The UK and the USA have suffered more than their fair share of clinical crises within their health care systems. In the UK, neonates and the elderly are dying in inordinate proportions in hospitals. In the US, deadly infectious diseases are now carried out of the research labs into the wards of the most prestigious hospitals.

More doctors have been convicted as serial killers than all the other professions put together.

There is an inherent assumption that these disasters should not happen. Despite regular ghastly discoveries, there is still a view that clinicians are capable of working under stressful conditions within a loosely regulated environment that no harm will come to patients.

To continue to be effective, all stakeholders must trust that clinicians will always behave in a professional manner and that these events are not the result of malfeasant intentions, but rather the neglect of insufficient resourcing in our health care systems.

Unfortunately, this is not universally true. We are always going to find health professionals who will violate their vocation and behave in a criminal manner. The fact that their behaviour sits so far outside of the accepted norms and defences, can often be ignored or dismissed by the avoidant behaviour of those around them.

Decision making in health care is quite complex and it often difficult to differentiate actions with criminal intent from those with therapeutic intent. For example, relieving, or even just managing pain and the accompanying distress is not the role of any individual but a clinical team. If, despite relieving the pain and distress, a clinician goes on giving more opiates until a patient dies, that is clearly criminal.  In this case the two actions, can look the same in all respects, including their outcomes, but differ in the clinician’s intentions, and that is how they become two different actions.

Foreseeing that death might be likely from the administration of a drug to relieve pain but not intending to kill someone is different from foreseeing and intending death. Whilst one unusual death can be attributed to a mistake, more than one death is cause for investigation. Perhaps, because of their proximity to patients and deathly means, more doctors have been convicted as serial killers than all the other professions put together.  To date, the count is over two dozen.

At this time more than ever before, where shrinking real budgets are resulting in shrinking services, it is important to differentiate intentions driven by lack of funding from criminal actions.