AACE focused on violence reduction and prevention

Words: Carl Rees, Head of Communications, Association of Ambulance Chief Executives (AACE)

Violence and aggression by service users against UK ambulance staff is a major challenge for the ambulance sector. In the past year there has been a 17 percent increase in physical assaults alone, and a 39 percent increase over the past five years. This growing, worrying trend is a key focus of national work being coordinated by various workstreams under the auspices of the Association of Ambulance Chief Executives (AACE), the representative body for chief executives of all UK ambulance services.

In many ambulance services, staff are now asked to record any incidents of violence and aggression on their organisation’s own internal risk management systems. In one such incident reporting system, DATIX, incidents can be broken down into a number of categories, the key ones being as follows:

Physical contact (actual assault) – aside from the more common punching, kicking, biting and headbutting incidents, examples in one trust alone include staff being physically assaulted with items including knuckle-dusters, syringes, sledgehammers, glass bottles, stones, ashtrays, crowbars, a desk fan, snooker cues and balls, razor blades and hammers.During the COVID-19 pandemic, across a number of services we have seen the emergence of some service users spitting and coughing at staff with a view to deliberately causing harm by intentionally spreading the virus. This is an extremely worrying development and these events have a lasting psychological impact on the staff involved.

Physical threat (no contact) – examples include staff being held against their will in domestic premises, threatened with sticks, attempts to bite, threatened with dogs, threats to kill (including details as to how) and being lunged at with scissors/knives etc. There have also been threats related to firearms, with patients armed with live ammunition.

Psychological abuse – these are usually of a very personal nature and are based around extremely threatening and intimidating behaviour, of the ‘I know where you live’, ‘I’m coming for you and your family’ nature, alongside threats to kill.

Sexual assault / harassment – ambulance staff have been sexually assaulted repeatedly while caring for patients, for example hands being placed on genitals, making sexually suggestive comments, stripping naked when not required for medical treatment, exposure, kissing staff, staff being slapped on their body parts or groped and patients trying to sit on the knee of crew members. Both male and female crew members are being targeted equally in this area.

Verbal abuse – there are endless examples of extreme verbal abuse using foul and threatening language, which are inappropriate to print in this article.

Verbal abuse with racist content – again, there are endless examples of extreme racist verbal abuse using foul and threatening language, which are inappropriate to print in this article.

All of these incidents have a significant impact on the wellbeing of ambulance crews, not only physically but mentally too, with many forced to take significant time off work to recover.

Attacking our vehicles and equipment

Aside from the assaults on staff listed above, we have started to see more attacks on our vehicles and equipment. Along with items being stolen, we have had reports of some service users: stealing ambulances; throwing bricks and bottles at vehicles; punching equipment; tearing apart equipment (for example, a defibrillator worth £17,000); deliberate urination and defecation on and in equipment and vehicles.

So why is this happening? There is no simple answer to that question, although the data we have collated across the ambulance service shows that alcohol and drugs are a very significant factor in most of these attacks.

There is also the need for the ambulance service to work with certain conditions that can cause some patients to be irritated and aggressive. There are a small number of clinical presentations which can result in patients becoming aggressive, particularly: cerebral irritation – usually resulting from a head injury; hypoglycaemia – low blood sugars can cause severe agitation; and mental health conditions – a lack of understanding of what is appropriate and what is not.

What are AACE doing to address the problem?

AACE is working in tandem with all of its member ambulance services and links in closely with the national NHS England and NHS Improvement work on violence and aggression against NHS staff.

Through the National Ambulance Security Group we are seeking to obtain a greater understanding of the wider extent of the problem and trying to understand more about why this is happening and what can be done to effectively reduce the behaviour and the impact of that behaviour. The group is gathering examples of best practice to inform the consideration of actions that could be taken collectively as a sector (working with other emergency service colleagues) to fight the problem.

Through the National Ambulance Diversity Group we are seeking to obtain a greater understanding of hate crime in general, looking at ways to prevent it and strategies for staff to cope with its effects.

A small number of NHS ambulance trusts are now engaged with a pilot project to trial body-worn cameras on ambulance staff, something that – further down the line – could prove to be a valuable tool in the armoury to combat violence and aggression.

Some local services have introduced spit kits / spit hoods into their vehicles during the COVID-19 pandemic, with staff particularly welcoming of this type of initiative.

Some ambulance trusts undertake dynamic risk assessment training and de-escalation training which focuses on conflict resolution, although as yet there is no clear data to measure how effective this is.

What can we do about the perpetrators?

The Assaults on Emergency Workers Offences Act 2018 legislation was brought in to give courts the power to give significant sentences to perpetrators of assaults against ambulance staff. However, to date, there is a palpable feeling across ambulance services that there has been a lack of meaningful sentences handed down to those found guilty and that the judiciary must be seen to punish offenders to the full extent of the law in order to get the message across.

A recent case in the West Midlands was a step in the right direction, with a perpetrator receiving a jail sentence of seven years and two months for grievous bodily harm after he broke the jaw of a student paramedic so badly that it needed a metal plate inserted (see below).