Raising concerns: Republic of Ireland

• All registered doctors have an ethical obligation to raise concerns when they believe that patients are being harmed, or could be harmed, by systems or events outside the patients' control¹.
• Raising concerns about patient safety can require doctors to speak up about issues as diverse as: the systems within which they work; resourcing issues; or the clinical or personal conduct of their colleagues.

Raising concerns when a doctor believes that patient safety could be at risk can feel intimidating, but you should not be criticised for raising concerns in good faith. Raising concerns at an early stage may prevent potential harm to patients from actually materialising, and can allow colleagues in difficulty to be offered the help and support they might need before they actually become involved in a serious incident.

It is very important that doctors follow Medical Council guidance when they need to raise concerns and, where necessary, that they afford themselves the protection of the law by raising concerns in an appropriate way.

Medical Council guidance

In its guidance, the Medical Council explains doctors' obligations to raise concerns². It says that if you have concerns about the safety of patients, or that of yourself or your colleagues, you should inform an appropriate person or authority. It goes on to explain that when doing so you should follow your organisation's procedures for raising concerns. For most hospital doctors this will mean approaching their clinical or medical director in the first instance.

If the concern is not investigated or acted on appropriately, it may become necessary for a doctor to escalate their concerns. In all but the most exceptional cases this should usually be done in stages and within their organisation, ending up (if necessary) at the level of the chief executive or the hospital's board of directors.

Seek advice from the MDU before escalating your concerns outside your own organisation.

Doctors who manage a team

The Medical Council's guidance also sets out the additional requirements placed on doctors who have management roles³. These doctors should ensure that staff are encouraged to report concerns, that there is an effective system in place to assist with this process, that staff are informed about this, and that staff concerns are investigated promptly. The guidance emphasises that staff members who raise concerns in good faith should never be subjected to any disciplinary action as a result.

Use of healthcare resources

Medical Council guidance states that doctors in management roles are must make sure that available resources are used efficiently and fairly⁴. It says that doctors must put the care and safety of patients first when resources are limited, and also explains that on occasions when a doctor is managing limited resources, the overall needs of a patient community may take precedence over the needs of individual patients.

Doctors sometimes have cause to raise concerns about risks to patient safety resulting from a lack of resources. This might occur when a service is apparently underfunded, or when medical personnel are in short supply. In emergency situations, such as a colleague becoming ill, doctors can be called upon at short notice to fill gaps in a rota, or even in extreme situations (such as the coronavirus pandemic) to cover wards or services in which they might not normally work.

When such gaps are appearing regularly, however, doctors may become concerned that action will need to be taken in order to mitigate the risk to patients. In such circumstances they would be obliged to raise concerns just as they would in any other; the lack of resources and the fact that doctors may understand the reasons for this should not of themselves be a barrier to speaking up.

Concerns about colleagues

The Medical Council has specific guidance for doctors who have concerns about the clinical or personal conduct of a medical colleague⁵. This says that you should usually first discuss your concerns with the doctor themselves. However, if you're concerned there is a risk to patient safety, you must notify the relevant authorities, including the Medical Council.

The guidance goes on to say that if you have concerns that the health of a colleague or their use of alcohol or drugs may be putting the safety of patients at risk, you must raise concerns with an appropriate authority without delay⁶. If there is no current risk to patient safety, you should encourage the colleague to seek professional help or, again, consider referring them to the Medical Council's Health Committee directly.

Disclosure of confidential information without consent

Some situations may require you to disclose confidential information in accordance with law or in the public interest, including where you know or have reasonable grounds for believing that a crime has been committed against a child or other vulnerable person that involves sexual assault or other violence.⁷ The Medical Council Guidance states that in such situations, you should inform patients of the disclosure, unless this would cause them serious harm, or would undermine the purpose of the disclosure.⁸

Disclosure in the public interest may be made to protect the patient, other identifiable people, or the community more widely. Before making a disclosure in the public interest, you must satisfy yourself that the possible harm the disclosure may cause the patient is outweighed by the benefits that are likely to arise for the patient or for others. You should disclose the information to an appropriate person or authority, and include only the information needed to meet the purpose.⁹

Raising concerns regarding the protection and welfare of children and vulnerable persons

Some circumstances may lead you to believe or have reasonable grounds to suspect that a child or vulnerable person is being, has been or is at risk of being harmed through physical sexual or emotional abuse or neglect.

In situations concerning children, the Medical Council guidance says you must be aware of and comply with the national guidelines and legislation for the protection of children¹⁰ and report this to the appropriate authorities and/or the relevant agency without delay. Providing relevant information to the appropriate authorities is a justifiable breach of confidentiality,¹¹ as long as you comply with the guidance on the disclosure of confidential information in the public interest.¹²

In situations concerning vulnerable persons (someone who has a physical, intellectual or mental disability and is incapable of independent living),¹³ the Medical Council guidance states that you should be alert to the possibility of abuse and notify the appropriate authorities if you have concerns.

As in situations involving harm to children, providing relevant information to the appropriate authorities for the protection of vulnerable persons from serious harm is a justifiable breach of confidentiality - again, so long as you comply with the guidance on the disclosure of confidential information in the public interest.

Reporting of alleged historic abuse

The Medical Council sets out specific guidance where adult patients disclose historic abuse, and states that you must assess the current risk to the patient or to any other child or adult who may be in contact with the alleged abuser.

If you believe anyone is at risk, you should report this to the appropriate authorities, preferably with the patient's consent.¹⁴

Protected disclosures - 'whistleblowing'

The Health Act (2007) introduced legal protection for whistleblowers within the health service¹⁵. Those making protected disclosures in good faith cannot be penalised, disciplined, or treated unfairly by their employer, even if the concerns they raised turn out to be incorrect. The HSE website sets out the procedure to be followed when a doctor is considering making a protected disclosure.

A doctor can make a protected disclosure under the Act when they have a reasonable belief that:

• a patient's health or welfare is likely to be at risk
• the actions of a person working on behalf of a relevant body pose or are likely to pose a risk to a patient's health or welfare
• the person or the body has failed or may fail in their legal obligations to their patients
• the conduct of the person or the body has led, or is likely to lead to a significant misuse or waste of public funds
• evidence of any such matter is being, or is likely to be, deliberately concealed or destroyed.

The Act affords the same protection to doctors who believe that a risk is posed to the health or welfare of the public generally by the actions of a colleague who is required to be registered with a professional regulatory body.

Barriers to raising concerns

Even when doctors know they have an ethical obligation to raise concerns if they believe patient safety to be at risk, and when they are aware that raising concerns or making a protected disclosure should not lead to unfair treatment by their employer, they can be reluctant to speak up. Possible reasons for this include:

• assuming that someone else will do it
• discomfort at the thought of confrontation
• fear of personal or professional repercussions, e.g.
  • possible negative effects on their own career
  • the possibility of inviting scrutiny of their own practice
• misplaced loyalty, e.g.
  • a doctor with concerns about the practice of their own trainer or mentor
  • a team member wishing to protect their colleague from the ramifications of their actions
  • possible damage to the reputation of their institution or even the medical profession
• lack of knowledge, e.g.
  • of local systems for reporting concerns
  • of the ethical standards to which colleagues should be held
  • of the thresholds for breaching patient confidentiality.

None of these should be a barrier to a doctor raising honestly-held concerns. Remember that however difficult it feels, raising concerns at an early stage may prevent serious harm to patients in the future. Not raising concerns, once these have become evident, might be difficult to explain or justify, and could actually put you at risk of criticism in the future.

How to raise concerns effectively

Once a doctor has decided they need to raise concerns, it is important this is done in an appropriate way. The following tips can be useful.

• Read and follow your organisation's policy on raising concerns - a doctor will usually be expected to raise concerns within their own organisation as a first step.
• Raise your concerns in writing.
• Be factual and objective; in particular you might wish to avoid criticism of any involved individual.
• Focus on the effects or potential effects on patient safety.
• Be as specific as you can; if possible provide examples of how patient safety has been affected or may be affected.
• Consider patient confidentiality, particularly if you want to cite specific cases.
• If you're aware that colleagues share your concerns, consider whether it may be more powerful to raise them as a group.
• Be clear about the outcome you expect from the investigating authority - e.g. request a response in writing.
• Keep a record of all of the steps you have taken.

Always seek specific advice from the MDU if you are considering escalating concerns beyond your own organisation.

This page was correct at publication on 12/03/2021. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.