Crimes of violence are recorded increasingly frequently, including those involving health professionals. We reviewed records of violent incidents kept for a major Accident and Emergency Department over a ten-year period. Details were recorded in a Violent Incident Book by all grades of A/E staff, and separate records were kept by hospital security officers. A total of 407 incidents were recorded. Numbers, rank and sex of staff assaulted, types of assault, injuries received, weapons used and characteristics and disposal of perpetrators were recorded. Many were young males who had been drinking: others were regular attenders, of whom three subsequently died and one convicted of murder. Nurses and male doctors appeared to be at the greatest risk of assault and receptionists at the least risk. Recording of violent incidents and subsequent prosecution seemed inconsistent, and may have reflected the lack of a code of practice in this area. Suggestions are made about preventing, predicting and dealing with violence, and its aftermath, in the A and E department, including the use of security officers and closed circuit television, waiting room design, the recognition of body language and signs of alcohol or substance intoxication. The importance of staff support after an assault is emphasized, including immediate and long-term counselling, provision of legal advice, criminal or civil court action, victim support schemes and the workings of the Criminal Injuries Compensation Board. Free legal advice for staff assaulted at work should be included in the terms of service of NHS staff.

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General practice attachment 215 -and the prioritisation of calls according to the urgency of patient need is introduced, the opportunity exists to improve care across the spectrum of 999 callers. At the most urgent end, appropriately skilled and staffed ambulances can be dispatched without delay. At the less urgent end, there is the opportunity to explore other, possibly more appropriate responses than the current obligatory "lights and sirens" paramedic vehicle. The question of appropriateness of use recedes as not only difficult to measure but also of little relevance. The question becomes: "how can ambulance services best plan the cost effective provision of prehospital care so that varied healthcare needs expressed by the general public through 999 calls receive an appropriate response?" This requires ambulance services to understand their workload and factors which affect all types of demand, not in terms of appropriateness or otherwise, but in terms of patient type and condition, and social as well as clinical need.

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