Violence after an accident - practice dilemma

A female patient reports domestic violence from her blinded husband. What should she do?

The Dilemma

Three years ago a male patient was blinded in a motorcycle accident. He seems to have learnt to cope with his disability remarkably well and appears unfailingly cheerful. Over the past month or so his wife has come to see me to show me bruises on her arms and body, and haematomas on her head. The bruises bear clear imprints of finger-marks. She says that her husband gets uncontrollably angry at home and has been beating her almost since he returned after the accident. She wants to leave, but feels trapped because she thinks either people will think her stupid for being unable to escape the blows of a blind man, or that she will be branded as evil for abandoning or bringing a prosecution against a man who has suffered so much. I do believe her, but what advice should I give?

A GP's response - Dr Alison Glenesk is a GP trainer in Aberdeen

It is tempting to assume that the male patient is depressed and angry and is taking this out on his wife, however we also need to consider possible effects of head injury at the time of the accident. It is also possible that there were marital difficulties before his accident, and this sensitive area could be explored with the wife.

She may be anxious about asking her husband to see you. It would be useful to see the couple together. With the wife's agreement, you may consider arranging a home visit to see how the man has been coping.

You need to ask him how things are going, and if, as is likely, he denies any problems, put it to him that, in his situation it would be unusual not to feel distressed and frustrated. This may allow him to open up on how he is feeling; if not it may be necessary to feed back his wife's comments (if you have her consent). If he confesses, you can then assess his mood formally, arrange individual or couple counselling if possible, and offer both patients support.

A medico-legal view - Dr Sonya McCullough is a medico-legal adviser at MPS

As the husband is your patient you might have the opportunity to speak to him in a consultation of his own, however, you would need the wife's agreement to disclose anything she has told you. It is important to consider the possibility of an organic cause requiring investigation and possible treatment.

The possibility of abuse by the wife, fuelled by frustration and leaving the physical signs of self defence, should also be considered.

If your assessment leads you to believe that the wife (or others, such as children) is, or may be, the subject of domestic violence, you should consider whether a disclosure should be made to an appropriate authority, in the public interest.

The GMC advises that it may be appropriate to encourage patients to consent to disclosures you consider necessary for their protection, and to warn them of the risks of refusing to consent; but you should usually abide by a competent adult patient's refusal to consent to disclosure, even if the decision leaves them, but nobody else, at risk of serious harm. However, if there are others at risk, such as children, you could justify a public interest disclosure. Where practicable you should still seek the patient's consent and consider any reasons for refusal, and document the reasons for your decision.

A patient's opinion - Antony Chuter is an expert patient

Regardless of the perpetrator's gender, disability or past experiences, domestic violence is unacceptable.

This woman needs the unbiased support and reassurance that I am sure any GP would give to someone in this situation. She needs guiding towards the support services for people who are experiencing domestic violence.

She may or may not decide to leave him, but she needs to know that she can and that she would not be a bad person for doing so.

She may consider involving the police and a future prosecution. However, she may not want police involvement until she feels ready, and many people in this situation prefer never to have the police involved.

Her husband needs support, but any contact would need to be made very carefully in order to avoid making things worse for the female patient.

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