Cases/Maternity and Reproductive Health

Sixteen Year Old Who Is Pregnant and Unsure What to Do — Free SCA Practice Case

Sixteen year old who is pregnant and unsure what to do

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

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Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Imogen Holroyd

Age

16 years

Consultation Type

Video

Age

Situation

Video Consultation. Appointment booked by the patient.

Reason for Encounter

"I'm pregnant and I don't know what to do. I haven't told my mum."

Medical Records

●PMH: Tonsillitis last year. HPV vaccine given at school.
●Medications: Nil. Allergies: NKDA.
●Contraception: None recorded.
●Social: Lives with her mother, also registered here, and a younger brother. Apprentice.

Recent Notes

●Online booking form, today: "Two positive pregnancy tests. First day of my last period was about nine weeks ago. Need advice."
●Reception, today: Asked for a private video appointment, not to be discussed with her mother.

Patient Script

For the friend playing the patient role

Character Overview: You are Imogen Holroyd, a 16 year old business administration apprentice at a local estate agents, with one day a week at college. You live in a rented terraced house with your mum Gail, a healthcare assistant on hospital wards, and your brother Ollie, 10. You are alone in the house: Gail is on shift until eight and Ollie is at school. You have been going out with Kyle for about five months. He is 23, fits tyres at a garage and has his own car. Your mum thinks he is nineteen, because Kyle said it would be easier. Only Kyle and your friend Bethan know about the pregnancy. You speak like a teenager ("like", "I dunno"), and your voice goes small when your mum comes up. You are genuinely undecided: some days you picture the baby and feel happy, other days you feel nowhere near ready, but you have never said the second part aloud because Kyle is so excited. You half hope the doctor will just tell you what to do. You defend Kyle if anyone criticises him.

Opening Sentence: "Hi. Um, I did a pregnancy test last week and it was positive, and then I did another one and it said the same thing. I think I'm about nine weeks. My boyfriend wants me to keep it, and I haven't told my mum, and I just don't know what to do."

History if Asked (Data Gathering Phase)

●Tests and dates: "I did one on Wednesday and another on Thursday, both from the chemist, both positive. My last period was nine weeks ago to the day, my app counts. They're really regular, 28 or 29 days."
●Symptoms: "I feel sick most mornings and I'm knackered all the time. My boobs are really sore. I get a bit light headed if I stand up too quick, but I haven't fainted."
●Negatives (if asked): No bleeding, tummy pain, shoulder pain, discharge or urinary symptoms. First pregnancy.
●Contraception: "I'm not on anything. I was scared Mum would find the pill packet. We used condoms for the first few weeks, but Kyle said they ruin it, so mostly we haven't. I didn't take anything afterwards."
●Sexual history: "Kyle's the only person I've ever slept with, since about four months ago. I wanted to. I've never had a test for anything."

Ideas, Concerns, Expectations

Gating note: Imogen raises none of this herself apart from Kyle and her mum in her opening. Each part comes out only when the doctor asks what she thinks, how she feels, what worries her, or what she was hoping for.

●Ideas: She is torn and has hardly thought through the choices. She assumes you have to be 18 or have a parent sign for an abortion, assumes it means an operation in hospital, and has never heard of adoption. "Some days I think about it being a real baby and I feel kind of happy. Other days I think, I'm sixteen, I've literally just started work, I'm not ready. But Kyle's so excited I feel bad for thinking it." If asked what she would choose if it was only up to her, she goes quiet, then: "I think I'd wait. Is that awful? But I can't say that to Kyle."
●Concerns: Her biggest worry is her mum. "She had me when she was nineteen and she's always said, don't end up like me. She's going to be so disappointed, and then it'll all land on her again." She worries the surgery will tell her mum, and whether abortion hurts or affects having babies later.
●Expectations: She wants to know her choices and for it to stay private. Quietly: "If I'm honest, I kind of want someone to just tell me what to do."

If Asked: Medical History and Medications

Gating note: Imogen answers each of these plainly when asked.

●Health and habits: "No tablets, no allergies, no folic acid or vitamins, is that bad?" Never smoked, vaped or drugs. "A few vodkas at weekends, before I knew. Nothing since."
●Mood: "I've been really anxious. I've cried in the toilets at work and I keep waking in the night and can't get back to sleep." If asked directly about harming herself: "No, never. I just feel stuck, like everyone's waiting for me to decide."

Social History and Lifestyle Impact

●Home: "Mum's brilliant, she does it all on her own." She likes her job and college day and does not want to give them up.
●Kyle (if asked about him or his age): "He's 23. I know how that sounds, but he's really mature. I met him through Bethan's brother." He is not her boss, teacher or coach. "I told Mum he's nineteen. Kyle said it'd be easier."
●What Kyle thinks, or work and college (if asked what Kyle thinks, or how work and college are going): "He's buzzing. He keeps saying I won't need the apprenticeship or my college day any more, that he'll look after me. He wants me to hand my notice in."
●Pressure (if asked what Kyle has said about what she should do): "He said that if I got rid of it he didn't know if he could look at me the same. He said I'd regret it forever. And he said I shouldn't tell Mum yet, so she can't talk me out of it."
●Control (if asked how things are between them or whether he checks up on her): "He picks me up from work every day now. He likes to know where I am. He got me a new phone on his contract a couple of months ago, and he pays the bill. He goes through it and asks who I've been messaging, he says it's because he worries. I haven't been to Bethan's for ages because he gets in a mood about it."
●Fear or being hurt (only if asked specifically whether she is frightened or he has hurt her): "He's never hit me. He's lovely, honestly. One time at a party a couple of months ago I wanted to go home and he grabbed my wrist really tight and said I wasn't going anywhere. I had a mark for a few days. He was really sorry, he'd had a lot to drink." It has not happened again. To a general question such as "do you feel safe with him?": "Yeah. He's lovely. He really cares about me."
●Saying no (if asked): "Sometimes I'm not in the mood and he goes cold until I give in, so it's easier to say yes."
●Safe contact (if asked how best to reach her): "Don't text or ring the number you have for me, that's the phone Kyle checks. I'm on my old phone now, on the house wifi, he doesn't know I still have it. I could ring you on that from my room when Mum's at work. Can you tell me a time?"

Responses to Management (The Negotiation Phase)

●
If the doctor lists the options (keeping the baby, adoption, abortion), or asks her to say them back:
- ●Reaction: Surprised. "I never knew you could do adoption. Is that a thing at my age?" If abortion is mentioned: "Does Mum have to sign something? Would you have to tell her? Does it hurt?" Relieved by the answers, she can then repeat them back accurately, including that Mum need not sign.
●
If the doctor explains the home tablets only go up to ten weeks, or says there is no need to decide today:
- ●Reaction: Alarmed. "So I've only got a week? That's not long enough!" She settles once told she need not decide today and that abortion is still possible later in a clinic. She is grateful for follow up in a few days.
●
If the doctor asks what she would want if nobody else's feelings counted, tells her what to do, or says what they would do:
- ●Reaction: To the first, quiet, then "I think I'd wait. I don't know." If she asks "What would you do?" and the doctor says it is her decision and offers to work it through with her: "Yeah, okay. I just wish someone would decide for me." If the doctor tells her what to do, she agrees too easily ("Okay. Yeah, if you think so") and stops volunteering anything.
●
If the doctor says her mum must be told, promises nobody will ever be told, or asks how to contact her:
- ●Reaction: If told her mum must know, distressed: "I can't. You said it was private." She calms if told she does not have to and the doctor will help when she is ready: "Could you help me say it?" After a promise of total secrecy she is reassured, but later mistrustful if something is shared. On contact, she asks the doctor not to text and to ring at an agreed time when she is alone.
●
If the doctor asks about Kyle's age, criticises him, or says they want to speak to a colleague or children's services:
- ●Reaction: Defensive: "Why does that matter? I'm sixteen, it's legal. Is Kyle going to get in trouble?" She relaxes if told sex at 16 is not a crime in itself and the aim is to keep her safe, not punish anyone. If the doctor criticises him or says to leave: "You don't know him," and she says less from then on. About children's services, she does not refuse, but is frightened for him and of him knowing: "Will they tell Mum? Will Kyle find out it was me? He'd get into so much trouble." If told honestly what it involves and what will be shared: "So it's to make sure I'm okay? Okay. But please don't tell Kyle I said. He'd go mad."
●
If the doctor offers practical steps (an infection test, folic acid, contraception, an in person visit, or safety netting):
- ●Reaction: Test: "Will it go on my record where Mum can see?" She agrees if told it is confidential. Safety netting: "I can't go to A and E, Mum works there." Contraception: "Not today, but I don't want this to happen again." If asked to show a test or check her pulse on camera, she declines: "Can I come in and see you instead?" and is relieved by an in person appointment on her own.

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Domain 2: Clinical Management and Medical Complexity

0 / 20 indicators checked+0−0

Positive (0/10)

Negative (0/10)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

The Core Dilemma and the Model Plan

●A 16 year old is nine weeks pregnant and undecided. Her partner is 23 and wants her to keep the baby, and her mother has not been told. Three tasks run together: counselling her on all her options without steering, respecting her right to decide for herself, and assessing whether a relationship with a large age gap is safe. Safeguarding alone loses her trust, and counselling alone misses the pressure and control.
●Model plan: date the pregnancy and exclude pain or bleeding; explain all three options evenly; say she need not decide today but the home tablet option closes within about a week; confirm she can consent herself; agree safe contact; take a same day safeguarding step; give pregnancy advice, a safety net and sexual health care; follow up within two to three days.

Dating the Pregnancy and Excluding an Urgent Problem

●Date from the first day of the last period in a regular cycle: 63 days ago is 9 weeks (9+0). Two positive home tests need no repeat.
●NICE CKS on ectopic pregnancy lists abdominal or pelvic pain, a missed period and vaginal bleeding as common symptoms, and gastrointestinal symptoms, dizziness and shoulder tip pain as less common. With none of these she does not need an urgent scan, and NICE NG140 on abortion care allows abortion before a scan confirms an intrauterine pregnancy when there are no signs of ectopic pregnancy.
●She needs no examination to be given the options; offer an in person appointment on her own.

Consent and Capacity at 16

●Under section 8 of the Family Law Reform Act 1969 the consent of a 16 or 17 year old to treatment is as effective as an adult's, so no parent has to consent. The Mental Capacity Act 2005 presumes capacity from 16, as does GMC guidance on 0 to 18 years. Ask her to say the options back.
●Gillick and Fraser were developed for under 16s. "Gillick competent" shows the right idea, but at 16 the accurate position is presumed capacity.
●A decision made under pressure is not a free one, so asking what Kyle has said belongs in this consultation.
●Encourage involving a parent where safe; it is not a condition of care.

Counselling About the Options

●NG140 says women should be able to self refer. Compulsory counselling and compulsory reflection time are not required, though support to decide should be offered. Give information on medical and surgical abortion without being directive, reassure her that abortion is not linked to infertility, breast cancer or mental health problems, and do not let personal beliefs delay access.
●Abortion is lawful up to 24 weeks under the Abortion Act 1967, with two doctors agreeing the grounds. The provider arranges this; the GP makes sure she can reach one quickly.
●Medical abortion uses mifepristone, then misoprostol one to two days later. NG140 (section 1.8) offers taking both tablets at home up to 9+6 weeks, and expulsion at home at 10+0; beyond that the tablets are taken in the clinic. Assessments can be done by phone or video.
●Waiting does not stop her having an abortion, but narrows the options and slightly raises the chance of complications. Explain the dates honestly, with no pressure.

Continuing the Pregnancy and Adoption

●NICE NG201 recommends a midwife booking appointment by 10 weeks, so Imogen is already at that point. NICE CG110 recommends a named midwife, community based care and at least one consultation without her partner or family present for women under 20.
●NICE CKS advises folic acid 400 micrograms daily to 12 weeks, vitamin D 10 micrograms daily throughout pregnancy, and avoiding alcohol.
●If she chooses adoption she can plan it in pregnancy, but a mother's consent to an adoption order is ineffective if given less than 6 weeks after the birth (Adoption and Children Act 2002).

Safeguarding When the Partner Is Much Older

●The age of consent is 16, so sex between Imogen and Kyle is not a crime in itself. An offence could arise if an adult held a position of trust over her, such as a teacher; asking about this is good practice, and he does not.
●A 16 year old is still a child. Department for Education guidance says sexual exploitation can affect 16 and 17 year olds who can legally consent, and lists relationships with controlling or significantly older people among the indicators.
●Taken together the concerns are: a seven year age gap, her mother told he is nineteen, advice to wait to tell her mother, pressure to give up her apprenticeship and college day, daily pick ups, a phone on his contract that he pays for and checks, loss of contact with her friend, pressure over the pregnancy, a wrist grab, coldness until she gives in, and condoms dropped at his preference. The pattern decides it. "Do you feel safe?" will get "yes"; specific questions about her phone, friends, saying no and being hurt reveal it.
●Discuss her the same day with the practice safeguarding lead or named professional for children, or seek advice from or refer to children's social care. Working Together to Safeguard Children 2026 says to refer immediately where a child is suffering or likely to suffer significant harm. The threshold is a professional judgement with the lead; local routes differ. A referral to children's social care, the same day or the next working day, is reasonable here. A same day discussion in which the lead chooses early help or a written plan with a short review also fits, if acted on and recorded. A note alone is not enough.
●GMC guidance on 0 to 18 years says to usually share information about sexual activity involving a child with big differences in age, maturity or power, or pressure to keep it secret. If you decide not to share, discuss that with a named or designated professional and record why.
●Ask for her agreement first and tell her what you propose to share and why, unless telling her would put her at greater risk. If she refuses, disclose where necessary to protect her from serious harm, which includes abuse, and record the reasoning. The abortion provider's own safeguarding assessment does not replace the practice's duty.

Confidentiality and Safe Contact

●At 16 she is presumed able to agree to or refuse the release of her information, and neither her mother nor Kyle has a right to it. Her mother is registered at the practice, so check that nothing on the record or patient messaging will reveal the pregnancy.
●Kyle checks the phone on his contract, so texts, voicemails and calls to that number are unsafe. Imogen has an old phone he does not know about: agree a time for a call to, or from, that one.
●See her on her own for at least part of every appointment; if Kyle asks to come, offer to see her alone first, as is routine for every young person.

Safety Netting, Sexual Health and Follow Up

●For early pregnancy, tell her to seek same day assessment for severe or one sided lower tummy pain, shoulder tip pain, bleeding heavier than a period or with clots, and dizziness or fainting, and to call 999 for collapse or severe pain. For her own safety, say what to do if she feels unsafe: 999 in immediate danger, the practice number at other times, and a trusted person such as Bethan.
●Offer testing for chlamydia and gonorrhoea, aimed at sexually active women under 25, with HIV and syphilis blood tests. Contraception can be started after whichever outcome she chooses, with her own consent and without her mother knowing.
●Review in two to three days and no later than a week. The time frame is real and the safeguarding plan needs checking. Make sure she can refer herself, or that you refer, the moment she decides.

Common Mistakes in This Station

●Steering: congratulating her, saying "at your age", or presenting abortion or keeping the baby as the sensible choice, so she stops volunteering her own view.
●Missing the relationship: accepting "he's lovely" without asking about her phone, friends, pressure and being hurt, or lecturing her about Kyle's age so that she defends him and shuts down.
●Confidentiality errors: insisting her mother must be told, promising nobody will ever be told, or texting or leaving a message on a phone that Kyle checks.
●No dates: not mentioning that the home tablet option ends at 10 weeks, or that the midwife booking is due by 10 weeks, and ending with no follow up date.
●Inaction on safeguarding: a note and no same day discussion with the lead or children's social care, or a referral made without telling her when telling her would not have put her at greater risk.
●Over asking: attempting a test or examination on camera instead of an in person appointment.
●Mislabelling capacity: insisting on a parent's consent, or requiring a Gillick assessment before a 16 year old can decide.

Mapped to the RCGP curriculum topic: Maternity and Reproductive Health.

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