Medical colleges and unions call for inquiry over “shocking” levels of sexual assault in the NHSBMJ 2023; 381 doi: https://doi.org/10.1136/bmj.p1105 (Published 23 May 2023) Cite this as: BMJ 2023;381:p1105
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The BMJ will be hosting a webinar on this topic on 8 June 2023
Medical colleges and healthcare unions have urged the government to take immediate action against sexual assault and harassment in the NHS after an investigation by The BMJ and the Guardian found that trusts are failing to protect staff and patients.1
The BMJ and the Guardian sent freedom of information (FOI) requests to every single hospital trust and police force in the country for data on how many sexual safety incidents, a term which covers a spectrum of behaviours from abusive remarks to rape, they had recorded on NHS premises, as well as hospital trusts’ policies on how to manage and prevent the problem.
The responses show that more than 35 000 sexual safety incidents were reported to 212 NHS trusts in England between 2017 and 2022 and that less than one in 10 trusts has a dedicated policy to deal with sexual assault and harassment. Despite staff being the group predominantly affected (in 62% of incidents), trusts are no longer obliged to report abuse of staff to a central database.
The BMA told The BMJ that it called on the government to “urgently produce a plan of action to protect our colleagues,” with the Academy of Medical Royal Colleges and others going further and telling us that they are calling for a full independent inquiry into the epidemic of sexual assault in the NHS.
The Hospital Doctors Union (HCSA), GMB union, the Society of Radiographers, the British Dietetic Association, and the Liberal Democrats all told The BMJ that they are also calling for an urgent independent inquiry. HCSA said that employers have “no real grasp of this complex issue” and that their approach to dealing with it “only makes the situation worse, driving staff into ill health or out of the service.”
“These revelations are truly sickening,” says Liberal Democrat health spokesperson Daisy Cooper. “We need an independent public inquiry now, to uncover the full extent of this scandal and put an end to it.” She continues: “Ministers must hold the NHS to account: every trust needs a dedicated policy in place to prevent sexual harm, a clear and effective process for those affected to report incidents and a single system to collect data so we can see the full extent of the problem.”
“HCSA’s experience to date makes us doubt whether the NHS, despite the best intentions of many, is capable of getting its own house in order,” says HCSA president, Naru Narayanan. “We need a formal independent inquiry into the issue to uncover the truth and hold policy makers and employers to account. We need real cultural change.”
Poor reporting systems
Responses to FOI requests from 212 NHS trusts in England show a total of 35 606 sexual safety incidents were recorded over a five year period (2017-2022) (fig 1). At least 20% of incidents involved rape, sexual assault, or kissing or touching that a person did not consent to, although not all trusts provided a breakdown of the type of incidents recorded. The other cases included sexual harassment, stalking, and abusive or degrading remarks. The data show that patients are the main perpetrators of abuse in hospitals. Most incidents (58%) involved patients abusing staff, with patients abusing other patients the next most common type of incident (20%).
Yet experts say that these figures vastly underestimate the problem because systems for recording are so poor across the NHS. Trusts have wildly varying criteria for when a case is reported, says Deeba Syed, senior legal officer for Rights of Women, a helpline that provides support for women who have been sexually assaulted or harassed at work. Each trust has a different practice around whether they report cases before or after an investigation or disciplinary action, she says. “I don’t think there is a robust reporting system,” she told The BMJ. “There’s no one doing it correctly. They’re all doing it differently and on different understandings of when to report.”
Both staff and patients might be unsafe
Sexual safety incidents involving patients are reported through the National Reporting and Learning System, a central database of patient safety incident reports, which is being replaced with a similar system this year. But abuse of staff is not reported through this system, and trusts are no longer obliged to disclose it to NHS England, The BMJ and Guardian have learnt. Abuse of staff used to be monitored by NHS Protect, which was scrapped in 2016.
“By not counting staff assaults, we are making them invisible. I cannot see an argument against counting them,” says Katrin Hohl, professor of criminology and criminal justice at City University, London.
In 2017-2022, a total of 11 880 alleged sexual crimes on NHS premises were reported to 37 police forces (box 1). This includes at least 5164 sexual assaults and at least 3084 rapes. Other offences included exposure, masturbation, and voyeurism. But these figures represent only “a very small fraction” of the total recorded cases because police forces do not consistently record the location of crimes, says Hohl.
Children and elderly people raped on NHS premises
Police recorded 180 cases of rape of children under 16 on NHS premises between 2017 and 2022, with four children under 16 being gang raped, The BMJ and Guardian’s investigation found. There were a further 186 reports of children under 16 being sexually assaulted and 127 reports of crimes including grooming, assaulting a child by penetration, sexual communication with a child, inciting sexual activity with a child, and causing a child to watch a sex act.
The data were taken from 32 police forces that responded to either The BMJ and Guardian’s FOI request or to requests sent by other organisations or individuals.
It is not possible to tell from the data where these incidents occurred, but Liz Kelly, professor of sexualised violence at the London Metropolitan University, thinks there is a child safety issue in mental healthcare settings. She told The BMJ that she calls on police forces to record the location of crimes in more granular detail for a better understanding of where most incidents are happening, allowing for solutions. Previous research has also uncovered sexual assaults of elderly people on NHS premises.2RETURN TO TEXT
The investigation’s findings are “significant,” with the levels of abuse perpetrated by patients “under-reported” so far, says Rosalind Searle, professor in organisational psychology at the Adam Smith Business School, University of Glasgow, who has examined medical regulators’ failures in managing sexual assault and harassment. “These are places that people should be safe, and these data are suggesting that, actually, both staff and patients might be unsafe from potential abuse perpetrated by either staff or patients,” she says.
Lack of dedicated policies and training
Most NHS trusts have a range of policies that cover some aspect of sexual safety, such as managing violence or safeguarding children and adults, but most—187 of the 207 trusts that responded to an FOI request—do not have sexual safety policies: dedicated policies that set out how to safeguard staff, patients, and visitors from harm and what processes to follow when cases are reported. The 20 trusts that did have dedicated policies reported more cases than those that didn’t. Trusts that did not report any sexual safety incidents tended not to have policies.
“This is absolutely shocking and I think shows a terrifying naivety on the part of those trusts, the huge majority, without a specific policy,” says Elizabeth Duncan, a partner at Slee Blackwell Solicitors. “How they can possibly hope to keep patients and staff safe in the absence of policy and guidance is beyond me.”
Latifa Patel, the BMA’s representative body and workforce lead, says that she assumes that trusts without dedicated sexual safety policies are “sitting on huge numbers of unreported incidents,” which she describes as “a truly disturbing implication.”
In addition to a lack of policies, a study published in May found that only one NHS trust offers staff training on how to intervene when they witness sexual harassment at work.3
Staff on staff abuse
Trusts reported just 902 incidents of abuse against staff by colleagues, which is “the tip of the iceberg,” says Becky Cox, co-founder of Surviving in Scrubs, a campaign group that seeks to raise awareness about sexual harassment and assault in the healthcare workforce.
The BMJ and Guardian’s data show that 193 of the 212 trusts reported 10 or fewer staff on staff incidents between 2017 and 2022, which is implausible for trusts with their numbers of employees and shows the need for better policies and reporting systems, says Simon Fleming, orthopaedic registrar and co-author of Sexual Assault in Surgery: a Painful Truth, commissioned by the Royal College of Surgeons in 2021.
Staff are reluctant to report sexual assault, says Fleming. The BMA’s Sexism in Medicine survey found that 66% of women doctors who did not report incidents of sexist behaviour did so because they felt nothing would be done.4 Women don’t want to make a fuss, don’t think it will make a difference, or think that it will ruin their careers, Fleming says. “And that’s on top of all the usual things like shame, guilt, anger, having been silenced, having been slut shamed, having PTSD [post-traumatic stress disorder] and associated trauma.”
“I know hundreds of female doctors who’ve been assaulted, thousands who’ve been harassed, and a decent number who’ve been raped within the NHS,” he says. One person even shared a story about a consultant boasting to his team that he raped his wife. Incidents “at work” happen not only on NHS property, but elsewhere, such as at conferences and in work car parks, he says, “where certain consultants often perceive that the normal legal and social boundaries don’t apply anymore.
“Quite a few people describe being offered a lift to a clinic or to a remote site, and then something happens in the car.” Surviving in Scrubs and another campaign group National Survivor User Network told us that they backed calls for an independent inquiry into sexual assault and harassment in the NHS.
Trusts rarely take action
More than 4000 NHS staff were accused of rape, sexual assault, harassment, stalking, or abusive remarks towards other staff or patients in 2017-2022, yet few have faced action from their employers, The BMJ found.
Trusts took disciplinary action against only 577 staff for such incidents in this five year period. Only 149 of the 212 NHS trusts that provided data on sexual safety incidents also provided data on the level of disciplinary action against staff.
When complaints are made against colleagues, women claim that NHS trusts show a “reluctance to suspend perpetrators due to overall staff shortages,” says Syed. Instead of being supported, some staff that complained to their employers have been threatened with or put through disciplinary processes, she says. “In some cases, they were even referred to the professional regulator for allegedly failing to meet their duty of care to patients, which has left those women feeling frightened and intimidated into dropping their cases,” Syed says.
Lawyers with experience of bringing cases against NHS trusts for sexual safety incidents also say that trusts are reluctant to deal with cases and perpetrators effectively, often choosing to settle cases rather than accept liability and deal with longstanding problems. “Generally speaking, they’ll want to try and sort of sweep it away, because that’s easiest,” says Jayne Harrison, a partner at Richard Nelson.
Trusts can be reluctant to report incidents to the police and sometimes put insufficient restrictions on staff that are under investigation, several lawyers told The BMJ. “We are aware of cases of doctors under police investigation in relation to multiple counts of alleged sexual offences against patients, with a history of previous safeguarding investigations and findings by the [General Medical Council], being permitted to continue practising during the police investigation period, including intimate examinations on women,” says Catriona Rubens, associate solicitor at Leigh Day. “The only conditions being that there should be a chaperone present and a log kept of all the intimate examinations conducted. The idea that a doctor is allowed to continue practising and carry out intimate examinations while under that kind of scrutiny must be horrendous for the victims to know as well.”
When a staff member is under investigation or suspended, it doesn’t show up on a Disclosure and Barring Service check, she added, which leaves perpetrators free to gain employment elsewhere. Perpetrators often resign when an allegation is made, allowing them to move on to a different hospital, care home, or agency, says Amanda Warburton-Wynn, a partnership officer for sexual violence and domestic abuse at Cambridgeshire County Council, who spoke to The BMJ in a personal capacity.
Little progress at mental health trusts
The investigation found that nearly three quarters of the sexual safety incidents on NHS premises occurred in mental health trusts. More than 93% of the cases in which a patient was abused by another patient occurred in these settings.
The BMJ uncovered multiple cases of gang rape in mental health trusts. In the five years from 2017 to 2022, 56 gang rapes were recorded on NHS premises by 10 police forces in England. The real figure on gang rapes is likely to be higher because not all police forces in England provided detailed breakdowns of crime codes that enabled specific types of offences to be counted.
Leicestershire police force alone recorded 18 cases of gang rape, all but one of which took place in a mental health unit. The offenders were never identified—often because the victim was unable to support police efforts—so they could go on to assault other patients.
It seems that little progress has been made since the Care Quality Commission (CQC) raised the alarm over sexual safety in mental health facilities in a 2018 report,5 which found that sexual safety incidents were “commonplace” and occurred so frequently that staff became “desensitised” to them and felt ill equipped to respond to them.
Only 16 of the 47 mental healthcare providers that responded to our FOI requests have dedicated policies, despite government commissioned sexual safety standards requiring this. NHS England commissioned the National Collaborating Centre for Mental Health to draw up the standards after the CQC’s 2018 report.
The report said that mental health trusts had difficulty separating men and women on mixed sex wards and called for trusts to supervise common areas where a substantial proportion of incidents took place. It said that clinical leaders of mental health trusts often didn’t know what good practice looked like, were not always aware of the effects that unwanted sexual behaviour had on patients and staff, and lacked knowledge of how to respond to what seemed to be consensual sexual activity between patients (a particular problem on longer stay wards).
Duncan says that most cases of sexual assault in mental health trusts had involved staff such as occupational therapists, support workers, or nurses grooming patients into a “relationship.” Patients receiving psychiatric treatment are vulnerable and might be less likely to contact the Patient Advice and Liaison Service (PALS) about abuse, so end up calling a lawyer in desperation, she added.
These staff were rarely prosecuted, because cases rarely went to court, probably owing to concerns about the credibility of the victim because of their illness and how they would stand up to cross examination, says Duncan. “This means, in my view, that some of our most vulnerable members of society have the smallest chance of seeing justice,” she says.
Sarah Hughes, chief executive officer of mental health charity Mind, says: “It is unacceptable that in the five years following those reports so many people continued to be let down in such an appalling and traumatic way.”
What can trusts do?
Trusts need to be guided by NHS-wide policies on how to deal with allegations, including when to suspend staff and when to report individuals to the police, and should act swiftly to deal with complaints, say Tamzin Cuming and Carrie Newlands, from the Working Party on Sexual Misconduct in Surgery, a group of NHS surgeons, clinicians, and researchers who are working to raise awareness about this issue. Compliance with these policies should be a standard CQC reporting item, they add.
Any policies should always be introduced alongside training on what constitutes unacceptable behaviour, says Alison Millar, a partner at Leigh Day. If “low level” incidents are tolerated, people will be reluctant to report sexual violence.
The Working Party on Sexual Misconduct in Surgery told The BMJ that it is also calling for mandatory reporting of all serious sexual safety incidents to the police and regulators. It wants proven sexual misconduct in the workplace to be recorded on the staff records of a perpetrator and shared with new places of work.
Some experts are uncomfortable with mandatory reporting. “Isn’t it that adult’s choice as to whether a report is made to the police or not?” says Liz Kelly, professor of sexualised violence at the London Metropolitan University. “Especially adults who’ve had an experience of having control taken away from them over their body.” The more useful thing is for people who have been assaulted to be referred to a specialist sexual violence service so they can be supported, she says.
All agree that action is needed fast. “Employers must ensure that victims are supported and feel empowered to report sexual harm and resolve to take appropriate action,” adds Patel. “It is heartbreaking to see the extent to which the NHS has failed to provide this safety to patients and healthcare staff.”
Steve Barclay, health secretary, said that the government has doubled the maximum sentence for those who are convicted of assaulting health workers like doctors and nurses. “NHS leaders have a statutory duty of care to look after their staff and patients and prevent harassment, abuse, or violence in the workplace. I expect employers to be proactive in ensuring staff and patients are fully supported, their concerns listened to and acted on with appropriate action taken where necessary,” he says.
“We are also working closely with NHS England as it takes action to prevent and reduce violence against staff, including through body-worn camera trials and a national violence prevention hub to ensure NHS staff can work in a safe environment.”
“I quit my job in the NHS after my trust handled my sexual assault so badly”
Fleur Curtis, 43, was sexually assaulted on three occasions by a junior doctor in 2016 and 2017 when she was working as a physician associate at the Princess Royal Hospital in Telford. The assaults, and the trust’s poor handling of her complaint, left her experiencing panic attacks and PTSD, forcing her to quit her job in 2020. “I’d worked for the NHS all my life, and had a career that I loved, but I just felt that I had no other option than to leave” says Curtis. “The worst thing was how the trust handled my complaint, that had a massive impact on my mental health.”
In the latter part of 2016, Curtis noticed a doctor from a different ward using her ward’s doctors’ office. He would stare at her, and in December 2016, she says, he pulled up a chair next to her, leant on her, and put his hand on her thigh. “If this had happened to me outside of work, I would have reacted. I would have moved, I would have screamed and shouted, but you just don't expect a doctor at work to do that,” she told The BMJ.
A few weeks later, Curtis says that she was working in the office again when the doctor pulled his chair right up to where she was working. She pushed her chair back and stood up to get away, but he stood up at the same time and he pushed his groin against her. “I could feel he had an erection. It was gross,” she says.
The third incident happened in February 2017, as Curtis was walking into the doctor’s office. She says he pretended to stumble and fell on her left breast and continued to hold it. “Again, I just froze,” she says. “It was at that point I thought ‘I need to report this. I’m not imagining it, and it’s getting worse.’”
On 13 February 2017, Curtis used the Datix incident reporting system, a digital system used in hospitals to collect data for clinical adverse events and staff complaints, to report “unwanted physical contact.” When she asked if he would be suspended, she was told that no patients had complained and that suspensions are “bad for doctors’ careers.” She says, “I basically threatened to go to the media if he wasn’t suspended with immediate effect.”
The trust held an emergency meeting that evening, 23 February, and the doctor in question, Mahendar Katarapu, a specialist registrar working on a one year fixed contract in general and acute medicine, was suspended while an investigation took place. “During the investigation I found the trust had received complaints similar to mine before it happened to me,” Curtis says, and several more were reported to the trust after Curtis had made her complaint. In total nine Datix reports were made, and other concerns raised verbally.
After its investigation, Shrewsbury and Telford Hospital NHS Trust dismissed Katarapu on 10 July 2017 for gross misconduct, and the General Medical Council erased Katarapu from the registrar after a Medical Practitioners Tribunal Service fitness to practise hearing, which ended on 10 December 2020.6
Katarapu appeared at Shrewsbury Crown Court in January 2018, charged with seven allegations of sexual assault involving four women between August 2016 and March 2017. After the case was heard, and a retrial over two charges that took place in June 2018, he was cleared of all charges.
At Curtis’s request, Shrewsbury and Telford Hospital NHS Trust commissioned an independent report into its handling of her concerns. The report, produced by Vista (a company specialising in HR investigations) and seen by The BMJ, concludes that “on balance, the evidence does not show that the trust dealt with [Curtis’s] concerns appropriately” and could be said “to have fallen short of what might reasonably be expected.”
The report lists several areas in which the trust could make improvements, from its speed of responses and support offered to victims and witnesses to how it handles investigations and evidence that might be required in a criminal case.
A spokesperson for the Shrewsbury and Telford Hospital NHS Trust said that it could not comment on individual cases but has “acted upon recommendations to improve support and training for staff.” They added: “We are fully committed to creating a safe, supportive environment for all colleagues and have embedded Freedom to Speak Up, and many other routes, throughout our organisation to encourage any concerns to be raised and acted upon.”
This feature has been funded by the BMJ Investigations Unit. For details see bmj.com/investigations.
Competing interests: none.
Provenance and peer review: Commissioned; externally peer reviewed.