Public Health in the Emergency Department Series #2

Author: Olivia Villegas / Editor: Nikki Abela / Codes: SaC1, SaP2, SLO11, TP10, XC3, XC4 / Published: 17/10/2023

Knife crime in the ED – Everyone’s problem

This is the second blog in our public health series. Keep your eyes peeled for more public health goodness to follow in future blogs.

Knife crime in the UK is reaching peak records, and figures show that the number of people killed with a knife were the highest recorded for 76 years in year ending 2022, with around 45,000 offences involving knives or sharp weapons in the same year in England and Wales. Hospital data from NHS digital found a 2% rise in Emergency Department (ED) presentations with ‘assault due to a sharp object’ in 2022 compared to the previous year- a 14% increase compared to 10 years ago. Whilst these numbers are perhaps difficult to relate to when we think about our typical daily workload in the ED, particularly those of us in smaller hospitals or more rural areas, the growing issue of knife crime will inevitably be more evident in our departments over time, and sometimes in ways that we may not expect. 

Emergency departments can be stressful environments, and when you hear the word “stabbing” it tends to get our attention. If you’re not working in a trauma centre, it may be something you don’t have to face often, and we often have an idea of what this might look like when it comes through the doors. But what about the male with a deep wound to his forearm who alleges he cut himself on a tin opener. Or the female who is triaged with a “fall onto wardrobe” but has a linear incision on her inner arm, and something about the history feels right but you just can’t put your finger on it. And what about the 12- year old that gets flung out of a car at the doors of the department having been stabbed and then alleges to not know who did it?

Whilst the majority of these crimes do occur in adult males, the intersectionality of knife crime and violence against women and girls, domestic violence, and organised crime is an important consideration for us to make in the ED. These huge public health issues are having more of an impact on our workload and if not recognised can go undetected causing further harm to the patient. Whilst statistics can paint one part of the story, the lived experience is that an increasing number of women and young adults are involved in or subjected to harm involving knives. Whilst managing acute presentations, injury and wounds is our priority, it is important to understand the wider context in which these crimes are occurring, when we should be more suspicious, and when we have a duty to involve the police. 

Organised Crime

Organised crime gangs (or OCGs) work like a business, with those at the top profiting and planning, and those beneath them coordinating and expediting plans. Often at the bottom of this chain are children, who can be trafficked and groomed to carry out criminal activity or aggressions on behalf of the OCG. Aggressors can start by offering children money in return for small favours, building the child’s trust. This can then lead to them carrying weapons or transporting counterfeit goods and ultimately crime gangs use intimidation and corruption methods to control people’s lives in order to protect criminal activity. The abuse and exploitation of children has devastating and lifelong impacts, and there is mounting evidence highlighting the involvement of children as a scapegoat in these criminal businesses, and when they don’t want to talk, this is often why. No one wants to “be a grass”.  

As big part of OCG culture, knife crime can be interlinked to country lines drug dealing. County lines dealing describes OCGs that supply drugs to suburban areas including market and coastal towns, using dedicated mobile phones or “deal lines” to aid the transport of drugs. The map below shows that offences that were once most prevalent in highly populated areas such as London, are now showing patterns which may correlate to county lines distribution, for example between the ports of Liverpool and Hull as seen on the 2021/22 graph. We know that this type of drug dealing is strongly associated with the exploitation of children and vulnerable people, who are enlisted to move drugs, weapons and money between geographical areas. In 2020, the National Crime Agency identified that children represented the vast majority of victims within county lines dealing. However, organised crime is not always the just a big inner city problem that affects people of a certain age group or gender in the way we think it is, so we should be mindful of stereotyping individuals.

Modern Slavery

The term ‘modern slavery’ refers to human trafficking, slavery, servitude and forced or compulsory labour. The most commonly reported forms of exploitation in the UK are criminal, labour and sexual exploitation. Other types also occur in the UK, including domestic servitude. While the true number of modern slavery victims is unclear, the last recorded data in 2019 found a 45% increase in referrals through the National Referral Mechanism compared to the previous year. Social issues such as homelessness, isolation, and substance abuse- common issues we see in all of our ED’s- make individuals prime targets for perpetrators. The image below depicts how the criminal mastermind can orchestrate and upscale criminal activity from a different county, through a number of intermediarys, to eventually target the victims.

Modern slavery is linked to knife crime because, like with OCGs, the main players/perpetrators often have more disadvantaged individuals carry out criminal activity on their behalf so when you are seeing a potential knife injury, consider if the patient is a victim of something more complex like modern slavery.

Domestic Violence

Despite being a generic household item, the knife is also the most commonly used implement in intimate partner homicide. Many of the routine wounds that we may see have a hidden backstory. If the patient is reluctant to disclose the mechanism, the injury pattern does not match the mechanism, or there is generally something cagey about the story, ask yourself whether this patient could be a victim of domestic violence. In this case, you can only take their word for it, but asking questions like “is everything okay at home?” or “do you feel safe at home?” or “is there anything else troubling you?” might be a good way to broach this sensitive topic. If a partner is present in the room, be inventive in your rationale to get them out the room to assess the patient privately. Be mindful that a domestic violence victim will often be too scared to report an issue or sometimes unwilling to. Knowing the options (what do we do when domestic violence is disclosed) and ensuring a safe space to talk and stay could make the difference between a criminal conviction or a repeat offence and further harm to your patient.

Children and young adults

Figures posted by the All-Party Parliamentary Group (APPG) indicate that up to 21 young people per day required hospital treatment for wounds related to knives or sharp implements. The group acknowledged the place of knife crime within criminal child exploitation, however there is also a need to tackle the root causes of crime in the wider response to knife crime, for example adequate housing, education and youth services. Youths report carrying knives for defence, or because it makes them feel safer on the streets and in some places carrying knifes really is the exception rather than the rule. For those of us working in paediatrics, interpersonal violence and knife crime are not something necessarily encountered every day, however with knife crime affecting children and young adults both as victims and perpetrators, it is important that we are aware of the issue and equipped to deal with it in our ED, because as well as safeguarding issues it may have safety implications for our staff. Again think about the intersectionality of it, is this youth part of a gang, are they being exploited for something bigger? Know where you can look for help and reach out. While being an obvious safeguarding issue, many departments now employ youth workers to help with violence intervention. They are called “Navigators” in Liverpool, but potentially come under different names in other areas.

A comment on the data

The way we collect data in the ED can act to limit, misrepresent or underreport overall incidences in a condition or ED presentation. When we admit or discharge a patient, the codes we use ends up as Hospital Episodes Statistics (HES) which are overall used for regional and national data collection and by the government, and so getting the coding correct is really important. But how often do we try to assign a diagnosis that the system doesn’t have a code for, and we end up coding as something only vaguely related, or “no abnormality detected”? In the APPG data, 42% of health trusts across the UK were not able to provide data on youth attendances related to knife-crime and suggest that the true figure of victims could be much higher than recorded. Lastly, the most recent data used looks at hospital inpatient stats only, or the number of Finished Consultant Episodes (FCE’s), and therefore does not cover ED patients that were not admitted. Whilst this is somewhat frustrating, coding as accurately as possible does make a difference to the big data that comes out.

So what can we do to recognise these patterns and when do we need to report?

RECOGNISE RED FLAGS These patients may present with features that overlap signs you may associate with victims of modern slavery, trafficking, domestic abuse, and exploitation. 

SPEAK TO THE PATIENT ALONE This should be normalised in our ED as standard practice to avoid any conflict with relatives or friends, and to allow a safe space for patients to talk.

PROVIDING EDUCATION Often victims of trauma have been repeatedly exposed to violence and may not have had the opportunity to break the cycle, or might have sadly accepted this as part of their life. Using a non-judgmental approach to explain that there is support available and how to get it might be the first step in that victim’s recovery.

THE TRAUMA-INFORMED APPROACH This will be covered more thoroughly in future blogs, as it’s a term we are hearing more and more frequently – but do we really understand what it is and how to do it? Our understanding of the science behind trauma and stress on our bodies has improved in recent years and has provided the basis on which we approach victims of trauma. In short, this means supporting victims by offering a safe space, a calming environment, building trust and addressing their needs. It’s obvious that most of our ED’s are not the ideal set-up for this, but there are still ways we can deliver care sensitively amidst the chaos!

BE FAMILIAR WITH ED REFERRALS/POLICIES In building the trust relationship with your patient, it always helps to know what you’re doing. Many survivors of knife crime (and other similar acts of violence) will be wary of you involving other services and may have had previously negative experiences with the police or social services. It helps to know the referral process- who you’re referring to and why- so that you can explain this to your patient. 

BE CRITICAL of the mechanism and injury pattern. Knife wounds, or wounds caused by sharp-implements, are typically penetrating, linear incisions. Familiarise yourself with how these look and appear different to blunt injuries. If someone falls onto a wardrobe, it’s unlikely that they will have a linear incision on their inner arm!

LEGAL BITS 

Lastly, patients may withhold information or under-report symptoms if they fear that doctors will report them without their consent. Trust is a vital part of the doctor-patient relationship and is particularly important when managing these sensitive issues, and the last thing we want is for victims to be discouraged from disclosing a gun or knife crime that requires urgent medical attention. However, as per GMC guidance, we owe a duty of confidentiality to our patients, but a wider duty to protect and promote the health of patients and the public. We therefore have a duty to inform the police about any gun crime, or knife crime. Ideally, the patient should be informed of this disclosure and consent gained, however in the absence of consent you can still disclose in public interest. The exception to this is if the knife injury is accidental or caused by deliberate self- harm- however if the patient is alleging accidental or self- harm, and you feel that an injury does not fit with the mechanism and you are suspicious for a non-accidental injury, you should still report it to the police. 

References

1. Knife crime statistics England and Wales, Research briefing. House of Commons Library, 2023.
2. The unseen effects of knife crime on children. The Children’s Society, 2023.
3. National Crime Agency (NCA). National Strategic Assessment of Serious and Organised Crime, 2020.
4. Serious Youth Violence, Research briefing. House of Commons Library, 2022.
5. Cook EA, Walklate S. Gendered Objects and Gendered Spaces: The Invisibilities of ‘Knife’ Crime. Current Sociology, 2022; 70(1), 61-76.
6. Stoklosa H, Beals L. Human Trafficking in the ED – What you need to know. Academic Life in Emergency Medicine (ALiEM), 2022.
7. The APPG on Knife Crime and Violence Reduction hosts briefing for MPs on amendments to the Policing, Crime, Sentencing and Courts Bill. appg Child criminal exploitation and knife crime, 2021.
8. Confidentiality: reporting gunshot and knife wounds. GMC, 2018.