Medico-legal: Spotting signs of domestic abuse

Dr Helen Burnell of the MDU advises on identifying patients experiencing violence and abuse.

Victims are often relutant or unable to report what happened
Victims are often relutant or unable to report what happened

It has been estimated that at least 1.2m women and 784,000 men experience domestic violence and abuse in England and Wales each year.1 The actual figure is likely to be higher as victims are often reluctant or unable to report what has happened.

GPs should be alert to the possibility of patients experiencing domestic abuse and are often well placed to spot the signs.

However, it is important to know what to look out for, how to broach the subject sensitively and how to respond appropriately, including when to disclose information.

What to look out for in patients at risk
  • Frequent attendances
  • Depression
  • Anxiety
  • Self-harming
  • Tiredness
  • Chronic pain
  • Non-specific symptoms

What is domestic abuse?

The stereotypical image of a battered wife is unhelpful when identifying patients who are at risk. Victims can be from any age group and at any stage of a relationship. Although most victims are women, men can also be subjected to abuse.

In 2013, the government broadened its definition of domestic abuse. The current definition is: 'Any incident or pattern of incidents of controlling, coercive, threatening behaviour, violence or abuse between those aged 16 or over who are, or have been, intimate partners or family members, regardless of gender or sexuality. The abuse can encompass, but is not limited to, psychological, physical, sexual, financial, emotional.'2

Your practice policy

National guidance on domestic abuse was produced by NICE in 20143 and by the RCGP in 2012,4 including a flowchart to illustrate a model response.

Based on these documents, the MDU advises GPs to consider the following areas when developing practice policy on domestic violence and abuse.

Management

Identify a senior person in the practice with responsibility for managing practice policy, staff training and engagement with local domestic abuse services.

Training

Clinical and non-clinical staff may need training to recognise the signs of domestic abuse, to ask relevant questions in a sensitive manner and to understand the rules governing confidentiality and disclosure of information.

Patient information

NICE recommends that information should be displayed in waiting rooms about the support available for those affected by domestic violence and abuse, including contact details. It suggests the information should be available in a range of formats and locally used languages.

Referral

It may be necessary to refer victims of domestic abuse to outside agencies for specialist support. The RCGP says practices should identify a 'designated person' responsible for the initial assessment, such as a practice nurse or other health professional who is trained to carry out this work.

Confidentiality

Careful records should be made of interactions with patients who are victims, or at risk, of domestic abuse. Information should only be shared with the patient's consent, unless there are exceptional circumstances that justify disclosure, such as safeguarding and child protection.

In these cases, the patient's consent should still be sought, unless this is not practicable, in line with the GMC's confidentiality guidance.5 Your medical defence organisation can provide further advice.

Victims of domestic abuse may be reluctant to talk about their experience and many will not report what has happened unless directly asked. With sensitivity and persistence, you may persuade the patient to confide in you, but it is essential that if and when they do, they receive the most appropriate response.

Case scenario

This fictional case scenario is based on typical requests for advice received by the MDU.

A 20-year-old woman saw her GP, complaining of feeling tired all the time, generalised aches and palpitations. She was tearful and feeling anxious and low.

When taking her BP, the GP noted bruises on her wrists. However, when asked if everything was all right at home, she would not respond.

The GP recorded his concerns and when the patient returned following a positive home pregnancy test, he again asked her if all was well. She confided that the pregnancy was unplanned and when she told her partner, he had lost his temper and pushed her to the ground.

After confirming her pregnancy, the GP discussed referral to the domestic violence service with the patient. She agreed to consider this and the GP also gave her the details of a confidential helpline.

He arranged for her to attend during her pregnancy, so he could monitor her welfare, and discussed the case with the designated doctor for child protection. Several weeks later, the patient agreed to be referred to the local domestic violence service.

  • Dr Burnell is a medico-legal adviser for the MDU

References

1. NICE. NICE calls for greater awareness about domestic violence and abuse. 25 February 2014.

2. Home Office. Domestic violence and abuse. 25 November 2013.

3. NICE. Domestic violence and abuse: how health services, social care and the organisations they work with can respond effectively. PH50. London, NICE, February 2014.

4. RCGP. Responding to domestic abuse: guidance for general practices. 2012.

5. GMC. Confidentiality. 2009. www.gmc-uk.org/guidance/ethical_guidance/confidentiality.asp

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