- Overall consent documentation compliance is 77.1% across 54 consent episodes reviewed, with 6 of 31 criteria meeting the local target and 25 below target.
- The weakest criterion is criterion 11 (51.1% against a 90% target): Likely consequences of accepting, declining or delaying the intervention were documented where relevant.
- Compliance varies by location, from 80% (Acute Medical Unit) to 73.4% (Endoscopy Unit); local workflow and template differences may explain part of this variation.
- The most frequently recorded reason for delayed, incomplete or absent consent documentation is "Risks not documented" (6 episodes).
- 2 consent-related safety, capacity, safeguarding or governance concerns were identified and should be reviewed through local escalation routes.
- 47 criterion responses were recorded as "Unable to determine"; where this is frequent, record availability may be limiting interpretation.
Overall compliance across all 31 criteria was 77.1% (is below the local standard of ≥ 90% (gap of 12.9 percentage points)). 6 criteria met the local target and 25 fell below it. Documentation of the specific decision was 97.9%, patient involvement 89.6%, material risks 72.9%, reasonable alternatives 60.4%, capacity consideration 79.6%, consent form completion where required 93.5%, communication support where required 84.1% and agreed decision and action plan 89.8%. The strongest criterion was criterion 1 at 97.9%. The weakest was criterion 11 at 51.1%.
Consent documentation falls short of the local standard, and the pattern of findings suggests that the recording of individualised risk, alternatives and the option of no treatment is more variable than the recording of the decision itself. Variation between clinical areas (73.4% to 80%) suggests differences in templates, workflow and available prompts rather than clinician knowledge alone.
Single-service audit of 54 consent episodes based on documented records only; the audit measures what was recorded, not the quality of the conversation that took place. 47 criterion responses were recorded as "Unable to determine", which limits interpretation of those criteria. Results reflect the audit period and selected clinical areas.
2 consent-related safety concerns were flagged during data collection and should be reviewed through local governance, safeguarding or Mental Capacity Act pathways as appropriate.
This audit supports local governance review of consent documentation. Any concern about invalid consent, capacity, coercion, safeguarding, wrong procedure or patient harm must be escalated through local clinical, governance, safeguarding, Mental Capacity Act or legal advice pathways.