When Dr Miranda Roland, an A&E registrar, was held hostage by a patient brandishing a pair of steel surgical scissors in a cubicle, she didn’t panic. Moments earlier, she had gone in to check on the young patient, who was having a mental health episode after taking drugs, and had closed the door behind her. Although she was alone, Roland thought she was safe – all sharp and dangerous objects had been removed. Unfortunately, the patient had managed to hide a pair of scissors, which she pulled out before backing the doctor into a corner. “I was able to keep calm and talk her out of stabbing me,” Roland recalls. “I was lucky. It was that tense, it could have gone either way.”

The police were eventually called, and restrained the patient. Afterwards, Roland, the most senior clinician in the department on that shift, had no choice but to continue working. She was emailed twice afterwards by hospital management to check she was OK.

Roland says it is not the only time she has been threatened by a patient. And her experience is far from unique. Violence against NHS staff is a significant problem. In the latest available annual NHS staff survey, from last year, 14.5% of staff said they had experienced physical violence from patients, their relatives or the public. But the trade union, Unison, believes many incidents are going unreported. Its research with the Health Service Journal, based on freedom of information requests from all NHS trusts in England in 2016-17, found physical assaults on NHS hospital staff had risen 9.7% since 2015-16. The figures suggested that, on average, there were just over 200 reported violent attacks on NHS workers every day.

“Staff should never have to accept that violence is part of their job,” says Helga Pile, Unison’s deputy head of health. “Staffing shortages are helping create a hostile environment across the NHS where health workers routinely face patient anger, frustration and sometimes violence. Without significant investment in the NHS, the situation will only get more dangerous.”

Her fears are echoed by Simon Walsh, consultants’ committee emergency care lead for the British Medical Association. “We’ve created a cauldron where there are patients who need to be admitted and more coming in through the front door,” he says. “Peak times tend to be in the evenings, which is when patients under the influence of drugs and alcohol attend. That combination seems to result in people losing their patience and tempers.”

The government is aware of the problem. In October, it introduced the NHS violence reduction strategy, which set out to clarify organisational responsibilities, improve training and development of staff in dealing with violence and abuse, and raise the profile of the issue through publicity campaigns and updated agreements with the police and Crown Prosecution Service (CPS). The maximum sentence for violence against emergency services staff was doubled from six months to one year.

A spokesman for the Department of Health and Social Care claims early signs of the strategy’s impact are promising. “Latest figures show violence against NHS staff is at its lowest level in five years but there’s more to do.”

But Pile says the dangers staff face have not abated. “[Unison’s] evidence shows an increase in assaults and bears no relation to government claims that violent attacks are down.”

Matthew Tuck, an anaesthetics trainee working in north-east England, had a patient swing at him and narrowly miss before landing a punch on the consultant, dislocating his jaw. “There are lots of signs up saying there’s zero tolerance, but you can’t exclude anyone from receiving care,” says Tuck. “There is nothing hospitals can do to remove violent individuals. The support isn’t adequate. Most of the initiatives are shortlived. What happens in a department, how it’s responded to and how people are helped back to work doesn’t change … I don’t think anyone has any real grasp on how to help people.”

In some cases, the violence can be extreme: examples given to the Guardian include the nurse in Surrey who broke her back after being assaulted by a patient, and can never return to work; the junior doctor in a large teaching hospital in the south-east who was pinned up against a wall, spat at and threatened with rape; and the emergency department assistant in the Midlands who was screamed at and hit around the head when she asked someone to move out of the way so she could pass with an elderly patient in a wheelchair.





Patients waiting in a busy A&E department



‘A lot of people wait for a long time in A&Es and most of our violence is because of frustration,’ says Harriet Beard, senior sister at the Royal London hospital. Photograph: David Sillitoe/The Guardian

Under-reporting is partly due to lack of confidence in the process. Despite the government’s strategy, numbers of successful prosecutions are still low.

Harriet Beard, senior sister at the Royal London hospital, doesn’t believe any real action has been taken on behalf of the few staff who have reported violence. “We’re reporting incidents to police and the CPS is dropping every single case,” she says. “On the day that the law got announced, I had a nurse in court for [a case where someone] had physically assaulted her. [She was told] the CPS had dropped it.”

Beard herself was assaulted in December 2015 by a patient who bit into her thumb, grabbed her hair and punched her in the face. In 2017, she set up a working group and held drop-in sessions for all staff so she could get ideas for how to tackle the problem. Staff complained there was a lack of training on how to deal with such situations; they wanted more support and to improve the hospital environment while people are waiting.

Beard attended a course to learn how to spot the early signs that someone might become violent, methods to de-escalate situations, and how to protect herself. She, along with a few others, will train 1,600 staff next year, and hopes eventually to train all the hospital employees. She is rewriting the trust’s security policy and has introduced written warnings in the form of yellow cards.

Reporting of violence is going up in A&E, she says, and around 60 written warnings have been issued in the last year. As a result, some people have come back the next day to apologise for their behaviour. Beard wants to go further. “We have a lot of people waiting a long time, and most of our violence is because of frustration. I want to introduce a coffee machine, and some phone-charging stations and screens to keep people better informed. I just want to be able to look after my staff so we can care for people in need, which is what we’re here for.”

A spokeswoman for the CPS says: “When a case is referred to us by the police we will also charge a suspect if there is sufficient evidence for a realistic prospect of conviction and a prosecution is required in the public interest.”Pile says Unison would like to see a national system of recording attacks reinstated. She says: “Action to reduce violence must be based on solid evidence and a detailed understanding of the risks, so all staff can be protected. The full weight of the law must be used against those who think it’s OK to assault them.”

Roland, meanwhile, remains sceptical of any promised new approaches. “Nothing I’ve seen has had an impact and I think things are getting worse,” she says.

Some names have been changed


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