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.