‘This can’t go on’

‘This can’t go on, can it?’

It was a striking intervention from coroner Bernard Richmond KC, conducting an inquest into the death of consultant haematologist Paul Miller, as he stopped an occupational health consultant giving evidence.

The inquest had previously heard that a doctor dies by suicide every three to four weeks in England and Wales and how a culture among hospital doctors where ‘nobody takes time off sick’ exacerbates the many often-silent struggles that come with the pressures of the job.

The inquest, which concluded Dr Miller died by misadventure, not suicide, heard from those who had treated him that he was ‘not ready to return to work’, despite plans being drawn up and that he had been ‘desperate’ to return and felt under ‘pressure’ to do so.

His family say he asked for help to manage the stressors in his work and personal life but didn’t get the support he needed from his employer.

After delivering his conclusion, Mr Richmond called for the protection of funding for the NHS Practitioner Health service, which supports healthcare professionals with their mental ill health and which had treated Dr Miller.  

The service saw its long-term funding come under threat last year. Funding has since been guaranteed to March 2026, after the BMA warned that withdrawal of funding would be ‘a short-sighted financial decision with potentially harmful consequences for both doctors and their patients’.

Mr Richmond said the support given to health professionals by the service ‘could not be more important and necessary’, adding: ‘I hope that nobody with any sense or care for our doctors and our health workers would ever think of doing anything other than giving this service the maximum possible support.’ 

Surrey GP Kate Little, of NHS Practitioner Health, and who treated Dr Miller, told the inquest the levels of stress he was under is ‘a common theme’ among doctors she treats.

She said the level of mental-illness presentations among doctors has been ‘a long-standing problem’ and that ‘destigmatisation’ may help more people seek help sooner.

Data from the Office for National Statistics show 47 doctors died by suicide in England and Wales between 2020 and 2022, one every three to four weeks on average.

It does not record misadventure deaths by occupation, so the full extent of doctors taking their own lives – be it with definitive intent or not – is unclear.

While they say relationship issues were also a major factor, Dr Miller’s family said they would find it ‘horrible’ if his death was not included in statistics which measure the extent of medical professionals taking their own lives because of work pressures because the coroner concluded misadventure.

The Doctor put several detailed questions to Dr Miller’s trust, St George’s, including how it would respond to the conclusion of misadventure. Other questions asked how the trust was tackling a culture of presenteeism, how it planned to support staff after colleagues had taken their own lives and whether it believes in hindsight that the plan for Dr Miller’s phased return was correct.

While the specific questions were not answered, Richard Jennings, group chief medical officer at St George's, Epsom and St Helier University Hospitals and Health Group, said: ‘We offer our deepest condolences to Dr Miller’s family and friends, as well as to our colleagues.

‘Doctors across the NHS are facing increasing pressures and we encourage them to seek support – we continue to promote supportive measures, including our dedicated staff support service, the practitioner health programme and BMA counselling service to ensure staff receive support for any issues, in or outside of work.’  

Asked by the coroner what the trust has done to combat burnout among staff, London occupational health consultant Samuel Thayalan noted ‘a number of interventions’, including appointing a consultant psychiatrist to see staff and making adjustments for people with health issues.

He added that ‘other stressors need to be looked at’ including ‘things outside of work’.

‘People who have stressors outside of work can’t cope with work in the same way,’ he said.

The most recent NHS staff survey, from 2023, found that 54.8 per cent of staff went into work despite not feeling well enough to perform their duties. 

NHS Practitioner Health told The Doctor that about a third of its registered patients have some thoughts of suicide at the time of their treatment. The service sees around 6,000 patients a year, not just doctors.

Medical director Zaid Al-Najjar said: ‘There’s an awful lot of stigma in medicine. The service is already under great pressure so there’s a feeling that people who take time off sick put pressure on those who are left to run the service. Professionals don’t like to let patients, or colleagues, down so there’s a huge amount of guilt in terms of taking time off.’

He said many doctors feel like they ‘have to just soldier on’ and a culture exists where it is ‘more acceptable’ to take time for physical health reasons than mental health needs.

Dr Al-Najjar says healthcare workers are ‘not always the best at recognising when we’re unwell or need time off’ because of the ‘shame’ resulting from the culture of presenteeism as well as the ‘unique barriers’ to accessing care, such as potentially working with someone treating you.  

‘We try to destigmatise mental health and bring it to the attention of the general public and professionals,’ says Dr Al-Najjar. ‘Not everyone is comfortable talking about it.

‘During the pandemic everyone clapped and there was a lot of focus on mental health and the needs of the healthcare workforce, with pictures of people in masks looking broken. That’s old news now but it still needs to be on the Department for Health’s agenda.’

Dr Thayalan told the inquest he would ‘fully support’ protecting funding for NHS Practitioner Health, saying the service is ‘a very successful intervention’.

He accepted the coroner’s suggestion that working in the NHS ‘does not lend itself to healthy lifestyle choices’, noting how St George’s occupational health service was ‘very busy’, particularly since COVID, and sees ‘a lot of senior doctors’ presenting with mental-health issues and psychological stress.

Dr Thayalan agreed there is a ‘well-entrenched’ culture among doctors that many fear being off sick could be seen as a sign of weakness: ‘We have a big problem with doctors. They never admit they need help. It’s very challenging. It takes time to understand that they need to be human and to be kind to themselves.’

Dr Miller’s family, however, say he had sought help from his employer regarding the mounting stress he was under long before his death.

They say he informed senior leaders that he had been given an unmanageable workload and was not sleeping – and challenge the narrative heard in the inquest that if doctors under extreme stress ask for help they will receive adequate support.

His brother, Matthew Miller, noted how Dr Miller had been managing immune suppressed patients as a newly qualified consultant following the first winter of COVID, and that he had flagged being given an ‘uneven’ workload. At the same time, his separate research work became more pressing owing to COVID – which his brother says received ‘no acknowledgement’ from his management.

In a statement submitted to the inquest, Mr Miller said his brother ‘did not feel supported by his employer’ when he returned from paternity leave.

The inquest heard how Dr Miller had asked for two weeks off work, to work on his sleep and get on top of his research work but was only given one week. His brother told The Doctor this felt like ‘favouritism’ because another consultant had been given three weeks off which resulted in Dr Miller returning early from paternity leave. 

‘On his first week off he told me that he had been in a staff meeting where a senior doctor had been disparaging about staff going on sick leave for stress and said this wasn’t allowed in the medical profession. Paul repeatedly said to me that this has caused him anxiety as he could see how he was feeling and where things were heading for him.’

In a note found by his side, Dr Miller wrote that ‘by this point I was beyond burnt out and a complete bundle of nerves and anxiety’.

His brother said Dr Miller was ‘concerned about raising a grievance’ because of the added stress that would cause and because ‘he was worried about needing work references’. He said his brother felt that his relationship difficulties ‘undermined’ the effect of his work on his mental health.

Dr Al-Najjar said it is ‘crucial’ doctors who are unsure if they can take time off or not due to work pressures seek independent medical advice, ‘both to ensure that they are safeguarding themselves and to ensure that patient care is not compromised’.

Dr Miller’s note said he felt ‘trapped in several catch-22 life situations’, resulting from pressures at work and home that resulted in him being admitted under the Mental Health Act. Being sectioned, the inquest heard, led to feelings of ‘guilt’, ‘shame’ and not feeling like he could return to work.

The evidence, the expertise and the growing list of tragedies all make an urgent case for action and change to limit the pressures many doctors face in their workplaces, improve the support they receive when they ask for help and destigmatise the issue.

As the coroner said – this can’t go on.

• If you have been affected by this article, or are feeling pressure and stress as a result of your at work, you can find details of the BMA’s free and confidential wellbeing services here
• Details about NHS Practitioner Health service can be found here
• We have reported this inquest along Samaritans’ media guidelines for the reporting of self-harm, which recommends including no details of the methods used. You can find the guidelines here