the principles of consent will be put into practice. It is not a detailed legal or procedural resource due to the complexity and nature of the issues surrounding consent.
Where possible, a clinician must be satisfied that a patient understands and consents to a proposed treatment, immunisation or investigation. This will include the nature, purpose, and risks of the procedure, if necessary by the use of drawings, interpreters, videos or other means to ensure that the patient understands, and has enough information to give ‘Informed Consent’.
Implied consent will be assumed for many routine physical contacts with patients. Where implied consent is to be assumed by the clinician, in all cases, the following will apply:
- An explanation will be given to the patient what he / she is about to do, and why.
- The explanation will be sufficient for the patient to understand the procedure.
- In all cases where the patient is under 18 years of age a verbal confirmation of consent will be obtained and briefly entered into the medical record.
- Where there is a significant risk to the patient an “Expressed Consent” will be obtained in all cases (see below).
Expressed consent (written or verbal) will be obtained for any procedure which carries a risk that the patient is likely to consider as being substantial. A note will be made in the medical record detailing the discussion about the consent and the risks. A Consent Form may be used for the patient to express consent (see below).
- Consent (Implied or Expressed) will be obtained prior to the procedure.
- The clinician will ensure that the patient is competent to provide a consent (16 years or over) or has “Gillick Competence” if under 16 years. Further information about Gillick Competence and obtaining consent for children is set out below.
- Consent will include the provision of all information relevant to the treatment.
- Questions posed by the patient will be answered honestly, and information necessary for the informed decision will not be withheld unless there is a specific reason to withhold. In all cases where information is withheld then the decision will be recorded in the clinical record.
- The person who obtains the consent will be the person who carries out the procedure (i.e. a nurse carrying out a procedure will not rely on a consent obtained by a doctor unless the nurse was present at the time of the consent).
- The person obtaining consent will be fully qualified and will be knowledgeable about the procedure and the associated risks.
- The scope of the authority provided by the patient will not be exceeded unless in an emergency.
- The practice acknowledges and supports the right of the patient to refuse consent, delay the consent, seek further information, limit the consent, or ask for a chaperone.
- Clinicians will use a Consent Form where procedures carry a degree of risk or where, for other reasons, they consider it appropriate to do so.
- No alterations will be made to a Consent Form once it has been signed by a patient, it will be scanned electronically into the Patients medical record.
- Clinicians will ensure that consents are freely given and not under duress (e.g. under pressure from other present family members etc.).
- If a patient is mentally competent to give consent but is physically unable to sign the Consent Form, the clinician should complete the Form as usual, and ask an independent witness to confirm that the patient has given consent orally or non-verbally.
Other aspects which may be explained by the clinician include:
- Details of the diagnosis, prognosis, and implications if the condition is left untreated
- Options for treatment, including the option not to treat.
- Details of any subsidiary treatments (e.g. pain relief)
- Patient experiences during and after the treatment, including common or potential side effects and the recovery process.
- Probability of success and the possibility of further treatments.
- The option of a second opinion
Informed consent must be obtained prior to giving an immunisation. There is no legal requirement for consent to immunisation to be in writing and a signature on a consent form is not conclusive proof that consent has been given, but serves to record the decision and discussions that have taken place with the patient, or the person giving consent on a child’s behalf.
Consent for children
Everyone aged 16 or more is presumed to be competent to give consent for themselves, unless the opposite is demonstrated. If a child under the age of 16 has “sufficient understanding and intelligence to enable him/her to understand fully what is proposed” (known as Gillick Competence), then he/she will be competent to give consent for him/herself. Young people aged 16 and 17, and legally ‘competent’ younger children, may therefore sign a Consent Form for themselves, but may like a parent to countersign as well.
For children under 16 (except for those who have Gillick Competence as noted above), someone with parental responsibility should give consent on the child’s behalf by signing accordingly on the Consent Form.
Equality and Diversity Statement
The practice is committed to both eliminating discrimination and encouraging diversity amongst our workforce and in relation to our patients and service users.
The practice and its staff will not discriminate on grounds of gender, marital status, race, ethnic origin, colour, nationality, national origin, disability, sexual orientation, religion or age.
If you feel that this policy has been breached in any way, please let us know by clicking here to complete a feedback form and we promise to investigate and put things right.
General Data Protection Regulations (GDPR) / Data Protection Act 2018
The Practice Aims to comply fully with the provisions of the General Data Protection Regulations (GDPR) / Data Protection Act 2018.
Below are various resources including our Data Protection Policy information about the data we collect about registered patients and how we use it and access to your information.
The calculation excludes certain types of income and the rules are complex and open to interpretation.
Full time GP’s are defined in the guidance as working eight sessions or more. The number of GP’s includes salaried GP’s and locums who worked full or part time for 6 months or more.
It should be noted that the prescribed method for calculating earnings is potentially misleading because it takes no account of how much time doctors spend working in the practice, and should not be used to form any judgement about GP earnings, nor to make any comparison with any other practice.
All GP practices are required to declare the mean earnings for GPs working to deliver NHS services to patients at each practice.
The average pay for GPs working in Marple Medical Practice in the last financial year was £43,023 before tax and National Insurance. This is for 2 full time GPs and 5 part time GPs who worked in the practice for more than six months.
Infection Control Policy
This page sets out the surgery policy on infection control and should be used with reference to the principles outlined in the Practices Infection Control (biological substances) Protocol and the Infection Control Inspection Checklist (Available upon request)
This practice is committed to the control of infection within the building and in relation to the clinical procedures carried out within it.
The practice will undertake to maintain the premises, equipment, drugs and procedures to the standards detailed within the Checklist and will undertake to provide facilities and the financial resources to ensure that all reasonable steps are taken to reduce or remove all infection risk.
Wherever possible or practicable the practice will seek to use washable or disposable materials for items such as soft furnishings and consumables, e.g. seating materials, wall coverings including paint, bedding, couch rolls, modesty sheets, bed curtains, floor coverings, towels etc, and ensure that these are laundered, cleaned or changed frequently to minimise risk of infection.
Proposals for the Management of Infection Risk
The clinician responsible for Infection Control is Sister Maria Turner
The non-clinician responsible for Infection Control is Fraser Cherry
HCA Gwen Green will be responsible for the maintenance of personal protective equipment and the provision of personal cleaning supplies within clinical areas
GMS Cleaning Services Limited will be responsible for the maintenance of the provision of personal cleaning supplies within non-clinical areas
HCA Gwen Green will be responsible for the maintenance of sterile equipment and supplies, and for ensuring that all items remain “in date”
The following general precautions will apply:
- A daily, weekly and monthly cleaning specification will apply and will be followed by the cleaning staff
- Infection Control training will take place for all staff (new recruits within 4 weeks of start ) on a regular basis and will include hand washing procedures. See Hand washing Protocol (Available upon request)
- Hand washing posters will be displayed at each clinical hand basin.
- A random and unannounced Infection Control Inspection by the above named staff, using the Infection Control Checklist , will take place on at least a quarterly basis and the findings will be reported to the partners’ meeting for (any) remedial action.
- Patients are encouraged to report any issues that they believe may constitute an infection risk, to the Practice Manager, using a feedback form available on-line here or, in the waiting room.
Information Governance Policy
Information is a vital asset, both in terms of the clinical management of individual patients and the efficient management of services and resources. It plays a key part in clinical governance, service planning and performance management.
It is therefore of paramount importance to ensure that information is efficiently managed, and that appropriate policies, procedures and management accountability provide a robust governance framework for information management.
The Practice recognises the need for an appropriate balance between openness and confidentiality in the management and use of information. The Practice fully supports the principles of corporate governance and recognises its public accountability, but equally places importance on the confidentiality of, and the security arrangements to safeguard, both personal information about patients and staff and commercially sensitive information. The Practice also recognises the need to share patient information with other health organisations and other agencies in a controlled manner consistent with the interests of the patient and, in some circumstances, the public interest.
The Practice believes that accurate, timely and relevant information is essential to deliver the highest quality health care. As such it is the responsibility of all clinicians and managers to ensure and promote the quality of information and to actively use information in decision making processes.
There are 4 key interlinked strands to the information governance policy:
- Legal compliance
- Information security
- Quality assurance
- Non-confidential information on the Practice and its services should be available to the public through a variety of media, in line with the Practice’s code of openness
- The Practice will establish and maintain policies to ensure compliance with the Freedom of Information Act
- Patients should have ready access to information relating to their own health care, their options for treatment and their rights as patients
- The Practice will have clear procedures and arrangements for liaison with the press and broadcasting media
- The Practice will have clear procedures and arrangements for handling queries from patients and the public
- The Practice regards all identifiable personal information relating to patients as confidential
- The Practice regards all identifiable personal information relating to staff as confidential except where national policy on accountability and openness requires otherwise
- The Practice will establish and maintain policies to ensure compliance with the Data Protection Act, Human Rights Act and the common law confidentiality
- The Practice will establish and maintain policies for the controlled and appropriate sharing of patient information with other agencies, taking account of relevant legislation (e.g. Health and Social Care Act, Crime and Disorder Act, Protection of Children Act)
- The Practice will establish and maintain policies for the effective and secure management of its information assets and resources
- The Practice will undertake or commission annual assessments and audits of its information and IT security arrangements
- The Practice will promote effective confidentiality and security practice to its staff through policies, procedures and training
- The Practice will establish and maintain incident reporting procedures and will monitor and investigate all reported instances of actual or potential breaches of confidentiality and security
Information Quality Assurance
- The Practice will establish and maintain policies and procedures for information quality assurance and the effective management of records
- The Practice will undertake or commission annual assessments and audits of its information quality and records management arrangements
- Managers are expected to take ownership of, and seek to improve, the quality of information within their services
- Wherever possible, information quality should be assured at the point of collection
- Data standards will be set through clear and consistent definition of data items, in accordance with national standards.
- The Practice will promote information quality and effective records management through policies, procedures/user manuals and training
Responsible Person: Fraser Cherry Practice Manager
Deputy: Dr Madhu Valluri Partner
It is the Practice Policy that we will do our best using the resources available and within the framework of NHS regulations, to put the care of our Patients and their wellbeing first. We aim to retain the good Practice reputation for the standard of clinical care and our Practice Manager is always available if you encounter any problems (0161 983 0374)
- We are committed to providing high quality medical care in a friendly way to our Patients with a focus on the needs of young families
- If, for clinical reasons you need to see a Doctor on the day you contact us – it will be arranged.
- We will treat you with courtesy and respect at all times irrespective of your age, sex, race, religion, sexuality or the nature of your problem.
- Your rights to Privacy will be respected at all times and data held about you will be handled in accordance with the principles of the data protection act, including your access to your records.
- We aim to answer the telephone promptly
- We operate a transparent complaints procedure which is compliant with NHS standards
- We welcome any comments or suggestions for improvements in service – please address these to the Practice Manager.
- Repeat prescriptions will be available two clear working days after we receive the request. If there is an exceptional need arrangements may be made for a shorter timescale.
In return, we ask that Patients please;
- Be punctual / available for appointments and cancel in good time if they are not required.
- Plan ahead for repeat medication.
- Show patience & courtesy to Reception & Medical staff particularly when attending to other Patients.
- Respect other Patients in the Surgery
- Advise the Receptionist if special arrangements are required to accommodate a disability.
- Telephone in respect of non-urgent matters after 10:00 am (Test results 2:00pm)
- Be prepared to advise the Receptionist what your problem is – the Doctors insist upon this, so that they can prepare for the consultation and ensure that the time available is used most effectively to provide the best care for you.
- Request home visits before 10:00am
Safeguarding Children Policy
This is the practice agreed policy, applicable to all clinicians and staff as well as official visitors to the premises, and it represents the means by which the practice intends to keep children safe.
Under the 1989 and the 2004 Children Acts a child or young person is anyone under the age of 18 years.
Child Protection refers to the activity that is undertaken to protect specific children who are suffering or at risk of suffering significant harm. All agencies and individuals should be proactive in safeguarding and promoting the welfare of children.
The practice recognises that all children have a right to protection from abuse and the practice accepts its responsibility to protect and safeguard the welfare of children with whom staff may come into contact. We intend to:
- Respond quickly and appropriately where abuse is suspected or allegations are made.
- Provide both parents and children with the chance to raise concerns over their own care or the care of others.
- Have a system for dealing with, escalating and reviewing concerns.
- Remain aware of child protection procedures and maintain links with other bodies, especially the primary care organisation appointed contacts.
- The practice will ensure that all staff are trained to a level appropriate to their role, and that this is repeated on a refresher basis. New starters will receive training within 1 month of start date.
- The welfare of the child is paramount.
- It is the responsibility of all adults to safeguard and promote the welfare of children and young people. This responsibility extends to a duty of care for those adults employed, commissioned or contracted to work with children and young people.
- Adults who work with children are responsible for their own actions and behaviour and should avoid any conduct which would lead any reasonable person to question their motivation and intentions.
- Adults should work and be seen to work, in an open and transparent way.
- The same professional standards should always be applied regardless of culture, disability, gender, language, racial origin, religious belief and/or sexual identity.
- Adults should continually monitor and review their practice and ensure they follow the guidance contained in this document and elsewhere.
Dr Howard Sunderland is the appointed Clinical Safeguarding Lead within the practice.
The Clinical Safeguarding Lead is responsible for all aspects of the implementation and review of the children’s safeguarding procedure in this practice.
WHAT CHILD ABUSE IS.
There are 4 main categories of child abuse:
- Physical abuse
- Sexual abuse
- Emotional abuse
- Neglect/failure to thrive
These are not however exclusive, and abuse in one of these areas may easily be accompanied by abuse in the others.
Physical abuse may include:
- Hitting, shaking, throwing, poisoning, burning or scalding, or other forms of physical harm
- Where a parent or carer deliberately causes ill-health of a child
- Single traumatic events or repeated incidents
Sexual abuse may include:
- Forcing or enticing a child under 18 to take part in sexual activities where the child is unaware of what is happening
- May include both physical contact acts and non—contact acts
Emotional abuse may include:
- Persistent ill-treatment which has an effect on emotional development
- Conveyance of a message of being un-loved, worthless or inadequate
- May instil feeling of danger, being afraid
- May involve child exploitation or corruption
Neglect may include:
- Failure to meet the child’s physical or psychological needs
- Failure to provide adequate food or shelter
- Failure to protect from physical harm
- Neglect of a child’s emotional needs
Common presentations and situations in which child abuse may be suspected include:
- Disclosure by a child or young person
- Physical signs and symptoms giving rise to suspicion of any category of abuse
- The history is inconsistent or changes
- A delay in seeking medical help
- Extreme or worrying behaviour of a child, taking account of the developmental age of the child
- Accumulation of minor incidents giving rise to a level of concern, including frequent A&E attendances
Some other situations which need careful consideration are:
- Disclosure by an adult of abusive activities
- Girls under 16 presenting with pregnancy or sexually transmitted disease, especially those with learning difficulties
- Very young girls requesting contraception, especially emergency contraception
- Situations where parental mental health problems may impact on children
- Parental alcohol, drug or substance misuse which may impact on children
- Parents with learning difficulties
- Violence in the family
- Unexplained or suspicious injuries such as bruising, bites or burns, particularly if situated unusually on the body
- The child says that she or he is being abused, or another person reports this
- The child has an injury for which the explanation seems inconsistent or which has not been adequately treated
- The child’s behaviour changes, either over time or quite suddenly, and he or she becomes quiet and withdrawn, or aggressive
- Refusal to remove clothing for normal activities or keeping covered up in warm weather
- The child appears not to trust particular adults, perhaps a parent or relative or other adult in regular contact
- An inability to make close friends
- Inappropriate sexual awareness or behaviour for the child’s age
- Fear of going home or parents being contacted
- Reluctant to accept medical help
- Fear of changing for PE or school activities
- Concerns should immediately be reported to the Lead clinician within the practice or his / her deputy (above).
- In the absence of one of the nominated persons, the matter should be brought to the attention of the primary care organised appointed person, or, if it is an emergency, and the designated persons cannot be contacted, then the most senior clinician will make a decision to report the matter directly to social services or the police.
- If the suspicions relate to the designated person, then the deputy should be notified and the primary care organisation appointed person and / or social services should be contacted directly.
- Suspicions should not be raised or discussed with third parties other than those named above.
- Any individual has the ability to make direct referrals to the child protection agencies; however, staff are encouraged to use the route described here where possible. In the event that the reporting staff member feels that the action taken is inadequate, untimely or inappropriate they should report the matter direct. Staff members taking this action in good faith will not be penalised.
- Where emergency medical attention is necessary it should be given. Any suspicious circumstances or evidence of abuse should be reported to the designated clinical lead.
- If a referral is being made without the parent’s knowledge and non urgent medical treatment is required, social services should be informed. Otherwise, speak to the parent/carer and suggest medical attention be sought for the child.
- If appropriate the parent/carer should be encouraged to seek help from the Social Services Department prior to a referral being made. If they fail to do so in situations of real concern the designated person will contact social services directly for advice.
- Where sexual abuse is suspected the designated person will contact the Social Services or Police Child Protection Team directly. The designated person will not speak to the parents.
- Neither the designated person or any other practice team should carry out any investigation into the allegations or suspicions of sexual abuse in any circumstances. The designated person will collect exact details of the allegations or suspicion and to provide this information to the child protection agencies that will investigate the matter under the Children Act 1989.
ABUSE REPORTED OR ALLEGATIONS RECEIVED FROM A CHILD
- React calmly.
- Reassure the child that they were right to tell you, and that they are not to blame and take what the child says seriously.
- Be careful not to lead the child or put words into the child’s mouth – ask questions.
- Do not promise confidentiality
- Fully document the conversation on a word by word basis.
- Fully record dates and times of the events and when the record was made, and ensure that all notes are kept securely.
- Inform the child/ young person what you will do next.
- Refer to the practice designated clinician or deputy.
- Decide if it is safe for a child to return home to a potentially abusive situation. It might be necessary to immediately refer the matter to social services and/or the police to ensure the child’s safety and that they do not return home.
Staff are required to have access to confidential information about children and young people in order to do their jobs, and this may be highly sensitive information. These details must be kept confidential at all times and only shared when it is in the interests of the child to do so, and this applies to the restriction of the information within the clinical team. Care must be taken to ensure that the child is not humiliated or embarrassed in any way.
If an adult who works with children is in any doubt about whether to share information or keep it confidential he or she should seek guidance from the designated clinical Safeguarding Children lead. Any actions should be in line with locally agreed information sharing protocols, and the Data Protection Act applies.
Whilst adults need to be aware of the need to listen and support children and young people, they must also understand the importance of not promising to keep secrets. Neither should they request this of a child or young person under any circumstances.
Additionally, concerns and allegations about adults should be treated as confidential and passed to a designated or appointed person or agency without delay.
A parent or carer should be present at all times, or a chaperone offered. Children should only be touched under supervision and in ways which are appropriate to, and essential for clinical care.
Permission should always be sought from a child or young person before physical contact is made and an explanation of the reason should be given, clearly explaining the procedure in advance. Where the child is young, there should be a discussion with the parent or carer about what physical contact is required. Regular contact with an individual child or young person is normally part of an agreed treatment plan and should be understood and agreed by all concerned, justified in terms of the child’s needs, consistently applied and open to scrutiny.
Physical contact should never be secretive or hidden. Where an action could be misinterpreted a chaperone should be used or a parent fully briefed beforehand, and present at the time. Where a child seeks or initiates inappropriate physical contact with an adult, the situation should be handled sensitively and a colleague alerted.
ATTITUDE OF PARENTS OR CARERS
Parental attitude may indicate cause for concern:
- Unexpected delay in seeking treatment
- Denial of injury pain or ill-health
- Incompatible explanations, different explanations or the child is said to have acted in a way that is inappropriate to his/her age and development
- Reluctance to give information or failure to mention other known relevant injuries
- Unrealistic expectations or constant complaints about the child
- Alcohol misuse or drug/substance misuse
- Violence between adults in the household
- Appearance or symptoms displayed by siblings or other household members
If any Patient has any reason to suspect that a child it “at risk”, please contact one of the named leads below – in confidence.
CHILD PROTECTION: SOURCES OF ADVICE & SUPPORT
|Practice Clinical Safeguarding Children Lead||Dr Howard Sunderland|
|Practice Clinical Safeguarding Children Deputy Lead||Any Partner|
Vunerable Adults Policy
The purpose of this document is to set out the policy of the Practice in relation to the protection of vulnerable adults. Further guidance may be available on local inter-agency procedures via the Primary Care Organisation and / or Social Services.
WHAT IS A VULNERABLE ADULT?
The definition is wide, however this may be regarded as anyone over the age of 18 years who may be unable to protect themselves from abuse, harm or exploitation, which may be by reason of illness, age, mental illness, disability or other types of physical or mental impairment.
Those at risk may live alone, be dependent on others (care homes etc.), elderly, or socially isolated.
FORMS OF ABUSE
Abuse may be deliberate or as a result of lack of attention or thought, and may involve combinations of all or any of the above forms. It may be regular or on an occasional or single event basis, however it will result in some degree of suffering to the individual concerned. Abuse may also take place between one vulnerable adult and another, for example between residents of care homes or other institutions.
Where abuse of a vulnerable adult is suspected the welfare of the patient takes priority. In deciding whether to disclose concerns to a third party or other agency the GP will assess the risk to the patient. Ideally the matter should be discussed with the patient involved first, and attempt made to obtain consent to refer the matter to the appropriate agency. Where this is not possible, or in the case of emergency where serious harm is to be prevented, the patient’s doctor will balance the need to protect the patient with the duty of confidentiality before deciding whether to refer. The patient should usually be informed that the doctor intends to disclose information, and advice and support should be offered. Where time permits, the medical defence organisation will be telephoned before any action is taken.
Due regard will be taken of the patient’s capacity to provide a valid consent. (See also Consent Protocol).
In assessing the risk to the individual, the following factors will be considered:
If any Patient suspects that an adult may be vulnerable and “at risk” please advise one of the Practice Partners – in confidence
Consideration may be given to:
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