Iatrogenic injustice: an institutional ethnography of Fitness to Practise hearings

The public has an important role to play in the regulation of health and social care, including raising concerns about harms caused by health and social care professionals to improve the safety and quality of services. There is little evidence about the experiences of members of the public who engage in regulatory processes and raise concerns with regulators. We conducted an institutional ethnography of the experiences of public witnesses (patients, service-users or family members of patients and service-users) in Fitness to Practise hearings held in the UK 2021-2023. We found public witnesses' experiences of these processes were onerous and, often, disappointing. We argue that these negative experiences arose from the ruling relations of the regulatory powers. Witnesses were required to perform certain kinds of work to fulfil their role. The adversarial form of justice exercised by regulatory bodies entailed the systematic doubting of witnesses' testimonies; producing epistemic injustice. Witnesses were at risk of being made more vulnerable, in the sense of being exposed to further harm, through and by the Fitness to Practise processes. Troubling tensions were evident between witnesses' experiences of Fitness to Practise and what they expected from institutions ostensibly concerned with upholding professional standards of practice and conduct to protect the public. We interpret the exercise of power observed by the regulators over public witnesses as iatrogenic injustice; harm caused by interactions between the public and institutions of health and social care. There are important implications for reduced public trust in health and social care systems and regulatory processes.