Dr Adrian Boyle, Consultant Emergency Physician and Caldicott Guardian at Addenbrookes Hospital in Cambridge, and Chair of the Quality Emergency Care Committee at the Royal College of Emergency Medicine, reflects on the practical application of our revised guidance – Confidentiality: reporting gunshot and knife wounds (2017).
The GMC guidelines on confidentiality have recently changed. This is a potentially fraught area for doctors who treat victims of intentional injury. Research has consistently shown that doctors care for many assault victims who the police are simply unaware of, despite the severity of injury. Over 70% of assaults treated at emergency departments are never recorded by the police [i].
Patients may have many reasons for not disclosing their assault to the police. They may be too frightened of reprisals, they may not want their own behaviour scrutinised and they may make a judgement call that the police won’t take action. Wherever possible, disclosure of confidential information should be done with the consent of the patient, and this hasn’t changed. But there are some scenarios where consent to share information is withheld, or unfeasible or unsafe to obtain. In such cases a difficult judgement might need to be made.
Until April this year, many doctors understood GMC guidance to be saying that they must call the police for all intentional injuries caused by knives and guns and share limited information. This wasn’t quite the intention of the guidance – there was room for judgement to be exercised – but that wasn’t clear to all doctors and this led to several problems.
First of all, the guidance appeared to be limited to gunshot and knife wounds. Ask any experienced emergency department doctor and they will be able to tell you of cases where serious injuries were inflicted with weapons other than knives and guns, such as bricks, baseball bats and acid.
Second, there are variations in seriousness of injuries caused by guns and knives. Gunshot wounds are usually serious, and even air rifle pellet injuries should lead to the police being informed as they will be able to assess firearm licensing. Conversely, a knife injury isn’t always medically serious. Around 75% of stabbings are sent home from emergency departments with only wound care. Disclosing some knife wounds, such as those caused in a domestic violence incident, may not be in the public interest. For example breaching confidentiality without consent in a domestic abuse case may damage the patient’s trust and lead them to avoid further care.
The focus of the guidance has now shifted and it more clearly asks doctors to consider whether disclosing confidential information is in the ‘public interest.’
What is in the ‘public interest’?
So what does ‘public interest’ actually mean? My take on this is that this means that others could be seriously harmed or killed by the perpetrator. It doesn’t generally include crimes against property, though arson would be a worry. This can be a difficult decision to make and it is a good idea to discuss this with an experienced colleague.
The other area which has always been operationally difficult is knowing how much information to give to the police. This hasn’t really changed very much. The guidance states that you shouldn’t disclose personal information to the police, but when they arrive, they invariably ask medical or nursing staff to talk to the victim and the patient’s identity is known pretty quickly. It is, of course, entirely up to the patient how much information they give the police.
It is reasonable to tell the police whether a weapon was used, the location of the assault and the time of the assault.
The guidance asks you to consider a number of steps before disclosure.
- the potential harm or distress to the patient arising from the disclosure – for example, in terms of their future engagement with treatment and their overall health
- the potential harm to trust in doctors generally – for example, if it is widely perceived that doctors will readily disclose information about patients without consent
- the potential harm to others (whether to a specific person or people, or to the public more broadly) if the information is not disclosed
- the potential benefits to an individual or to society arising from the release of the information
- the nature of the information to be disclosed, and any views expressed by the patient
- whether the harms can be avoided or benefits gained without breaching the patient’s privacy or, if not, what is the minimum intrusion.
This guidance is hopefully an improvement on the previous guideline, as it makes clear to doctors that they can exercise discretion not to call the police* if they don’t think they are justified in doing so. It also more clearly advises that the principles in the guidance apply to injuries caused by weapons other than guns and knives. But the judgement still rests with the doctor. Guidelines like this are difficult to write and require your professional judgement to apply, as scenarios vary so much. In difficult cases, discuss with a colleague and always document your reasoning clearly.
Putting the guidance into practice; my experience
Testing these against some of my own cases is an interesting exercise and illustrates how this has changed.
Case 1: knife wound and domestic violence
A 35 year old woman attends the emergency department after a domestic assault. She had a fight with her husband in the kitchen. She picked up a knife, there was a scuffle and she sustained an incised wound to her little finger. She has decided to leave her home and has no children. She is adamant that she doesn’t want the police to be involved, and says that she is going to go home to her family.
In this case, it is difficult to argue that disclosing information about the knife wound is in the public interest. There is a real risk that reporting this incident will undermine her trust in doctors and may discourage future attendances. It also isn’t clear whether the police knowing this information would help the public or even the patient.
Case 2: baseball bat assault and potential gang violence
An 18 year old boy attends the emergency department after an assault. He says that he was attacked by a group of boys from another school with baseball bats. He doesn’t want anyone else to know about his assault. He has multiple limb fractures.
This case is very suggestive of gang related violence and, though there is no gun or knife crime, disclosing information here is clearly in the public interest as others could be at risk. While he may not want to press charges, the police can gain useful intelligence about where and when the assault took place.
Case 3: chemical burns from an unknown assailant
A 23 year old woman attends with a chemical burn. She opened the door to her house and an unknown assailant threw an unidentified liquid at her. It mostly missed, but she has a mild, non-serious burn to her hand. She doesn’t know why this might have happened. She is reluctant to involve the police, as she doesn’t think it will do any good.
Sharing information is clearly in the public interest here, as there is an ongoing risk of serious harm to the public. This probably outweighs the patient’s reluctance to involve the police.
* In Northern Ireland, section five of the Criminal Law Act (Northern Ireland 1967) places a duty on all citizens to report to the police information they have about a relevant offence (one with a maximum sentence of five years or more). However, the duty does not arise where the person has a ‘reasonable excuse’ not to disclose the information.
[i] Faergemann C, Lauritsen JM, Brink O, et al. Trends in deliberate interpersonal violence in the Odense Municipality, Denmark 1991–2002. ‘The Odense study on deliberate interpersonal violence’. J Forensic Leg Med 2007;14:20–6.
Improving medical education and practice across the UK 
Paragraph 5 makes mention of air pellet injuries. Air rifles under 12 ft lb muzzle energy are not subject to licensing in England and Wales so although injury of another person with such a weapon should quite correctly be reported, unless the weapon is in excess of the muzzle energy limit (such weapons should only be held by individuals in possession of a firearms certificate that clearly permits them to hold it), there is no licensing issue for the Police. The relevant laws and age limits for possessing and using air weapons are summarised by the BASC (British Association for Shooting and Conservation): https://basc.org.uk/airgunning/advice/basc-air-rifle-code-of-practice/
Sadly though this helps with regards to other weapons and also the concept of trying to keep patients engaging with the medical community, it will further muddy the waters of when we should or should not involve the police. As doctors, someone will eventually point the finger at us when something goes wrong because we used our “judgement”. Furthermore, as identified today in the news, violent crime is on the increase and this apparent taking a step back by the GMC seems to almost condone this trend. I agree we should not feel we live in a police state, but the concept of fear in involvement of the police is the publics issue, not ours. Perhaps a more rigid step in the opposite direction would have been more appropriate and supportive of society and our police colleagues.
It seems to me that this guidance is very unclear and therefore unhelpful.
Decisions about what is in the public interest are outside the expertise of most doctors likely to vary enormously between individuals.
Since when are doctors experts in identifying gang violence or in resolution of domestic violence? In my experience patients often deliberately provide inaccurate information in such cases, which makes any attempt at a meaningful judgement on ‘public interest’ even more ineffective.
Reblogged this on fluffysciences and commented:
Disclosure is a fraught issue – and this is a really useful take on the updated GMC guidelines
I have to agree that this advice is unclear and the waters still remain muddy. However, some responsibility has to lie with the public/patients themselves in cases where weapon violence are involved, and the role of the clinician as policeman will always be open to debate. Lawyers often use the term ‘realistic prospect of a prosecution’ and this is something to consider when any doctor is contemplating compromising his or her professional registration.
Perhaps we’re all guilty of wanting guidance that is impossibly simple and directional?
Apart from the air gun licensing error, the author does a good job of identifying and applying the key issues in decision making. Alas, some judgement will always be required
major cases involving fire arms and those where gangs are involved should be reported to prevent public disorder but those of domestic injuries should not be, unless the victim specifically desires. The domestic group usually resolves with time and with the help of relatives and friends. m.jalisi
I’m troubled by your assessment of the woman who was knifed by her partner. Whilst she may not appear to be at risk from him at present, women frequently return to abusive partners and are most at risk of harm at the point of exiting the relationship. The presence of a weapon also demonstrates increases the risks to her.
It is not usually possible for an Emergency Department professional to carry out a DASH (a nationally recognised measure of domestic violence risk which was established by assessing cases where women had been killed or seriously injured), so medics would not be able to identify women at high risk of being killed.
Even with training, it is unlikely to be appropriate or safe for an ED professional to carry out this assessment, so whilst a referral to police may not be the most appropriate measure, an understanding of domestic violence risk and referral to a professional agency who can assess that risk and/or refer to a MARAC may be helpful.
You can find out more about assessing risk here:
http://www.reducingtherisk.org.uk/cms/content/risk-identification-and-assessment
Not sure whether you misread this: “She picked up a knife, there was a scuffle and she sustained an incised wound to her little finger.”
Hardly being “knifed by her partner”.
Ben this is the precise reason medics cannot and should not attempt to assess risk of gender violence unless they have appropriate training.
Look beyond your semantics. Remember that minimisation is one of many tools of abuse in domestic violence, she may also be minimising in order to cope or even trying to frame what happened in a way she feels will protect the man who is has abused her, who she very probably still loves.
Remember that most women self-treat wounds (on average a woman is assaulted an average of 35 times before she contacts the police, I don’t believe there are stats for medical help seeking). If things have reached the point that she sought help (and was so fearful she picked up a knife in the first place) then the risk level is pretty bad.
Remember that whatever you think, her risk level is increased because she is leaving the relationship. In the scenario described you know nothing about the offender, so you cannot assess the risk.
You’re a medic, treat the wound and refer for appropriate support, don’t act beyond your training.
I’m not going to get into a slanging match or even any sort of debate. You have no idea what training I have or haven’t had so please don’t assume.
The article clearly stated she had a cut to her finger and had picked up the knife herself and yet you stated that “she was knifed by her partner”, which is a gross misrepresentation of what had happened. People don’t “knife” other people in the finger. She even had admitted she was the one that picked the knife up.
It’s fairly easy to twist anything and assume that the man is to blame but as I’m sure you know men can also be victims of domestic violence. In this case it seems there were no other factors to be concerned about and so a judgement was made to leave things at that.
Reading too much into a situation and assuming that there’s some terrible situation going on and that the person who picked up the knife must be the victim is not helpful at all and can make things a whole lot worse. Of course we have to be vigilant but twisting things to suit one’s own agenda isn’t useful. An open mind is the best course.
Again, don’t assume anything about my training. As I said, I’m not interested in some internet slanging match (especially as I get the distinct feeling we won’t agree on this), I’ve made my point and that’s my last word on this.
I think, from the information given, we cannot tell whether woman or the man is the abuser. Perhaps she picked up the knife to defend herself, having experienced abuse from him before, perhaps she picked it up with the intention of stabbing him. What is important is that people in normal relationships, even those which are coming to an end, do not end up with knife injuries after a row with their partner. To ignore this incident and put it down to “oh it’s just between the two of them and she is leaving anyway” seems grossly irresponsible – what if she changes her mind? What if her leaving provokes another row? What if the abusive partner moves on to someone else and the same happens? What if this “row” was a result of untreated mental illness in one of the partners? There is so much to consider and this incident would be a huge red flag to me.
Domestic violence should be signalled to police officers as well. This political correctness is hateful.
Thanks for sharing such useful piece of information. Its necessary to know all these stuff as accidents can happen to anybody.
Thanks for the blog and if someone has minor burns & scalds due to some incident then use Jelonet dressings as it help s to cur such wounds.