Abstract
Introduction
The incidence of knife crime in England and Wales has been rising since 2014; between April 2019 and March 2020 criminal offences involving knives or other sharp instruments resulted in 4674 hospital admissions (Office for National Statistics, 2021a, 2021b). Firearm offences, on the other hand, have remained fairly stable, but still result in hospital admissions and even fatalities (Office for National Statistics, 2021c). Doctors working in the emergency department may encounter such patients during their practice and may be faced with complex decisions about breaches of confidentiality in the context of public interest.
Given the complexity of these matters, patients may be unaware of what rights they hold and whether or not they have any say in the involvement of the police. Similarly, doctors may not know what is required of them and how to weigh up decisions that may breach patient confidentiality. The General Medical Council (GMC) has produced guidance on confidentiality and a specific document in the context of reporting gunshot and knife wounds (GMC, 2017a, 2017b). It is important that both parties understand the various factors involved in such decisions, in order to preserve trust in doctors and ensure that personal information is handled appropriately.
Literature review
Firearm and knife crime in England and Wales
Since 2014, the incidence of knife crime in England and Wales has been rising. The rates in the year ending September 2020 were 84% higher compared with the rates seen in the year ending March 2014. In recent years, the rate of increase has slowed and even decreased by 3% from 2019. The COVID-19 pandemic and its associated national lockdown, particularly between April and June 2020, had significant impacts on crime within England and Wales. It not only affected the collection of data on criminal offences, but also affected the rates of crime seen over the year 2020. During this time, knife and sharp object-related offences fell by 22% and subsequently increased from July to September, in line with some easing of lockdown restrictions (Office for National Statistics, 2021a).
Not all criminal offences involving knives and sharp instruments result in injury or hospital admission, and people may be charged for ‘possession of an article with a blade or point’, for example. However, between April 2019 and March 2020, 44% of offences were for assault with injury or assault with intent to cause serious harm, and there were 4674 hospital admissions as a result (Office for National Statistics, 2021b).
Firearms offences make up only ∼0.2% of all offences recorded by the police and encompass not only the firing of a firearm, but also its use as a blunt instrument and as a threat (Office for National Statistics, 2021b). Since March 2017, the trend of firearm offences has remained stable and in the year ending September 2020 there was a 7% reduction in offences compared with the previous year (Office for National Statistics, 2021a, 2021b). Similar to knife crime, there were drops in the rates of offences between April and June 2020 and subsequent increases between July and September, correlating with national lockdown due to the COVID-19 pandemic (Office for National Statistics, 2021a). The vast majority of firearms offences result in no injury; however, firearms have the capacity to injure and cause death. In the year ending March 2020, there were 9406 offences involving firearms (including air weapons), of these 1541 resulted in injuries. Of these, 290 resulted in hospital stay or serious injury and 26 were fatal (Office for National Statistics, 2021c).
In summary, although not as great a problem as in other parts of the world, crime involving knives or firearms is ongoing in England and Wales and can lead to injuries requiring medical treatment. Therefore, doctors working in the emergency department of hospitals may encounter such patients during their practice. Given the possible criminal nature of these events, and the chance of further harm occurring, they must consider not only a duty to their patient, but also a duty to act in the public interest. These are complex decisions surrounding confidentiality and disclosures of personal information, but guidance has been created to support doctors in this situation.
Confidentiality
The Good Medical Practice document produced by the GMC sets the benchmark for clinical practice as a doctor. The most recent version of this document came into effect in 2013 (GMC, 2013). Paragraph 50 under domain 3 of the most up-to-date version of Good Medical Practice clearly outlines ‘You must treat information about patients as confidential. This includes after a patient has died’ (GMC, 2013). Further, more extensive guidance on confidentiality is outlined in the document Confidentiality: good practice in handling patient information (GMC, 2017a).
Confidentiality refers to the duty of keeping something private; in a clinical context, the knowledge that everything said in a consultation is being kept confidential allows patients to fully open up and develop trust in the relationship. It is a concept that has been around for thousands of years and can even be dated back to the Hippocratic oath (Morris, 2009). It is an ethical and legal duty linked to common law, data protection law and human rights law (GMC, 2017a).
Gunshot and knife wounds
For more complex confidentiality scenarios, the GMC have produced further guidance documents. One such document relates to the reporting of gunshot and knife wounds (GMC, 2017b). The most recent version of this document came into effect in April 2017 and was updated in May 2018 to reflect the General Data Protection Regulation and Data Protection Act 2018 (GMC, 2017b). This guidance utilises the eight principles that underpin confidentiality and aids doctors’ communication with the police when a patient presents to them with a gunshot or knife wound that was not self-inflicted (GMC, 2017a).
Information about injuries resulting from gunshots and knife wounds can be useful to the police. Simple information about the weapon used and location of the incident can be used to generate statistics that can guide police in crime reduction operations that in turn can keep the public safe. So, when a patient with such injuries presents to hospital this limited information should be passed on to the police. Relevant injuries include most gunshot wounds, including accidental and those with licensed firearms, and wounds from knives or sharp objects that are not self-inflicted and are non-accidental (GMC, 2017b).
In certain instances, it is justifiable to go on to disclose confidential information about a patient. The most relevant in the case of gunshot and knife wounds is when the disclosure is in the public interest (GMC, 2017a, 2017b). To decide whether or not this is the case, doctors must consider if the disclosure would either prevent any potential risk of serious harm or death or if it would help in the prevention, detection and prosecution of serious crime (GMC, 2017b). If there is risk of further violent attacks, for example, it would be in the public interest for police to be made aware and be allowed to investigate and thus an argument can be made for disclosure in the public interest. However, it is not the duty of a doctor to act as the police. A doctor’s primary duty is to their patients and they should be at the forefront of their considerations (Boyle, 2017).
If a doctor decides that a disclosure is necessary, they should first seek out the patient’s consent to do so. If consent can be obtained, this simplifies the interaction, and a doctor can go on to report the incident to the police and they may speak to the patient. Throughout these interactions, safe and appropriate management of the patient should be the first priority and discussion with the police should not impact the patient’s care or recovery (GMC, 2017b).
In some instances, a patient may not consent or taking consent may not be possible. For example, if this undermines the disclosure, or if the patient is unconscious or lacks capacity. This is where decisions become more complicated, and the benefits of disclosure must be weighed up against the benefits of maintaining confidentiality. Where possible, the patient’s wishes should be respected in order to prevent any disengagement in further treatment and ill effects on their overall health. Respecting their confidentiality also maintains trust in the profession and allows patients to be comfortable disclosing information to doctors in the future (GMC, 2017b). The guidance allows for doctors to exercise discretion and not call the police if they deem it more harmful than beneficial (The UK Caldicott Guardian Council, 2021).
However, if the public interest still outweighs these drawbacks, then a breach of confidentiality would be justified. As with all disclosures of information: it is important that only the minimum necessary information is disclosed and only to the necessary individuals or authorities. Patients should ideally be informed of any disclosure and the doctor should thoroughly document their decisions (GMC, 2017b).
Establishing whether or not disclosure is justified can be very difficult, and each case should be assessed individually. Fortunately, there is support available for doctors making difficult decisions on breaching confidentiality. Doctors often utilise the knowledge of more experienced colleagues in clinical decisions and this can be extended to matters of confidentiality (Boyle, 2017). In addition, every trust will have a Caldicott Guardian, and they too can be another useful source of advice (Boyle, 2017). Their role is to ensure the legal, ethical and appropriate use of personal information and help maintain confidentiality in the organisation for which they work, and they can be sought out to discuss complex cases (GMC, 2021a). Medical defence organisations are well versed in the law and professional guidance that may surround a decision to breach confidentiality and are therefore also well placed for such discussions (Boyle, 2017).
Finally, the GMC provide documents outlining guidance on confidentiality as well as a variety of tools that can be used when considering if a disclosure is appropriate or not (Boyle, 2017). Such tools include a confidentiality decision tool and workable real-world scenarios in their Good Medical Practice in Action resource (GMC, 2021a, 2021b).
