Sample policy · Termination of pregnancy

Consent and reflection policy (termination of pregnancy)

Statutory anchor: Regulation 11 (need for consent), Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (SI 2014/2936). This policy also engages the Mental Capacity Act 2005 and, for the provider's statutory termination obligations, the Abortion Act 1967, the Abortion Regulations 1991 and the Care Quality Commission (Registration) Regulations 2009 (Reg 20, requirements relating to termination of pregnancies). · primary source

1. What the regulation says

Care and treatment of service users must only be provided with the consent of the relevant person. (Regulation 11(1))

The full text of Regulation 11 is at https://www.legislation.gov.uk/uksi/2014/2936/regulation/11. Where this policy and the regulation diverge, the regulation wins.

The provider's separate statutory termination obligations sit in the Abortion Act 1967, the Abortion Regulations 1991 (HSA1/HSA4 certification and the register of terminations) and the Care Quality Commission (Registration) Regulations 2009. The two-practitioner opinion required before a termination arises under section 1(1) of the Abortion Act 1967 and is recorded on form HSA1 under the Abortion Regulations 1991; Regulation 20 of the 2009 Regulations separately requires the registered provider to ensure that certificate is completed and retained in the service-user record, and that no termination is carried out and no fee demanded or accepted unless the certification has been received (Reg 20(2)). The Crime and Policing Act 2026 (section 241) removed the criminal liability of a woman in England and Wales acting in relation to her own pregnancy. It does not remove or alter the provider's obligations under the Abortion Act 1967, the Abortion Regulations 1991, the HSA1 and HSA4 process or the Care Quality Commission (Registration) Regulations 2009, which continue to apply in full.

2. Plain-English summary

You can only provide care or treatment with the consent of the relevant person. If the service user is 16 or over and lacks capacity, follow the Mental Capacity Act 2005. If Parts 4 or 4A of the Mental Health Act 1983 apply, follow that instead. Section 5 of the MCA (acts done in connection with care or treatment) still applies underneath.

For termination of pregnancy, consent is held to a higher communication standard than most clinical procedures because of the gestational-age dependency, the statutory framework, and the particular sensitivity around coercion and capacity.

3. Purpose

This policy sets out how the Service obtains valid, voluntary, informed consent for termination of pregnancy and how it manages reflection time and capacity assessment.

Termination consent is held to a higher communication standard than most clinical procedures because of the gestational-age dependency, the statutory framework, and the particular sensitivity around coercion and capacity.

4. Scope

This policy applies to:

Before adoption, the Service must insert its current treatment pathways, approved patient information, consent and HSA1 forms, named safeguarding route, interpreter arrangements, record location and staff authorisation process. Remove any pathway or role the Service does not provide.

5. Roles and responsibilities

6. Operational consent procedure

  1. Confirm the person and proposed pathway. Use the Service's identity checks, confirm gestational age and establish which treatment and incidental procedures are being considered.
  2. Give current information. Explain what will happen, material risks, expected effects, alternatives, aftercare and how to obtain urgent help, using communication support where needed.
  3. Check understanding and capacity. Invite questions, ask the patient to explain the decision in their own words and complete a decision-specific capacity or Gillick-competence assessment where indicated.
  4. Check that the decision is voluntary. Give the patient an opportunity to speak without an accompanying person and follow the safeguarding route if coercion or exploitation is suspected.
  5. Offer reflection without imposing delay. Record the time offered, whether the patient wants more time and any later conversation. No mandatory cooling-off period is created by this policy.
  6. Record consent and complete the statutory pathway. Complete the consent record and any separate HSA1 certification steps required for the pathway. A signed form does not replace the conversation.
  7. Reconfirm before treatment. Immediately before treatment, check that the patient still agrees and that the planned procedure matches the consent record. Stop if consent is withdrawn or becomes unclear.

7. The consent conversation

A trained clinician conducts the consent conversation. The discussion covers:

The clinician answers the patient's questions. The Service does not impose a minimum number of conversations; one conversation is sufficient if the patient is clear, but the patient may take additional reflection time at their request (section 8).

8. Reflection time

The Abortion Act 1967 does NOT impose a statutory cooling-off period. The Service's policy is to:

Where the patient explicitly states they have already reflected and want to proceed, the Service does not require an artificial delay. Adding a delay against the patient's wishes is itself a violation of patient autonomy.

9. Capacity assessment

Capacity is assumed in adults aged 16 and over unless there is reason to believe otherwise (Mental Capacity Act 2005, sections 1 to 3).

Where capacity is in doubt, the assessing clinician documents:

If the patient is assessed as lacking capacity for this decision, the termination cannot proceed on the basis of their consent. The Service follows the best-interests pathway under the Mental Capacity Act 2005 and consults with the patient's representatives or seeks judicial input where appropriate. The Service's clinical lead is involved in every such case.

10. Patients under 18

10.1 Patients aged 16 and 17

Presumed competent to consent. Parental involvement is encouraged but not required. The Service applies the same consent standard as for adults. Safeguarding considerations may still apply (see safeguarding policy).

10.2 Patients aged under 16

For under-16s, the clinician must assess Gillick competence for the specific decision. Fraser principles may be relevant where contraception or sexual-health advice is involved, but they must not be applied mechanically as a substitute for a full Gillick competence assessment, safeguarding assessment and termination-specific consent process. The assessing clinician documents:

Where Gillick competence is not established, or a safeguarding concern arises, the Service does NOT proceed on the patient's sole consent and follows the safeguarding pathway under Working Together to Safeguard Children 2026 and local safeguarding children procedures.

10.3 Patients under 13

Patients under 13 are not legally able to consent to sexual activity. Any patient presenting under 13 is referred under the child-safeguarding pathway in the safeguarding policy. The clinical question is then secondary to the safeguarding response.

11. Coercion screening

Every consent conversation includes screening for coercion or pressure from a partner, family member, or third party. The Service's clinicians are trained to:

Where coercion is disclosed or suspected, the safeguarding policy applies.

12. Information provision

The Service provides written information to the patient covering:

Patient-facing written information is reviewed annually by the Service's clinical lead and is updated whenever clinical evidence or regulatory guidance changes.

13. Documenting consent

The consent record includes:

Consent records are retained per the Service's records retention policy and the Abortion Regulations 1991 retention requirements.

14. Training

All clinicians taking consent for termination complete:

15. Audit and monitoring

The clinical lead audits consent records monthly. The sample includes every case involving a patient under 16, a capacity concern, suspected coercion or withdrawn consent, plus 10 other completed pathways or all completed pathways if fewer than 10 occurred.

The audit checks that information matched the pathway, material risks and alternatives were discussed, reflection was offered, voluntariness and capacity were considered, consent was reconfirmed and the clinician was authorised. It identifies the staff member responsible for each correction and sets a due date. Findings are reviewed by the Registered Manager and recorded in the governance action plan. Overdue actions, repeated omissions or a concern that consent was not valid are escalated immediately. Closure requires evidence that the change was made and a follow-up sample showing that it worked.

After three consecutive monthly audits meet the Service's agreed standard, the routine-record sample may move to quarterly. Exception cases remain subject to monthly review.

16. Review

This policy is reviewed at least annually and whenever GMC consent guidance, RCOG best-practice guidance, or the Abortion Act 1967 materially changes.

17. Related policies in this pack

18. Sources and further reading

This template is based on CQC's guidance for providers and managers, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and other topic-specific legislation and guidance listed below. It is a starting point for adaptation, not a substitute for legal, clinical, HR, safeguarding or specialist professional advice.

19. When to seek further advice

Seek specialist advice where the issue involves serious harm, safeguarding, deprivation of liberty, restraint, children, professional misconduct, controlled drugs, radiation, termination of pregnancy, infection outbreak, water safety, employment dismissal, DBS barring referral, or regulatory enforcement.

20. Document control

Version Date Author Changes
v1.1 2026-07-19 Verivius (sample) Added role ownership, an operational consent workflow, risk-based audit cadence, local adoption controls and related policies.
v1 2026-06-10 Verivius (sample) Conformed existing draft to the Verivius policy standard; added statutory anchor, verbatim Regulation 11 quote, plain-English summary, source stack and document control. Original sections and sources preserved.

This sample policy template was issued by Verivius. It is a template, not a substitute for legal advice or the provider's own policy-development process. Where this template and live law or regulator guidance diverge, the live source wins.

What good looks like here

Written from an ex-CQC inspector's chair, but the point is safe, well-led care your team can stand behind. Each row shows what strong evidence looks like, what thin evidence looks like, and where the expectation comes from.

Consent for a termination is not like consent for most procedures, and the reason is time. The lawful pathways narrow as the pregnancy advances, so a delay imposed on a person who has already decided is not a neutral safeguard but a harm to them, while a decision rushed or pressed in the room is a different harm. Around that pressure sit the two risks this policy exists to catch: a partner, a parent or someone exploiting the person steering the decision, and a young person or a person whose capacity is in doubt being treated as agreeing when the law says otherwise. None of that shows on a signed form. What shows it is the trail: the conversation pitched to what this person would want to know, the opportunity to be seen alone actually taken up, the Gillick or capacity reasoning written at the time, and the reflection offered with the person's own choice about it recorded. That record is how the service can show, later and to anyone who asks, that the decision was this person's own, made with capacity, free of coercion, and neither hurried nor delayed against their wishes.

  1. Valid, voluntary, informed consent for the termination is evidenced by the recorded conversation, showing the pathways available at this person's gestational age, the material risks including incomplete termination and continuing pregnancy, and the alternatives including continuing the pregnancy and the support for each, pitched to what this particular person would want to know, rather than a signed consent form standing in for a discussion that may never have taken place.

    Strong evidence: The consent record in the clinical system (the clinician who took consent and their professional registration number, the gestational age confirmed, the pathway consented to, the material risks and alternatives discussed in summary, and the person's questions raised and answered), held to the General Medical Council decision-making-and-consent standard and the Royal College of Obstetricians and Gynaecologists best-practice-in-abortion-care standard (sections 7 and 13).

    Weak evidence: A consent form carrying a signature and a date while the clinical note reads only "consent obtained", an identical pre-printed risk list on every person's file, no record of the alternatives including continuing the pregnancy, and no sign the conversation was pitched to this person; or a note written up after the procedure rather than before treatment began.

    A legal duty. This comes from legislation that applies to your service, so meeting it is not optional. The exact provision is cited beneath the badge.

    Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, reg 11(1)

  2. The record shows the decision was the person's own and free from coercion, with the opportunity to be seen without an accompanying person genuinely offered and taken up, not a voluntariness box ticked while a partner or relative answered the questions; and where pressure, exploitation or abuse is suspected the safeguarding route is followed, a duty in its own right that does not discharge any separate statutory notification or referral.

    Strong evidence: The coercion-screening record (the direct question asked when there is any cue, the opportunity for the person to be seen alone recorded, and the safeguarding decision and referral route where coercion is disclosed or suspected), with the clinician trained in coercion-screening communication (sections 6, 11 and 14).

    Weak evidence: "Voluntary" ticked on every consent record with nothing showing the person was ever seen alone, a consultation the accompanying person answered throughout with no note that the cue was recognised, or a disclosed pressure closed inside the consent record with no safeguarding decision recorded and no referral route named.

    The recognised standard from a professional or clinical body, such as NICE or a royal college. Not a legal duty, but the accepted mark of safe practice, and a departure needs a documented reason.

  3. Where there is reason to doubt capacity, the assessment is specific to the decision to have this termination and to the time it is taken, with the two-stage Mental Capacity Act test and its reasoning recorded rather than a blanket label; and where the person is assessed as lacking capacity for this decision, the termination does not proceed on their consent, the best-interests pathway is followed and the clinical lead is involved.

    Strong evidence: The decision-specific capacity-assessment record applying the Mental Capacity Act 2005 two-stage test (an impairment of, or a disturbance in the functioning of, the mind or brain, then whether the person can understand, retain, use or weigh, and communicate the relevant information), the assessor and the date, and where capacity is lacking the section 4 best-interests record with the clinical lead involved (sections 5 and 9).

    Weak evidence: "Has capacity" or "lacks capacity" written as a global conclusion with no impairment identified and no working-through of understand, retain, use or weigh, and communicate; a capacity assessment borrowed from an unrelated decision or an earlier day for a person whose capacity fluctuates; or a best-interests decision reached with no options recorded and no one consulted.

    A legal duty. This comes from legislation that applies to your service, so meeting it is not optional. The exact provision is cited beneath the badge.

    Mental Capacity Act 2005 s.1 to s.4 (esp. s.2(1) and s.3(1)); Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, reg 11(3)

  4. For a person under 18, consent rests on the right basis for their age: 16 and 17 year olds presumed competent to the adult standard, under-16s assessed for Gillick competence for this specific decision, and anyone under 13 referred under the child-safeguarding pathway because the clinical question is secondary to the safeguarding response, with a full Gillick-competence assessment done rather than Fraser principles applied mechanically as a shortcut.

    Strong evidence: The under-18 consent record: for under-16s, the Gillick-competence assessment for this specific decision, the safeguarding assessment including any indication of coercion, exploitation or abuse, and whether a parent or trusted adult was encouraged and the person's response; and for a person under 13, the referral under the child-safeguarding pathway (Working Together to Safeguard Children 2026 and local procedures), following General Medical Council 0-18 years guidance (section 10).

    Weak evidence: An under-16's termination consented to on Fraser wording alone with no full Gillick-competence assessment and no safeguarding assessment recorded, a 16 or 17 year old's consent taken from the accompanying adult rather than from the young person, or a person under 13 processed as a routine consent question with no child-safeguarding referral on file.

    The recognised standard from a professional or clinical body, such as NICE or a royal college. Not a legal duty, but the accepted mark of safe practice, and a departure needs a documented reason.

  5. Reflection time is offered and the person's own choice about it is recorded, without an artificial delay imposed against their wishes, because the Abortion Act 1967 creates no cooling-off period, and adding one the person has not asked for is itself a breach of their autonomy just as pressing them to confirm in the consultation is.

    Strong evidence: The consent record showing the reflection time offered, whether the person wanted more time and any later conversation (section 8), so the record demonstrates reflection was made available and the choice about it was the person's own.

    Weak evidence: A consultation note and a consent signature carrying the same time with nothing showing reflection was ever offered, a routine delay applied to every patient as a house rule regardless of what the person wanted, or wording implying the person was pressed to decide before leaving the room.

    The recognised standard from a professional or clinical body, such as NICE or a royal college. Not a legal duty, but the accepted mark of safe practice, and a departure needs a documented reason.

  6. Consent is taken and reconfirmed only by a clinician the service has authorised as competent to take termination consent, the person is checked to still agree and the planned procedure matched to the consent record immediately before treatment, and a monthly audit that always samples every under-16, capacity, suspected-coercion and withdrawn-consent case assures this happens, rather than a booked appointment or a reception-collected form being treated as agreement.

    Strong evidence: The record of who was authorised to take consent and the reconfirmation immediately before treatment (procedure step 7), and the clinical lead's monthly consent audit sampling every under-16, capacity concern, suspected coercion or withdrawn-consent case plus a set of routine completed pathways, with findings owned, dated and closed on evidence the change worked (section 15).

    Weak evidence: A consent form collected and filed at reception before the treating clinician has seen the person, an administrative staff member answering a clinical consent question or presenting a booked appointment as agreement to treatment, no reconfirmation recorded at the point of treatment, or an audit whose sample never actually includes the exception cases it is meant to catch.

    Our recommended baseline. Not a legal or regulatory requirement, but a sensible standard we suggest where the rules leave the detail to you. Adapt it to your service.

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Last verified 23 July 2026

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Last reviewed 10 June 2026