• Safety and assessment of risk.
  
• An overview of specialist support services.
  
• Multi-agency risk assessment conferences (MARACs): what they do and when to refer.
  
• The role of independent domestic violence advisors (IDVAs) and specialist domestic violence courts (SDVCs).
  
• Domestic homicide reviews.

If a health care professional identifies or suspects domestic violence, or if a disclosure is made, this must be acted upon quickly and appropriately. The abuse may be current and ongoing or it may have taken place in the past. In either case, the survivor should be given a sympathetic hearing and pointed to suitable sources of help and support.

In most cases, giving contact details (‘signposting’) or directly referring to a specialist domestic violence organisation within the voluntary sector will be the first choice. Such organisations provide a variety of services, including refuge accommodation and associated support, advocacy, outreach work, counselling, support groups and so on. Many will also provide support for the survivor’s children. They will be able to refer survivors to other services as needed, and will support them through practical and legal issues, such as getting rehoused or going to court (see later).

Remember that a patient will not necessarily disclose domestic abuse – or not on the first occasion she is asked. Health professionals should bear in mind the need to make routine and selective enquiries about abuse on a number of occasions, particularly when patients attend frequently with suspicious symptoms.

If you suspect abuse, and the patient is accompanied by someone else, always ensure that you find a safe way to talk to her alone. Chapters 3 and 7 describe how enquiries about such sensitive subjects may be undertaken safely and explain the limits of confidentiality. If a patient discloses that she is currently experiencing domestic violence, it is crucial that any action you or anyone else takes does not in any way increase the danger she is facing. Your response to this disclosure could be crucial to her safety, health and well being, both now and in the future.

If a patient discloses abuse – however unlikely the story might seem – you must believe her, and show that you believe her. It is also important to be supportive and nonjudgmental. Case studies drawn from real life are given throughout this chapter (see Box 9.1).

The following actions should then be taken:

• Attend to her immediate health needs (e.g. if she has an injury).
  
• Assess the level of risk and ensure safety (see later). This will include:
  
  
  
  • assessing whether she or any of her children are at risk of immediate harm;
    
  • helping her develop a safety plan; or, if necessary, referring her to someone else who can help her with this.
  
  
• Give her time to talk, if she wants; or suggest someone else she could talk to.
  
• Give contact numbers for local and national domestic violence support services – perhaps by providing small cards – but do not insist she takes any information in writing: it may not be safe for her.
  
• Do not give advice on what she should do: it is her decision.
  
• Support her in whatever decision she makes.
  
• Keep detailed records, separate from the main patient record. Always ensure that these records can only be seen by those directly involved in the patient’s care and that they are kept according to your Trust’s guidelines on confidentiality.

Depending on your role, and the policies and procedures of your institution, some of the preceding actions might be undertaken by or in association with other health care professionals within your practice or hospital. If you do need to refer the patient to another member of your team, you should ideally ask her permission before you do so as this demonstrates respect and trustworthiness and enables her to feel in control.

Following on from this, and particularly where abuse is ongoing, you should make sure that any communications or actions will not alert the alleged perpetrator, unless or until the survivor wishes to do so. Ask her how you can get in touch with her safely in future, should you need to. If you have to give her details to another agency, for example because of child protection issues, ensure that they also know how they can contact her safely.

Ideally, a risk assessment should be undertaken with anyone who discloses current domestic violence. One commonly used risk assessment checklist can be found in Appendix B. Risk assessments should ideally be carried out by someone who has been appropriately trained in their use. Remember that risk levels can change – sometimes quite rapidly – and that they are never foolproof.

If it appears that the patient is in immediate danger then it might be necessary to call the police and/or other emergency services. If a patient is frightened to return home, referral to a refuge service (either locally or out of the area in order to increase the patient’s safety) might be the best option.

If the danger seems less immediate, support staff working for specialist domestic abuse services can help the patient develop a safety plan (see next section).

When a patient appears to reject help (see Box 9.2), it is harder to deal with; but it is important to make it clear that help is available when she is ready for it and that she can come back to you at any time. It might be worth making a follow-up appointment to talk again, or talking to a specialist agency for your own support and to get some other ideas.

When risk levels seem high, referral to an MARAC might also be considered.