Ensuring consent in school vaccination programme

The Deputy Health and Disability Commissioner has found a public health nurse breached the Code of Health and Disability Service Consumers’ Rights (the Code) during a school based vaccination programme (SBVP).

A 12-year-old female school student received the second dose of human papillomavirus vaccine (HPV) despite expressing that her mother no longer consented to the vaccination. The student’s mother had previously provided written consent for the HPV vaccine. The vaccinating nurse misunderstood that the student’s concerns related to a different vaccine, and proceeded with the vaccination after reassuring the student and her father (by telephone) that the vaccine was for HPV. According to the student’s mother, the girl experienced undesirable long-term symptoms following the vaccination.

Dr Caldwell found the nurse in breach of Right 7(1) of the Code which stipulates that services may be provided only if the consumer makes an informed choice and gives informed consent.

"It is imperative that providers take appropriate steps to obtain informed consent," said Dr Vanessa Caldwell.

Given the student’s vulnerability as a young consumer and the fact that her consenting parent was not present Dr Caldwell considered the threshold for questioning whether the parental consent was still valid needed to be low. Dr Caldwell was concerned that the nurse did not make contact with the mother to discuss the consent further.

"To be clear, I do not consider that the nurse meant any harm to the student in administering HPV2 or that this was an assertion of the nurse’s views or beliefs over those of the student or her mother," Dr Caldwell said. "But I do consider that the nurse was on notice that the student’s mother had withdrawn consent for her daughter to receive HPV2."

The nurse also breached Right 7(7) of the Code, which ensures that consumers have the right to refuse services and to withdraw consent to services.

"When uncertainty about the mother’s consent was raised, this cast doubt on the validity of the consent that was held," said Dr Caldwell. "As the registered nurse administering the vaccine it was her responsibility to ensure she had appropriate consent before doing so."

Dr Caldwell did not find Te Whatu Ora in breach of the Code, however, she was critical that the information leaflet provided to parents and caregivers did not explain the process for withdrawing consent adequately, and that the process for informing parents and caregivers when a student misses the initial vaccination clinic was not followed.

Dr Caldwell recommended that the nurse provide a written apology to the student and her family and undertake HDC’s online module on informed consent.

She also recommended that Te Whatu Ora:

• Review the SBVP Policy Manual with regard to confirming parental consent and arranging "catch-up" clinics.
• Communicate to the Public Health Nursing Service (PHNS) the expectation that the process for informing parents/caregivers when a student misses the initial vaccination be followed.
• Use an anonymised version of this case for wider education of the PHNS.