Chapter 11
General Practice
Emmeline Brew-Graves
General Practice, Southway Surgery, UK
OVERVIEW
- Domestic violence and abuse are common and hidden
- The majority of ‘victims’ are female
- The majority of general practice consultations are with women, making this an ideal location for detection and intervention
Apart from the obvious case of attendance with a clear history or injury, domestic violence should be considered in other scenarios, such as those listed in Box 11.1. Also consider routinely enquiring about domestic abuse at antenatal appointments, postnatal checks, pill checks, cervical screening or when a sexually transmitted infection (STI) screen or emergency contraception is requested.
Box 11.1 ‘Red flags’ for abuse and violence presenting in a general practice consultation
- The frequent attender at the surgery/the frequent attender elsewhere – remember emergency departments (A&E) and out of hours contact letters/slips. The frequent attender often presents with:
- Vague symptoms.
- Depression, anxiety, self-harm or psychosomatic symptoms.
- Patients who frequently attend as an ‘emergency’ but do not attend scheduled appointments.
- Frequently missed appointments.
- Injuries inconsistent with the explanation given.
- Injuries that are hidden (e.g. to the breast or abdomen) or minimised.
- The subdued or silent patient always accompanied by a family member who talks on the patient’s behalf without reference to them.
Enquire directly but sensitively about domestic abuse. This must be in a safe place, with no other family members, including children (except the very young), present. If an interpreter is needed, do not use a family member.
Use the HARK questions (see Chapter 7, Box 7.7) and make a note of the date and time in the patient records.
There are four main factors:
- Focus on the here and now.
- Remain calm.
- Listen carefully.
- Record what you are told using the patient’s own words.
Assess the situation
Ask yourself:
- Is there an immediate and significant risk?
- Has a crime been committed?
- Are the emergency services (ambulance or police) required?
- Are the safety and well being of your patient in jeopardy?
- Are the safety and well being of any children in jeopardy?
- Is your role today to provide support and advice?
Ask your patient:
- ‘Are you safe to go home?’
- ‘Are either you or the children in danger?’
- ‘Has violence become more frequent or severe recently?’
- ‘Are there any weapons in the home? For example, a bread knife or a hammer?’
- ‘Have there been threats to kill [you/your children/your pets]?’
Box 11.2 provides some indications of high-risk cases.
Box 11.2 High-risk cases
Women are at greatest risk:
- At the point of separation and afterwards.
- If there is sexual violence, strangulation, threats to kill or use of weapons.
- After separation; 76% of domestic violence homicides occur following separation.
Children are at greater risk:
- If they are under the age of 7 years.
- If their mother is pregnant.
- If either the mother or the child has special needs.
Safeguarding children and vulnerable adults
Inform your patient that you are required to share certain information, explaining what will be shared and why. Keep your statements relatively simple: ‘I am worried about you’, ‘I am worried about your child’, ‘Even if he is sorry, this can happen again and again and get more serious’.
Domestic violence is a child protection issue
You can seek advice (without necessarily disclosing the identity of the individual) from an experienced colleague, local safeguarding/domestic violence lead or medical defence organisation. If a rape is alleged, consider seeking advice from your local sexual assault referral centre (SARC).
Articulating your concerns to another professional often crystallises a way forward.
Examine the patient if physical violence is disclosed
Use diagrams to document any injuries. If police involvement is rejected, advise the patient to photograph injuries or consider photographing the injuries at the practice or the local hospital medical photography department.
- Do not assume that domestic violence spells the end of the relationship.
- Treat any injuries that can be managed in primary care.
- Discuss a management plan and seek consent for appropriate information sharing.
- Arrange referrals: hospital referrals, safeguarding referrals and referral to a local domestic violence organisation. Local domestic violence agencies have independent domestic violence advisors (IDVAs) who can support the patient via advocacy; they can also broker access to housing, and provide criminal justice and social care support.
- If you are familiar with the CAADA-DASH Questionnaire (Coordinated Action Against Domestic Abuse & Domestic Abuse, Stalking and ‘Honour’-Based Violence), it may be appropriate to complete it at this encounter or to consider arranging another appointment to complete it (see Appendix B).
- Discuss safety planning and safety numbers.
- Make sure the patient leaves with the 24 hour National Domestic Violence Helpline number (0808 2000 247) and the numbers of any local domestic violence organisations.
- Consider a referral to the local multi-agency risk assessment conference (MARAC; see Box 11.3 and Chapter 9).
