Violent patients

Authors: Ingrid Torjesen 

Publication date:  28 May 2008


Violence against doctors is becoming an increasing problem. Ingrid Torjesen charts the trends and finds out what you can do about it

One in three doctors is attacked at work every year, yet few of these will have been trained on how to handle the situation. General practitioners, doctors working in accident and emergency departments, psychiatrists, and doctors in training are the most at risk.

Most attacks are verbal, but a third are physical attacks, according to a BMA survey published in January. Doctors could be spat at, kicked, punched, bitten, or even stabbed by patients or one of their relatives or friends. One in three of the doctors physically assaulted is injured, 5% seriously.

But alarmingly, while doctors say the frequency of attacks is increasing, only 53% of GPs and 23% of hospital doctors have received any form of training in dealing with incidents.

Policy

The National Audit Office report A Safer Place to Work, published in 2003, made a series of recommendations for tackling violence and aggression in the NHS, including setting up a single body to implement national policy. The NHS Counter Fraud and Security Management Service was established, which has set standards for violence training by developing a conflict resolution training syllabus. It has also created a network of local security management specialists to ensure primary care trusts and hospital trusts are following national policy, such as setting up special general practice schemes to deal with violent patients. The Department of Health claims that a fall in the number of reported assaults over the past three years is evidence that this body is making a difference.

However, the BMA survey found that doctors are much less likely to report aggressive incidents than they were in 2003, when the BMA’s last survey was done. Half of doctors attacked do not report the attack. Some claim they do not know how to, while others see their injuries as minor and not worth reporting, indicating a worrying acceptance that being attacked is now part of the job.

Getting away with it

Despite government assurances of a zero tolerance policy on violence in the NHS, doctors who do report incidents often see their attackers being treated leniently or walking away completely because of lack of evidence, mitigating circumstances, or the foibles of the legal system.

In June 2007, Gordon Shepard, a consultant orthopaedic surgeon at the Royal Bolton Hospital, received death threats from an unhappy patient. The patient was interviewed by police, and the Crown Prosecution Service authorised a charge of abusive or insulting words or behaviour in December. The defendant disappeared and the police took two months to find him, by which time the case had to be dropped by the Crown Prosecution Service because it had passed a six month time limit. Mr Shepard is angry and now trying to forget the experience.

John Grenville, a member of the BMA’s general practitioners committee, was hit on the jaw by a patient several years ago. He says: “I was on my own with this guy late at night in a building with just his friend, who was sat in the waiting room. That was a mistake.”

Luckily Dr Grenville was not seriously hurt, but this also meant his attacker escaped a conviction. “The problem was that although he hit me he didn’t produce any visible injuries, the only thing the police could have charged him with would have been assault. I think in the end he admitted to having hit me so they cautioned him.”

Dr Grenville says a lot of words are spoken and written by the government about zero tolerance, but doctors often don’t get the support they need. He says sentences need to be tougher for patients who step out of line, and when a doctor asks for a police escort the police need to treat that as a fairly high priority. Also, training in dealing with abusive patients should be compulsory and a core part of undergraduate and postgraduate medical training.

Training

Although the NHS Security Management Service is “promoting” conflict resolution training for all frontline staff, it is not compulsory. This is a shame because those who have done it have found it beneficial. An NHS Security Management Service survey found the proportion of NHS staff who felt able to manage a verbally abusive patient increased from six out of ten to nine out of ten after they had done the training. After taking the course 67% of NHS staff felt safe from violence at work, compared with 47% beforehand.

Michael Devlin, a medicolegal adviser at the Medical Defence Union, says it is important that doctors take the training and follow NHS Security Management Service guidelines to ensure they balance their rights against their responsibilities if they encounter an abusive patient.

“Medical staff on the receiving end of an incident can face a counter allegation that their behaviour was inappropriate and they were the cause of the incident,” he warns.

Stephanie Bown, director of policy and communications at the Medical Protection Society, says the first thing a doctor has to do is to determine whether aggression was the result of an underlying medical condition, such as low blood sugar or cerebral compromise.

When it wasn’t it was important to follow the right procedures. In the case of physical violence, hospital staff should contact security and GPs should contact the police immediately to enable the patient to be removed from their list. In the case of verbal aggression “removal can only be requested if during the previous 12 months the patient has been provided with a written warning that he or she is at risk of removal and has been given reasons explaining why this is so,” she emphasised.

Nottinghamshire was one of the first areas to set up a robust general practice scheme specifically to treat and rehabilitate violent patients. Patients are seen at an out of hours centre in Nottingham during the day, and a mobile surgery is used at other times and to see patients in rural areas. The mobile surgery has an escape hatch and everything is bolted down.

Chris Locke, chief executive of Nottinghamshire Local Medical Committee, says: “They have transgressed so we take them out and put them in an environment where we minimise the risk to others and then we have got the time to find out what is going on and find out why they have become violent and see if we can’t tackle it.”

The central Nottingham scheme has around 30 patients, whereas the local emergency department has banned 110 patients for violent behaviour. Although alerts are put out on particularly violent offenders under Multi-Agency Public Protection Arrangements, Mr Locke complains there is no formal sharing of regular information. He says: “GPs will encounter some of these people who are banned from A and E [accident and emergency] without knowing that they are potentially violent, so what is needed is a national central register.”

Violence indicator

Rather than a central register, what is being considered is an indicator on the electronic summary care record of violent patients who have physically assaulted a member of NHS staff. The NHS Security Management Service launched a consultation on this at the beginning of May. As well as alerting staff the indicator would include advice on how to avoid the threat of violence while ensuring patients receive the necessary treatment. It is proposed that all NHS staff with access to the electronic patient record system would be able to see the marker, and the decision to put the marker in a record would be made by a specifically appointed panel of at least three members of that health body’s staff.

Richard Hampton, head of the NHS Security Management Service, says: “In 2006-7 there were over 55 000 physical assaults reported against NHS staff. This is not acceptable, and we must take every suitable measure to ensure that those incidents do not happen.

“NHS staff deserve to work in an environment that is free from violence and abuse, and the violent patient indicator is a further measure to help us tackle the antisocial minority without compromising patient care.”

Box 1: Dealing with abusive behaviour

Avoiding incidents

  • Be prepared

  • Get training in dealing with abusive behaviour for yourself and other staff who have face to face patient contact

  • Make sure you are not alone in a surgery building

  • Make sure you have an exit strategy—the patient is not between you and the door

  • In the surgery do not leave anything that could be used as a weapon lying around

  • When visiting make sure people know where you are, what you are doing, and when you should be back

Assessing risk

  • If you are visiting someone with a history of violence or if you are concerned about going alone, take someone with you or get a police escort

  • Be aware that situations can develop rapidly, particularly if a patient is mentally ill, drunk, or a drug abuser

  • Be aware that patients and their relatives may be stressed and afraid, so their threshold for aggression might be lower than normal

In an incident

  • Call for help

  • Keep a barrier such as a desk between you and the patient

  • Try not to escalate the situation, keep calm, and do not mirror the patient’s behaviour

For comprehensive advice go to www.cfsms.nhs.uk/training/crt.html

Box 2: GP head butted in face

Iain Procter, a GP in Dundee, was head butted in the face by a patient he went to visit during an out of hours shift on a Saturday during the day in November 2006.

The door was opened by the patient’s mother, and Dr Procter walked into the hall. The patient appeared from another room and head butted him in the face.

“Normally you get some sort of warning that they are going to be violent,” Dr Procter says. “People normally swear at you first, but without any warning and without saying anything within two or three seconds he just head butted me in the face. It was a bit of a shock.

“Basically I just staggered back a wee bit and got out of the house as quick as I could. I went back to the out of hours car and the driver drove me back to the base and we rang the police.”

The patient was convicted of assault, but received community service rather than a jail term. “I think there was some sort of excuse, some sort of family stress and I think he had had some alcohol overnight,” Dr Procter recalls. “I thought he should at least be put in jail for a while.”

Although Dr Procter sustained only minor injuries, a bloody jaw and some loosened teeth, the experience shook him and he has been much more cautious at work ever since.

“I still do the occasional out of hours shift but I would probably have a lower threshold for getting the driver in with me, if I thought it sounded like a bit of a dodgy call or it was in a dodgy area,” he says.

Dr Procter had not received any training in dealing with violent patients. He says: “There are courses and so on but unless they are compulsory you don’t tend to have time to go to them because you are that busy at your job. It would help if it was a core part of GP training.”

Ingrid Torjesen freelance journalist London

 ingrid_torjesen@hotmail.com

Cite this as BMJ Careers ; doi: