Examination of Witness (Question Numbers
60-79)
PROFESSOR KARIM
BROHI
25 NOVEMBER 2008
Q60 Gwyn Prosser: You have painted
a picture of an alarming trend in terms of knife crime. How does
it compare with serious violence other than knife crime?
Professor Brohi: We have seen
very little increase in the way of gun crime, for example. Our
rates of gun crime were 1% in 2003 and they are now 2%. Overall,
guns have not mirrored the significant rise in knife crime. As
mentioned earlier, that is very much related to availability.
The people with access to guns tend to be the organised crime
syndicates rather than the teenage youth gangs where the knife
is an opportunistic weapon.
Q61 Gwyn Prosser: In terms of the
concerns that practitioners at your level have about these matters,
I suppose we should take it for granted that there is much greater
worry about the issue of knife crime than other serious assaults
and injuries caused by guns because of the number?
Professor Brohi: I do not know.
You can be killed no matter how you are injured. We are as concerned
about road traffic accidents as we are about knife crime. Obviously,
we are seeing a rise in the teenage population particularly which
is of concern to us in terms of where we target services and who
we can plug into in the community. I am not sure that our level
of concern is different.
Q62 Gwyn Prosser: Are you able to
quantify the proportion of your valuable time that is absorbed
by dealing with knife crime compared with all the other injuries
and problems that people have?
Professor Brohi: As for my trauma
workload, one in three inpatients is a knife victim, so about
a third of my time is dedicated to looking after victims of knife
crime.
Q63 Chairman: One third of your time
as a consultant is spent on this?
Professor Brohi: I also do elective
vascular surgery, but of my dedicated trauma time one third is
spent on knife injuries.
Q64 Mr Brake: You have already identified
a trend of younger people coming in with knife wounds. Can you
tell us anything about any trends in relation to gender and also
ethnicity?
Professor Brohi: Ninety-five per
cent of our knife patients are male. The only female patients
are those who suffer domestic violence. Therefore, this is really
a male problem.
Q65 Mr Brake: Has that percentage
remained approximately the same in terms of gender balance?
Professor Brohi: Yes. As to ethnicity,
we do not have solid figures but our local area is such that the
majority of the youth-related stab victims are Asian or black.
Q66 Mr Brake: In terms of trends
or ethnicity, it has been put to us in the past that perhaps in
the Polish community there may be a greater culture of knife-carrying
than in other communities. Have you picked that up?
Professor Brohi: Not so much with
Polish gangs. Our experience of Baltic state and Turkish gangs
and so on is that these are really organised crime gangs and they
tend to have a mix of knives and guns and come in waves depending
on who is in the ascendant at the time. The rising demographic
of youth crime tends to be related to the local population who
are not really immigrants; they are British Asian, British black
or Manchester/British white people.
Q67 Mrs Dean: From the nature of
the stabbing injuries that you see can you say whether you believe
they are inflicted with intent to kill or to wound or scar?
Professor Brohi: It is very hard
to say. It implies a level of knowledge of anatomy and physiology
that maybe these people do not have, or I hope they do not have.
A lot of people do not realise what damage can be done by a knife,
but it is very difficult to identify intent. If you stab someone
in the heart or head the intent is probably quite clear.
Q68 Mrs Dean: Of those you see, what
proportion would be injuries to the heart or head?
Professor Brohi: Potentially to
the heart or head?
Q69 Mrs Dean: Yes.
Professor Brohi: Potentially to
the torso it is more than 50%.
Q70 Chairman: More than half?
Professor Brohi: Yes.
Q71 Mr Clappison: Do you speak to
the victims when they recover consciousness?
Professor Brohi: Yes.
Q72 Mr Clappison: Can you say anything
about their attitude to what has taken place? Is it possible to
make any general remarks about it?
Professor Brohi: First, it is
difficult to generalise. Second, like the police the NHS certainly
initially are seen to be in a position of authority and therefore
are not necessarily trusted for some time down the line, so the
truth about the situation may take some time to come out. Most
of the people who stay in contact with us are not directly involved
in the gangs themselves or find themselves in that situation by
virtue of their situation rather than being active members of
those gangs. Undoubtedly, there is a mixture and often we do not
hear the full story.
Q73 Martin Salter: I asked the previous
witnesses a series of questions about the procedures for reporting
stabbing incidents to the police. I have just been looking through
the guidance issued by the General Medical Council and the Department
of Health. It seems to place considerable onus on the doctor.
Obviously, the primary role is to preserve life and treat the
patient. According to the GMC guidance doctors are then required
to make a decision about disclosing information to the police
in relation to a stabbing in terms of whether or not there is
a risk of somebody else suffering a consequence if they do not.
It is a very difficult decision for a doctor to make, is it not?
How can a doctor be expected to deal with much more than the stab
wound in front of him or her and the patient's welfare? Should
we not be putting doctors in this position? Should it not be just
an automatic process that if somebody enters an A&E unit with
a stab wound that information is passed to the police in the same
way that gun crime is reported? I suppose the question is whether
there is much difference between someone being penetrated by a
bullet or a blade from your end of the telescope?
Professor Brohi: I do not believe
the issue of automatic reporting to the police is as clear cut
as many would like it to be. There are two questions. First, what
will the police do with that information which will be of use
either to the victim or society at large? If you treat trauma
as a public health rather than criminal problem then the benefit
of doing that becomes less apparent. Second, in trauma if we are
to save lives, limbs and prevent disability we need to have the
person with us within minutes of the incident. If there is any
delay about presenting to hospital because of concerns about whether
the incident will be reported to the police and place the patient
in more danger later on it is likely that more people will die
because of it. Is there a difference between knives and guns?
From our point of view one is much more likely to die from a gunshot
wound than a knife wound. The injuries are very different. Is
there any difference in terms of social responsibility? Probably
not. I believe the issue must be given greater thought than to
suggest that if we report them to the police everyone will be
caught and everything will be fine because it goes a lot deeper
than that.
Q74 David Davies: To pick up Mr Salter's
question, about 5% of the injuries you see result from incidents
of domestic violence. Surely, if a woman presents to the hospital
suffering stab wounds and does not want to say how she has received
them—I know we have to jump to conclusions—there is
a reasonable chance that she has received them from a partner.
She may well be afraid to let the police know, but surely the
hospital has a moral duty to let the police know this has happened
so they can investigate it?
Professor Brohi: No. Our moral
duty is to the patient and the protection of the patient. If the
patient is competent we must respect the wishes of the patient.
We can involve social work and make sure the patient has a place
of safety to go to, but it is entirely up to the competent patient
to decide how she wishes her domestic affairs to be conducted.
Q75 David Davies: I am referring
here to a hypothetical situation. Obviously, we respect the work
that you do and the very difficult decisions you have to make.
Sometimes the patient may not want to report something to the
police or be seen to report it herself, but if there is an obligation
on the hospital to do it and that is known she might at least
feel glad that the responsibility is out of her hands and some
action will be taken on her behalf. The patient will not feel
that she—or he, because there are rare occasions when the
victim of domestic violence is a male—is the one who has
precipitated it?
Professor Brohi: I think that
hypothetically there are some people who would benefit from that
and some who might be harmed by a blanket policy. It is very difficult
to talk hypothetically. Our duty is to the patient. A decision
does not have to be made when the patient comes in the door. If
it is a severe injury the patient will be admitted and spend some
time there which may be days, weeks or months. In the course of
that time a lot of people are involved in discussions with these
patients about keeping them safe, what they want to do and discussing
and reporting it to the police, so it is not a one-shot situation.
Q76 David Davies: By the same logic
do you think you should not be obliged to inform the police when
you admit people with firearm injuries? Do you think the law should
be changed?
Professor Brohi: I do not think
that the law should necessarily be changed or that reporting knife
injuries is a bad thing. What I suggest is that it is not black
and white; a lot more things need to be considered when making
such laws.
Q77 David Davies: What you are arguing
for reasonably enough is that doctors should have discretion in
the case of knife wounds. Would you argue that doctors should
have discretion in the case of firearm wounds?
Professor Brohi: I think the two
should be the same, yes.
Q78 David Davies: In reality do doctors
use their discretion a little bit with firearms injuries as well?
Professor Brohi: No; firearms
are reportable and they get reported.
Q79 Mr Winnick: Do you see some similarity
between the confidentiality of the confession in the Catholic
religion where a priest refuses to give details because of the
religious oath he has taken and your position as a doctor where
your first priority is, as you say, to save lives and not necessarily
inform the public authorities of an incident that has occurred?
Professor Brohi: I do not think
it is that similar because the priest perhaps has a responsibility
towards his ward. We have a responsibility both to the patient
and public health though the latter is less well defined than
the responsibility to the patient. There is undoubtedly also a
responsibility to the population we serve. In these cases it is
very difficult to know who is at risk and whether this is a one-on-one
injury or there is a wider danger to people at large and to make
decisions.
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