The scene

An A&E consultant called the MDU's advice line to ask about a patient he had seen with a crossbow wound. The patient had a bolt protruding through his lower leg, and initially said he had accidentally shot himself with a friend's weapon. However, the consultant queried this given the angle of the bolt, and after further questioning the patient admitted that his friend had accidentally shot him while they had been hunting rabbits in a local woodland.

The doctor knew he had a duty to inform police about knife and gunshot wounds and wondered if this applied to a crossbow injury.

MDU advice

The GMC's guidance, Confidentiality: reporting gunshot and knife wounds (2017) does not specifically mention crossbows but says that doctors should usually tell the police whenever a patient presents with a gunshot wound, and that 'even accidental shootings involving lawfully held guns raise serious issues for the police about, for example, firearms licensing.'

The above example involving a crossbow injury might not be especially common, but the GMC's guidance does make clear that you should usually inform the police if you see a patient with an injury 'from an attack with a knife, blade or other sharp instrument.'

Why - and when - do the police need to know?

It is the responsibility of the police to assess whether the public are at risk from someone armed with a gun or knife, and has used it in a violent manner. The GMC's guidance points out that they need to consider:

• the risk of a further attack on the patient
• the risk to staff, patients and visitors in the emergency department or hospital
• the risk of another attack near to, or at, the site of the original incident.

Information about weapon injuries also contributes to statistics that help inform operational and strategic priorities relating to how such incidents are dealt with.

However, the guidance goes on to clarify that the police would not usually need to be informed if an injury from a knife or blade seems to be accidental or due to self-harm. It also highlights that there may be other situations when contacting the police for a knife wound might be excessive - such as when it appears that no one other than the patient is at risk and to disclose may cause the patient harm or serious distress, or it could harm their trust in the doctor or the medical profession in general.

Disclosure of information

The doctor responsible for the patient must ensure that the police are informed when necessary, but they can delegate the actual disclosure to an appropriate member of staff.

Importantly, the initial disclosure should not usually include the patient's name or address.

The police will attend regardless of whether they have been given the patient's identity but when they arrive they should not be allowed contact with the patient if this would compromise the patient's treatment or recovery.

If the patient is able to talk to the police then they should be asked if they are willing to do so. If they decline, then this decision should be respected.

When consent is withheld

The GMC outlines that if it is likely a crime has been committed, then the police will ask for more details of the case. If possible, the patient's consent for disclosure of this information should be sought before doing so, unless it may put doctors or others at risk of serious harm or it is likely to be problematic to the purpose of disclosure - for example, by interfering with the criminal investigation or prosecution.

If the patient declines their consent or are unable to give it then disclosures can still be made if they are required by law or can be justified in the public interest. Paragraph 14 of the guidance explains that:

14. 'Disclosures in the public interest may be justified when:

• failure to disclose information may put someone other than the patient at risk of death or serious harm (you should not usually disclose information against the wishes of an adult patient who has capacity if they are the only person at risk of harm)
• disclosure is likely to help in the prevention, detection or prosecution of a serious crime.

Although the guidance on knife and gunshot wounds doesn't include a specific definition of what constitutes a serious crime, the Department of Health guidance Confidentiality: NHS Code of Practice (2003) lists the examples of murder, manslaughter, rape, child abuse, substantial financial gain/loss, risk of state security/public order.

If there is any doubt about whether disclosure is justified, doctors should seek advice from the responsible consultant or the trust's Caldicott guardian. In addition, you may wish to seek advice from your trust's legal department and your medical defence organisation.

Documentation about the context of the disclosure is important in these cases. As such, the GMC instructs doctors that they must include in the patient's notes the rationale for any disclosure made and the steps taken, if any, to obtain the patient's consent. It also advises to make notes of whether patients have been informed about the disclosure and if not, why not. It would usually be expected that the patient would be informed promptly about disclosure made without their consent, but not if doing so would be unsafe or impractical.

The urgency of the situation should also be taken into account with the GMC stating that if there is 'no immediate reason for disclosing personal information in the public interest' then additional information need not be given as it is open to the police to seek a court order or warrant to obtain the information they require.

Patients under 18 years of age

As with adults, wounds in under 18s resulting from an attack with a gun, knife or other sharp instrument would require police and child safeguarding team involvement. Even cases where a knife wound arises from an occupational or domestic accident, or from self-harm, may generate serious child safety concerns.

The GMC advises doctors to consult its guidance Protecting children and young people: the responsibilities of all doctors in cases where someone under 18 years of age is at risk of, or has already experienced, serious harm.

Back to our case study…

No licence is required to buy a crossbow and they can be purchased online provided you can prove you are over 18. As such, there is no regulation about which adults can own a crossbow and no checks about their suitability to do so.

Given that the injury in our case example appeared to have been accidental and was not a gunshot or knife wound, it wouldn't fall under the obligation to report identified in the GMC requirements.

However, the doctor should also consider whether information should be disclosed to the police or others in the public interest.

In keeping with paragraph 14 of 'Confidentiality: reporting gunshot and knife wounds' (2017) mentioned above, paragraph 65 of the GMC's general confidentiality guidance explains that disclosing information without consent might be appropriate if 'likely to be necessary for the prevention, detection or prosecution of serious crime, especially crimes against the person.'

It goes on to explain even if a victim of violence declines police assistance, disclosure might be justified if there remains a risk to others. One of the examples given is from someone who is prepared to use weapons.

MDU advice

The MDU adviser suggested that in the first instance the doctor could ask the patient's permission to discuss the injury with the police. The member explained that he had already discussed this with the patient, who had not given his consent as he knew that using a crossbow to hunt animals in the UK was illegal and was worried the police would prosecute him.

The doctor was aware that the woodland where the injury occurred had a public footpath running through it. Paragraph 68 of the GMC guidance highlights the need to balance the needs of the individual versus those of society. It advises that if doctors consider that failure to disclose relevant information would leave individuals or society exposed to a sufficiently serious risk (ie, one that outweighs the patient's and the public interest in upholding confidentiality), they should disclose it promptly to an appropriate person or authority. It also says that the patient should be informed about any disclosure beforehand, provided it is safe and practical to do so, and even if they have withheld their consent.

On balance the doctor concluded that using a crossbow in an area accessed by the public posed a risk of serious harm to others and that the police needed to be made aware.

The MDU adviser suggested the doctor kept a detailed record of his reasons for disclosing information without consent and any steps he had taken to get the patient's consent, to inform him about the disclosure, or his reasons for not doing so.

On the MDU's advice, the doctor discussed the case with the trust legal adviser and his Caldicott guardian, both of whom supported his decision. He then explained to the patient that he needed to inform the police but explained that he would only share the minimum relevant information so they could investigate the circumstances surrounding the injury.