When I was pregnant a patient, stabbed me in the hand with a dart while I was examining him. The physical injury was relatively minor; however the mental impact was far greater than I had realised.
Stories such as these are becoming increasingly common across healthcare. According to recent data, incidents of violence at GP surgeries have almost doubled in five years.
Many doctors who have experienced lower levels of criminal or violent activity from patients contact Medical Protection to ask whether they can report these incidents to the police.
Sometimes there is no physical injury; doctors can be victims of theft, verbal abuse and other crimes, and they are concerned as to whether they are deemed 'sufficient' or appropriate to breach confidentiality. Racial abuse and whether doctors can report this, or are required to continue seeing patients, is also a common concern.
GMC guidance makes clear that confidentiality is not absolute and patients should be aware that there are circumstances where doctors may need to breach confidentiality.
Many zero tolerance protocols advise patients that information may be passed to the police or that their behaviour could risk prosecution. It is therefore implied that patients should be aware that criminal behaviour could result in their information being shared with police.
However, doctors understandably remain concerned as to where they stand from a medicolegal perspective if they are victims of a crime and wish to report a patient to the police.
The NHS constitution for England sets out patients’ rights along with their responsibilities. The constitution is clear that violence or causing a nuisance/disturbance on NHS premises could result in prosecution, and that abusive and violent behaviour could result in refusal of NHS services.
While most patients would not be familiar with this document it may provide reasonable justification for action. The GMC’s ethical guidance also suggests that 'doctors are not expected to put up with even petty crime with no recourse to the police, and doctors may be able to justify disclosing information in circumstances like this'.
Informing the police
GMC guidance states that breaching confidentiality needs to be considered in the context of the fundamental principle of maintaining trust between the doctor and patient. In some circumstances, informing the police of the details of a patient who commits a crime in the context of their medical attendance, may need to be balanced against the risk of harm to the patient should the relationship be lost.
This can make some decisions on reporting a crime to the police a difficult balancing act which may need to be justified in the event of a subsequent complaint, or, if the crime is not reported, a subsequent incident that arises following non-disclosure.
There are circumstances where there is a clear public interest in disclosing information about a crime, particularly a serious crime where there may be risk of future harm to others. While there is no definition of 'serious crime' the NHS code of practice suggests this may include murder, manslaughter, rape or child abuse.
If the decision is made to disclose information to the police, it should be the minimum required and there are few circumstances when it would be appropriate to disclose medical information.
Doctors may also need to consider obtaining consent, if appropriate, or advising the patient of their intent to disclose.
Continuing to provide care
The GMC provides guidance for circumstances where a GP is considering whether a crime committed by a patient has led to a breakdown in the relationship, and whether there is an ongoing duty to treat the patient.
Reasons for ending the relationship include where a patient has been violent or threatening, or where they have stolen from an individual or the premises.
Updated guidance from NHS England in May 2022 also outlines unacceptable behaviours which may result in a practice wishing to remove a patient from the practice list.
The special allocation scheme also enables practices to remove patients who have exhibited violent or aggressive behaviour. As part of the scheme, GP practices are expected to report the behaviour to the police and the CQC.
There is no clear guidance for doctors which fully endorses disclosure when they have been a victim of crime, therefore it is often a judgement call.
Doctors should consider the individual circumstances of a crime, the practice’s policy and other GMC/NHS guidance. Doctors need to consider the principles of confidentiality and be able to justify their decision making.
If in doubt, GPs can contact their medical defence organisation.