Violence and Knife Crime
I welcome everyone to the second meeting in 2006 of the Justice 2 Committee. I have received no apologies. Carolyn Leckie is currently attending a Parliamentary Bureau meeting, but she will join us in the course of the afternoon.
Item 1 concerns violence and knife crime. On behalf of the committee, I welcome Dr Michael Sheridan, who is from the Southern general hospital in Glasgow, and Dr Jean Moller, of the Royal Alexandra hospital in Paisley. They are going to brief the committee on violence and knife crime. I am not a technical genius, but I can see that we are going to get a PowerPoint presentation.
Dr Michael Sheridan (Southern General Hospital):
Good afternoon. My colleague Jean Moller and I are emergency registrars working in the west of Scotland. Emergency medicine became the new term for accident and emergency about two months ago, so I might use the two terms interchangeably.
Thank you for inviting us to speak to the committee. We are here to present a study on violence presentations to emergency departments, which was prompted by what happened on my return to Scotland after two years working in Australia. I worked in Melbourne in the emergency and intensive care trauma service in one of Australia's tertiary referral centres for trauma.
On my first shift after my return to the Southern general in January 2004, I met the gentleman who is shown in slide 2. He had been attacked in a public place with a knife, which had ripped through his face. He had also been stabbed in the chest and the leg. He was drunk and aggressive and required to be restrained by four policemen. He was spitting virally infected blood at those who were trying to help him—the nurses, doctors, ambulance staff and police. My repulsion at the vicious nature of the attack, the injury and the behaviour of the patient was compounded by the fact that in my two years working in Australasia, I had not seen anything like that. The rest of the A and E staff responded professionally, but with a resigned acceptance that the patient was, unfortunately, just another victim of an attack that they described as commonplace.
My experience was not unique. As the local evening paper noted and as one of my consultant colleagues with 25 years' experience said, there has been a problem for a considerable time. The west of Scotland, and Glasgow in particular, has an historical image of high levels of interpersonal violence. Despite previous initiatives such as operation blade, which was run 10 years ago, such violence has remained an on-going problem in the community and for the emergency services.
Statistics from the past year have highlighted the issue. There have been 137 murders—72 with a sharp implement. In Scotland there are 22 murder victims per million and in Glasgow there are 55 per million. In 2003, Strathclyde police noted 357 attempted murders, with 193—nearly 60 per cent—involving a knife. That is against a background of a knife culture, as it has been described.
Professor McKeganey's research on knife carrying among more than 3,000 11 to 16-year-olds in 20 Scottish schools, from a wide range of social backgrounds, showed that 34 per cent of males and 8.6 per cent of females had carried a blade in the previous year.
Our aim was to perform a prospective study to characterise the details of assaults and investigate the resources that are dedicated to the assessment and management of assaulted patients in emergency departments. The emergency departments involved were those at the Glasgow royal infirmary, the Victoria infirmary and the Southern general hospital. We conducted the study in April 2004, which was not an unusual month. My colleague and I considered cases that were documented on a two-page proforma when the person presented to the triage service. We considered the age and gender of the victim, the time of the alleged assault, involvement of psychoactive substances, the formal reporting of the incident, details of the assault, such as weapons used, the disposal from the department—where the patient went after our care—and the time that the victim spent in the department.
In that 30-day month, 484 information sheets were filled in. There were 153 in the Victoria infirmary, 113 in the Southern general, and 218 in the royal infirmary. The average time for victims to spend in the department was two hours. The times ranged from 15 minutes to five and a half hours, which obviously created a significant burden and pressure at the front door of the hospital and increased waiting times for those who had not come in with what is a preventable problem.
Slide 8 might be difficult to see from a distance, but I will explain all the numbers. Of the 484 victims, 82 per cent were male and 18 per cent were female. Fifteen to 24-year-olds accounted for 43 per cent; 25 to 34-year-olds accounted for 28 per cent; 35 to 44-year-olds accounted for 17 per cent; 45 to 54-year-olds accounted for 8 per cent; and those above the age of 54 accounted for 4 per cent. It is young males who are being assaulted.
The next two graphs show when victims presented to the emergency departments. As you can see, there is a gross distortion in the numbers presenting on a Friday, Saturday or Sunday night. The number of assaults then are statistically significant. Over four weekends, there were more than 250 assaults.
The time of presentation is also significant in that 41 per cent of victims presented between 8 pm and midnight and 26 per cent presented between midnight and 4 am. Overall, two thirds of those who had been assaulted presented between 8 pm and 4 am. That is often when emergency departments are at their busiest and when the level of staffing by senior and experienced staff is lower, which has a significant impact on those working at the time.
The statistics also show the weapons that were used to carry out the attacks. About 23 to 24 per cent of attacks, as described by the police, were made with a sharp implement or a knife. That is statistically significant, as those who had been attacked in that way sustained more serious injuries and more often required admission to a ward, intensive care unit or high-dependency unit or went straight to theatre. A firearm was used in only 1 per cent of attacks and, thankfully, such attacks remain a rarity in this part of the world.
Of the people who were seen in the emergency departments, 44 per cent could be treated and discharged home, but 56 per cent of cases had to be followed up: 32 per cent had to be followed up by a specialist clinic—an accident and emergency clinic, an orthopaedic clinic, a plastic surgery clinic or a maxillo-facial clinic—and 23 per cent required an in-patient admission.
I have here a typical picture of someone who has been assaulted. It is not unusual to see this sort of thing every weekend; indeed, over the weekend that I have just worked I saw somebody like this. Blood from a head injury is coming out. The injury must be cleaned, washed and sutured and it may require radiological investigation by a computed tomography scanner or a skull X-ray. The picture shows three small stab wounds. Such stab wounds can cause a disproportionate injury to the internal organs. The one on the left side of the chest—which you can see just below the lead—could have caused a pneumothorax or a punctured lung. The one just below the second lead could have caused injury to the bowel or to the heart. The one on the left-hand side could easily have perforated a bowel. Each stab wound could have required an operation and each was potentially fatal.
The figure of 357 attempted murders in Strathclyde, of which 193 were knife-related, is one of the most concerning. The potential for the murder figures to be much worse than they are and the seriousness of knife crime as a public health issue cannot be underestimated. The person who left their house with a knife on their person and who stabbed this patient had no idea of what injury they were going to cause. When such people plunge the knife, it is only by chance that more fatalities do not occur.
We asked those who were being treated in the accident and emergency department whether they were going to report the incidents to the police. Forty-seven per cent said that they were not going to report the incident to the police. That supports other figures that were gathered in Cardiff between 1995 and 2001, where it was found that fewer than 40 per cent of victims had reported the incident to the police after a case of violent assault.
We considered a one-month period in three accident and emergency departments. April was not an unusual month. Extrapolating those data, we could account for almost 5,800 such cases received annually in those three departments. That is not considering the other two accident and emergency departments in Glasgow and other emergency departments such as those in Paisley, Monklands, Wishaw, Hairmyres, and Ayrshire and Arran. The police agree that we really do not know how many people are being injured, as the statistics that they have are probably flawed. John Carnochan of the violence reduction unit agreed that the figures that we have probably reflect the picture more accurately.
I have mentioned some of the other departments. Knife attacks are a problem not just for accident and emergency departments but for general surgeons; orthopaedic departments; cardiothoracic departments; neurosurgeons; ear, nose and throat specialists; plastic surgeons; head injury wards; the blood bank; and radiology departments. Back in the community, after people have left hospital, the cases are passed on to general practitioners, psychiatric services and counselling services. I was brought up in Glasgow, and two of my contemporaries from school received significant facial injuries, which required them to have counselling for a time. The effect that that has had on the past 10 years of their lives, both socially and educationally, has been significant.
So, what are emergency departments doing about it? In Cardiff, Professor Jonathon Shepherd introduced the violence prevention unit, which collected anonymised information in emergency departments and shared it with the police. Hot spots were identified as a result of people who had been assaulted telling the police, anonymously, where the assault on them had happened. Over a three-year study period, violent crime has been reduced by up to 20 per cent in Cardiff. Change has been implemented through police patrols, through the provision of bus services and through proprietors of licensed premises meeting police and accident and emergency consultants to see what is happening outside their establishments.
The Strathclyde violence reduction unit, which is headed by John Carnochan, and accident and emergency departments in the west of Scotland have been trying for over a year to implement a strategy such as this. The strategy has faced scrutiny by ethical committees. The plan is that anonymised violence assault data that are aimed at focusing policing on problem areas and allowing A and E staff to deal more effectively with violence victims will be introduced shortly in Glasgow royal infirmary. That data will no longer be anecdotal and will, we hope, be more authoritative.
In conclusion, knife injuries are a significant cause of mortality and morbidity, often requiring high-level in-patient care. Victims of knife assaults sustain more serious injuries than those who suffer trauma from blunt instruments. Knife crime commonly affects young men, who are generally a healthy sector. As such, it is a major public health concern. In our eyes, the public health problems are preventable and innovative legislation and clear sentencing deterrents are required to eradicate them. Assaulted patients create a considerable workload for emergency and in-patient services, especially at weekends and overnight, when departments are busy with other problems and less experienced staff are working. We hope that data that have been collected from emergency departments can provide valuable and accurate information about violent crime and give an insight into how to implement effective change.
That has brought us to the stark reality of knife crime in Scotland, particularly in Glasgow and the west. I assume that we will be able to get copies of your presentation.
They have been supplied.
That is fine. Are there any questions?
I found the presentation fascinating. However, I am slightly troubled. On a different day of the week, could the victims just as easily have been the perpetrators? I know that I am asking you to make assumptions.
Dr Moller and I will try to answer all questions. What you suggest is a possibility. However, that is not to suggest that innocent people are not being injured and maimed for life.
Sure, but the cohort that you described—15 to 24-year-old males—accounted for 82 per cent of the victims. I have seen similar statistics that describe most of the perpetrators as falling into that cohort. I pose the question because that connection could be made.
Is a trend in knife crime emerging? The use of swords is increasing, particularly on the streets of Glasgow. You have described a problem that we have talked about and on which we all agree and you have shown us newspaper headlines, yet it has taken a year to agree that one hospital will collect anonymous information. Is there a way of speeding up that process? Is there a duty on those who work in emergency care to report the incidents of violent crime that appear on their doorsteps?
Dr Jean Moller (Royal Alexandra Hospital):
You saw in our presentation the picture of Michael holding a sword that someone had brought into his department. The person was sitting in the waiting room with a samurai sword. I work in Paisley and every Friday and Saturday night we see somebody who has been hacked with a machete. Therefore, I can say that knife injuries are common.
Returning to your first question, I think that the victims may be the perpetrators on other occasions. We often have to take knives off people, but that does not decrease the problem. Knife crime needs to be addressed on such a level that people are informed that it is not right to carry knives and get themselves into that position.
With regard to taking a year to implement change, we found it difficult to raise awareness for the strategy. The media are happy to splash the headlines, but it is difficult to implement change. There is the idea that we will breach confidentiality to report crime, but we are allowed to inform the police of injuries only if we have the patient's permission. You can see from our presentation that victims do not report the crime to the police. If an anonymised database falls into place at Glasgow royal infirmary, we will think about implementing a database in Paisley. I think that other departments would fall into line if a precedent were set. A Glasgow-wide database would help us to implement changes where they need to be made.
Dr Sheridan, you said that the first patient whom you showed was in a state of intoxication. Is a state of intoxication common in victims?
Approximately 73 per cent of those who had been assaulted suggested that alcohol had been a factor in their assault. Intoxication certainly seems to be an important factor before assaults occur. I think that Strathclyde police's figures show that around 70 per cent of assaults are committed within 25m of public houses. Publicans and the alcohol trade therefore need to be aware that such things are happening in their environment and that alcohol seems to play an important role in assaults.
Are your patients frequently under the influence of alcohol?
Alcohol is frequently a component factor that leads to patients being admitted.
Is it also thought to be an influence on the behaviour of perpetrators?
That is difficult to say because the only people whom we see are the victims who have been sent to us.
Okay.
I echo what the convener said about the presentation, which will have enlightened colleagues. I am aware of your report, which I have read, and of the fact that only 53 per cent of assaults are reported to the police.
I have carried out my own survey of accident and emergency doctors and the figures that I found might surprise you. They suggest that the amount of information that goes to the police needs to be upped. I found that only 21 per cent of doctors would report knife injuries to the police—that figure excludes accidental knife injuries—and that only 63 per cent would report gun-related injuries. Do those figures surprise you? There is obviously some resistance to a mandatory reporting system among your colleagues.
I read what you said in The Sunday Times at the weekend. The article suggested that that is the case. However, the issue of confidentiality always raises its head. If a person has an injury that is not thought to be life threatening and they do not want to raise the matter with the police, I understand why doctors will feel that they are in a difficult position with respect to whether the person should be reported to the police. I also understand that police officers have said that if giving information about individual incidents were mandatory, people would be less likely to present at accident and emergency departments. I am not sure whether that is the case; I think that somebody who has been injured probably will present, but some people may not do so.
That was how some police officers reacted, although many police officers to whom I spoke, including some chief constables in Scotland, absolutely supported the idea and said exactly the opposite.
Given that we lack the intelligence to allow police officers and police forces to focus their resources effectively and given the resistance and problems that exist, could a mandatory system be rapidly implemented through legislation, guidance or directions from the Executive, for example, in the light of the experience from the Cardiff pilot and the local work that you have done in the west of Scotland and Glasgow, particularly on the anonymised reporting system? The issue is about intelligence rather than necessarily about individuals, and doctors would give their support.
I think that they would. The police have presented to the accident and emergency consultants, of whom there are around 20 in the west of Scotland. The vast majority of those consultants think that using anonymised data is a good idea and that doing so would give us a bit more information to deal with the hot spots. However, one or two still raise issues relating to consent and confidentiality and therefore the proposals will probably not be implemented in their departments. Glasgow royal infirmary, led by Dr Ireland and Dr Rudy Crawford, and people in Paisley have been keen to get involved, but the south Glasgow hospitals are still discussing matters. If legislation were passed after discussions and the system were anonymised, the data could be very informative.
None of us will forget this presentation in a hurry. The problem is obviously very serious. Dr Sheridan, you said that you and most doctors would see the benefit of having anonymised data. However, you spoke about the resistance of one or two institutions. Would you go so far as to say that if there is still resistance, the collection of anonymised data should be mandatory, for use in a focused way by police forces? Would you and your colleagues support that?
I cannot speak on behalf of accident and emergency consultants.
I accept that. You may answer just for yourself and surmise what the rest of your colleagues might think.
There should be and would be no concern about anonymised data being used. The scheme has been implemented in Cardiff without great concern and with great improvements. The issues that Cardiff faces are slightly different from those that are faced in the west of Scotland. However, in Cardiff there was a significant decrease in knife crime over a three to four-year period of 20 to 25 per cent. If that happened in the west of Scotland, it would be important.
Was there resistance in Cardiff before the violence prevention unit was set up and anonymised data were collected? Because of what has happened in doctors' experience, has that resistance diminished markedly?
I spoke to Professor Jonathon Shepherd, who led and implemented the scheme in Cardiff. He is a maxillofacial surgeon and deals with facial injuries. He said that initially there was resistance, which was based on the same issues of confidentiality, consent and concern that people would not present to A and E departments. Over time, that resistance has been smoothed out. Because of the results that they have had, people now think that the scheme is a good idea.
You mentioned your two years in Australia and the fact that your experience in Scotland when you returned was remarkably different from your experience there. What makes the situation in Australia different? Is it a cultural issue? Is there a greater educational drive there?
I will let my Australian colleague answer that question.
The reason is cultural. The major difference between Scotland and Australia that I notice is the vast range in socioeconomic status here. In Glasgow, in particular, there is a huge population that is not happy with its standard of living, for good reasons. There is also a culture of violence that goes back years. In Australia there is not such a wide spread in socioeconomic status. Traditionally, we do not have a culture of violence, especially with implements. People do not tend to attack one another with knives.
Notwithstanding the socioeconomic and cultural aspects of the issue, the lack of consideration of the danger of carrying a knife and the lack of comprehension of the fact that putting a knife in one's pocket, taking it to a club or going out with it on a Friday night could lead—statistically, will lead—to very serious incidents, I was struck by the comparison with firearms. A very small number of attacks involved firearms. This is a legislature, and we are considering laws. What is your view on having knife crime laws aligned more closely with firearms legislation? That would not solve the socioeconomic or cultural problems, but it would send a signal that knives are very dangerous implements. I refer not only to means of accessing knives or swords but to sentences that the courts can issue for possession and for repossession, if there has been a previous conviction. In the case of firearms, those are much tougher.
As you pointed out, and as I am sure you appreciate, thankfully gun crime in Scotland is not a big problem. In other parts of the United Kingdom, especially Nottingham, it is an increasing problem. In Scotland, the number of murders and attempted murders that are committed using knives—72 murders, which is just over 50 per cent of the total number of murders; and 60 per cent of the total number of attempted murders—is a far greater problem for emergency departments and for those who sustain injuries as a result. Tougher sentences, or greater awareness of the problems that knives can cause, would be better than the headlines that are associated with the one or two gun crimes that we have each year.
Dr Moller, do you agree?
Absolutely. On a personal level, being at work is frightening. We see guys coming in who have been stabbed. When we take their trousers off, we find that they have massive knives in their pockets. They carry them all the time. I do not think that we have any idea of the level of knife use and knife carriage. It is frightening.
I know that your answer will be subjective, but will you comment on the degree of comprehension of the implications of carrying knives on the part of those who carry them, who are predominantly young men? In your professional experience, do you think that they are aware that carrying a knife is equivalent to—or more dangerous than—carrying a firearm? Are they aware of the significance of what they are doing?
I do not think so. They do not realise that the person who puts a knife in his pocket along with his iPod might, later that day, be a murderer or an attempted murderer. The Scottish Executive could hammer home that message through education and advertising.
I am sorry that I was late. I was at another meeting, so I missed your presentation. I apologise for that.
I come from a health background, so I am interested in the dilemmas to do with patient confidentiality and consent. I suppose that I would like to hear the arguments of the people who are objecting. I imagine that even anonymised data could be identified to a locality and given to the police who, with even limited intelligence, could identify where the incident took place. Obviously, there would be concerns about repercussions. I suppose that it is a precedent—
May I intervene for a moment, Carolyn? We are pretty pushed for time. That is an important matter, but I appreciate that the witnesses will not have the answer at their fingertips. Could a response be submitted to us in writing?
Indeed.
That would be helpful.
I just want to get the other side of it, because I think it is an ethical minefield.
Thank you for that suggestion.
On behalf of the committee, I thank the witnesses for giving us a chilling indication of the situation that confronts them in the real world of emergency departments, as we now have to call them. I will find that difficult, being an almost lifelong resident of Bishopton. Your presentation was extremely instructive. Thank you for taking the time to come before us. The committee found the information invaluable.
Meeting suspended.
On resuming—