Intended for healthcare professionals


NHS regulator plans to make it easier for doctors to raise concerns and break “mafia” code of silence

BMJ 2013; 347 doi: (Published 23 October 2013) Cite this as: BMJ 2013;347:f6428

Re: NHS regulator plans to make it easier for doctors to raise concerns and break “mafia” code of silence

Doctors may not report adverse events, or speak up when they witness poor care, because they fear punitive action by their organisation or because they lack confidence that reporting will change anything. Clinicians can also experience psychological effects when their patients suffer adverse events (1), which may further deter them from reporting. Negative previous experiences of using incident reporting systems or of investigation processes compound these effects (2).

We conducted an on-line survey of Members and Fellows of the Royal College of Physicians about their experiences of adverse patient safety events. 1755 responded representing all (internal) medical specialties. Their demographic profile corresponded broadly to that of NHS consultant physicians (mean age 47 years, 37% female).

Most of those who have used NHS incident reporting systems have had negative experiences; only 21% noticed local improvements, 19% saw system change and 14% had useful feedback as a result of a report. 25% of respondents admitted that they had been involved in an incident which they knew that should have reported, but didn’t. Reasons cited for not reporting included lack of confidence that anything would change, a view that it was an onerous process and fear of punitive action as a result.

Respondents also reported significant psychological effects when their patients suffered adverse events. Over 50% had sleep disturbance or anxiety and in 63% it affected their professional confidence. A small but significant proportion suffered symptoms similar to Post Traumatic Stress Disorder.

There are few formal support mechanism to help clinicians in these circumstances. Only 5.5% of our sample had a formal mentor although over 80% would have used a mentor if one had been available. In the absence of a mentor most clinicians sought support from colleagues, friends and family.

Our findings accord with Professor Berwick’s description of an NHS where a culture of fear exists, staff are not supported and “bad news becomes unwelcome and, over time, it is too often silenced” (3).

We are unlikely to rectify this unless we understand and address the complex issues which prevent staff from speaking up. Other safety-critical sectors (like aviation or the nuclear industry) have recognized that front line staff will only speak up if they feel they will be supported to do so, treated fairly in any investigation and that their organizations will use the information for learning rather than for punishment. For the NHS, Berwick’s recommendation to “abandon blame as a tool” would be a good first step in this direction (3).


1. Wu AW, Steckler R. Medical error, incident investigation and the second victim: doing better but feeling worse? BMJ Qual Saf 2012; 21: 267-270.

2. Sirriyeh R, Lawton RJ, Gardner P. et al. Coping with medical error: A systematic review of papers to assess the effects of involvement in medical error on health care professional’s psychological well-being. Qual Saf Health Care 2010; 19: 1-8.

3. National Advisory Group on the Safety of Patients in England. A promise to learn—a commitment to act. Department of Health, 2013.

Competing interests: No competing interests

28 October 2013
Kevin Stewart
Clinical Director, Clinical Effectiveness & Evaluation Unit.
Reema Harrison, Rebecca Lawton
Royal College of Physicians
11 St Andrews Place, London NW1 4LE