Domestic Violence Abuse Dr Steve Blades GP Lead
Domestic Violence & Abuse Dr Steve Blades GP Lead, Adult Safeguarding Working together to maximise the health and wellbeing of North Tyneside communities by making the best use of resources.
Warning Discussion of DVA may raise painful memories of personal experience or link to a current situation. During the session is not the time to discuss them. If you would like to discuss any issues please refer to the contact details or speak to the presenter after the session. Working together to maximise the health and wellbeing of North Tyneside communities by making the best use of resources.
Learning objectives • Domestic violence and abuse – a definition • Understanding the extent of DVA • How DVA might present • Opportunistic and routine screening • How to respond to DVA • As an individual presented with a case • As a practice, in terms of policy/procedure • Local and national resources Working together to maximise the health and wellbeing of North Tyneside communities by making the best use of resources.
Lessons from Domestic Homicide Reviews • Need for increased awareness and training for GPs and healthcare professionals • Victims not followed up • Victims not referred to appropriate agencies • Some reviews reported that healthcare professionals had not known what to do when a patient disclosed domestic violence Working together to maximise the health and wellbeing of North Tyneside communities by making the best use of resources.
Jane • 40 year old female who consulted her GP with depression. Reported domestic violence. Was in touch with Women’s Aid and had left partner • She had two children with whom she had contact, but they lived outside the North East • Prescribed antidepressants • No code added for domestic violence • Reports sent to and received from two MARAC meetings but no code added to records Working together to maximise the health and wellbeing of North Tyneside communities by making the best use of resources.
Jane continued • Multiple consultations over the next year for depression and sick notes issued. Only one further mention of domestic violence and no evidence of GPs asking about this. • Consulted with a back injury having fallen on a “sharp object”. Potential significance of this not considered. Subsequent review identified she had probably been stabbed by her partner. • 13 months after first consultation stabbed to death by her partner Working together to maximise the health and wellbeing of North Tyneside communities by making the best use of resources.
Jane – learning points • • Supportive GPs – accessible but continuity issues Coding Follow up Curiosity Focus on medical model – prescribing, sick notes Reassurance – left partner, other agencies involved, MARAC Children not visible Working together to maximise the health and wellbeing of North Tyneside communities by making the best use of resources.
What is Domestic Violence? • 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 Working together to maximise the health and wellbeing of North Tyneside communities by making the best use of resources.
Controlling or coercive behaviour • Controlling behaviour – is a range of acts designed to make a person subordinate and/or dependent by isolating them from sources of support, exploiting their resources and capacities for personal gain, depriving them of the means needed for independence, resistance and escape and regulating their everyday behaviour • Coercive behaviour – is an act or a pattern of acts of assaults, threats, humiliation and intimidation or other abuse that is used to harm, punish or frighten their victim Working together to maximise the health and wellbeing of North Tyneside communities by making the best use of resources.
Mary • • • Mary is a 42 year old female patient who attends complaining of feeling depressed In the course of your assessment she reports that her husband frequently belittles her, telling her she’s ‘useless’ He doesn’t let her go out with her friends, and he doesn’t allow her only sister to visit He controls all the finances and she has no money of her own She says she loves him, but she’s also frightened of him although he has never been physically violent Working together to maximise the health and wellbeing of North Tyneside communities by making the best use of resources.
The scale of the problem • At least 1 in 4 women experience domestic violence in their lifetime and 1 in 10 women experience it annually. Less than half of all incidents are reported to the police, but they still receive one domestic violence call every minute in the UK • On average, two women a week are killed by a violent partner or ex-partner. This constitutes nearly 40% of all female homicide victims • On a typical day, 3615 women and 3, 580 children are resident in refuge accommodation in England. 50% of these children are aged under 5 years • At least 750, 000 children a year witness domestic violence • Nearly three quarters of children subject to child protection plans live in households where domestic violence occurs Working together to maximise the health and wellbeing of North Tyneside communities by making the best use of resources.
Who are the victims? • Office for National Statistics estimates 1. 4 million women and 700, 000 men suffered domestic abuse in the past year • Women are considerably more likely to experience repeated and severe forms of violence, and sexual abuse, and are particularly at risk during pregnancy • Women may experience domestic violence regardless of ethnicity, religion, class, age, sexuality, disability or lifestyle • Women in poorest households more than 3 times more likely to be victims than those in higher income families • Domestic violence can also occur in a range of relationships including heterosexual, gay, lesbian, bisexual and transgender relationships, and also within extended families Working together to maximise the health and wellbeing of North Tyneside communities by making the best use of resources.
Impact on victims • Mental health problems e. g. depression, anxiety, Post Traumatic Stress Disorder • Drug and alcohol problems • Chronic health problems e. g. chronic pain, gynaecological and GI disorders • Obesity • Trauma • Social isolation • Loss of income or work Working together to maximise the health and wellbeing of North Tyneside communities by making the best use of resources.
How to ask • Be alert to the possibility of DVA • Only ask when potential victims are alone and in a private place • Don’t ask in front of children • Use professional interpreters • Start with general questions “How are things at home” • Move on to more specific and direct questions Working together to maximise the health and wellbeing of North Tyneside communities by making the best use of resources.
How to ask - HARK • • HARK is a series of questions that can remind you of the various types of abuse to ask about – standing for: Does your partner Humiliate you Are you ever Afraid of your partner? Has your partner Raped you? Has your partner ever Kicked (or physically harmed you? ) Working together to maximise the health and wellbeing of North Tyneside communities by making the best use of resources.
How to respond • • • Be sensitive, respectful and listen carefully Seek to empower not take over. Ask them what they want you to do. Remain non-judgemental. Validate the victim’s experience. Tell them you are glad they told you. Give key messages. You are not alone. You do not deserve to be treated like this. There is help available Follow up in subsequent consultations Working together to maximise the health and wellbeing of North Tyneside communities by making the best use of resources.
Coding • 13 VF – At risk of violence in the home • 14 XC – Alleged perpetrator of domestic violence • 14 X 3 – History of domestic violence (perpetrator) • 13 Hm – Subject of MARAC • Children’s records • Visibility of records • Perpetrator records Working together to maximise the health and wellbeing of North Tyneside communities by making the best use of resources.
Impact on children • • • Anxiety or depression, self-harming, feelings of guilt Difficulty sleeping, nightmares or flashbacks Physical symptoms such as abdominal pain Enuresis Temper tantrums, aggression Social withdrawal Older children may start to use alcohol or drugs Negative impact on education A high proportion of children living with domestic violence are themselves being abused - either physically or sexually - by the same perpetrator. Estimates vary from 30% to 66% depending upon the study. Working together to maximise the health and wellbeing of North Tyneside communities by making the best use of resources.
Fiona • Shared details of several incidents of DVA with her GPs who were very supportive • Lots of issues – physical, psychological and social • Signposted to local services but did not attend • On one occasion attended with significant injuries following a sexual assault but did not want to go to the police Working together to maximise the health and wellbeing of North Tyneside communities by making the best use of resources.
Fiona – learning points • • Coding Risk assessment Signposted to services but not followed up Safety planning Information sharing MARAC Adult safeguarding Working together to maximise the health and wellbeing of North Tyneside communities by making the best use of resources.
Adult Safeguarding • Applies to an adult who • has needs for care and support (whether or not the local authority is meeting any of these needs) and • is experiencing, or at risk of, abuse or neglect; and • as a result of those care and support needs is unable to protect themselves against the abuse or neglect or the risk of it Working together to maximise the health and wellbeing of North Tyneside communities by making the best use of resources.
Risk Assessment (1) • http: //www. caada. org. uk/marac/RIC_with_guida nce. pdf • Injury • Fear • Isolation • Depression / suicidal • Separated or tried to separate • Conflict over child care • Financial problems • Pregnancy Working together to maximise the health and wellbeing of North Tyneside communities by making the best use of resources.
Risk Assessment (2) • • Harassment Frequency and severity of abuse Use of weapons Threats to kill Sexual assault Control Others afraid of Perpetrator history – violence, convictions, drug and alcohol etc. Working together to maximise the health and wellbeing of North Tyneside communities by making the best use of resources.
Safety Planning within a Relationship • • • Have access to phone and important numbers Tell neighbour to call police if they hear suspicious noise Move out of kitchen or bathroom during arguments Identify escape routes and where to go if leaving the house Leave money, documents etc. outside the house Working together to maximise the health and wellbeing of North Tyneside communities by making the best use of resources.
Safety Planning after Relationship • Change locks • Advise people that partner is no longer there and ask them to call the police if they have concerns • Advise school etc. who can pick up children • Change routines e. g. shops, pubs • Change phone number Working together to maximise the health and wellbeing of North Tyneside communities by making the best use of resources.
Northumbria Police and Legal • Independent and confidential advice – 0800 066 5555 • Flagging of police records following incidents so that they recognise repeat cases • Options include – prosecution for assaults, non molestation orders, occupation orders and restraining orders, Domestic Violence Protection Notices and Orders • Can apply for victimless prosecution if victim not willing to give evidence • www. northumbria. police. uk Working together to maximise the health and wellbeing of North Tyneside communities by making the best use of resources.
Domestic Violence Protection Notice and Order • DVPN issued by police and lasts 48 hours • Imposes restrictions e. g. stopping perpetrator entering house • Victim does not have to agree • Application to magistrates for DVPO which lasts 14 -28 days Working together to maximise the health and wellbeing of North Tyneside communities by making the best use of resources.
Clare’s Law • Domestic Abuse Disclosure Scheme • Application to the police can be made by person in a relationship or someone close to them when there is a concern about risk of abusive behaviour • Police will review records and consider disclosure of information and risk management Working together to maximise the health and wellbeing of North Tyneside communities by making the best use of resources.
Legal Aid • • The Legal Aid Sentencing and Punishment of Offenders Act 2012 (“LASPO”) governs the provision of legal aid from 1 April 2013. Under the new scheme victims of domestic violence will continue to be eligible for legal aid for family law cases but, For a victim to access this type of legal aid they will need to provide a prescribed form of evidence of domestic violence. One piece of evidence is a letter from a doctor confirming that they have examined the applicant within the 24 months preceding the application for legal aid and that the applicant had injuries or a condition consistent with someone who is a victim of domestic violence. It will not be necessary for the health professional to certify or make a judgement as to whether the person has in fact suffered domestic violence, or to identify who may have inflicted the injury. This evidence is not intended to be ‘proof’ of domestic violence - it is to be used simply for a legal aid funding decision A charge for the letter is discretionary Working together to maximise the health and wellbeing of North Tyneside communities by making the best use of resources.
Local Resources – Newcastle • Women’s Aid 0800 923 2622 or 0191 2652148 www. newcastlewomensaid. org. uk • Panah 0191 284 6998 • Victim Support 0191 2813791 includes access to IDVA service Working together to maximise the health and wellbeing of North Tyneside communities by making the best use of resources.
Local Resources – Northumberland • Victim Support 0191 2960148 • Cease 24 Domestic Abuse Project 01665 606881 • WHAC (Women’s Health Advice Centre) 01670 853977 • Sixtyeightythirty (Hexham) 01434 608030 • www. enough. me. uk Working together to maximise the health and wellbeing of North Tyneside communities by making the best use of resources.
Local Resources – North Tyneside • Victim Support 0191 2960148 • Acorns Domestic Abuse Outreach Service and access to IDVA service 0191 2572731 • Harbour Refuge and Outreach Service 0191 2513305 • Acorns Children’s Services 0191 2006302 Working together to maximise the health and wellbeing of North Tyneside communities by making the best use of resources.
Local Resources - Gateshead Victim Support 0191 4779099 Safer Families 0191 4333509 Domestic Abuse Support Service 0191 4332622 Victim Support 0191 4778395 Gateshead Women’s Refuge 0191 4779309 Working together to maximise the health and wellbeing of North Tyneside communities by making the best use of resources.
National Resources • Broken Rainbow (LGBT advice and support) 0300 999 5428 • 24 hour National DV helpline 0808 2000 247 • Men’s advice line 0808 801 0327 • Respect phone line to support perpetrators 0808 802 4040 Working together to maximise the health and wellbeing of North Tyneside communities by making the best use of resources.
MARAC • • The Multi-Agency Risk Assessment Conference (MARAC) is part of a coordinated community response to domestic abuse, which aims to: Share information to increase the safety, health and well-being of victims/survivors - adults and their children; Determine whether the alleged perpetrator poses a significant risk to any particular individual or to the general community; Construct jointly and implement a risk management plan that provides professional support to all those at risk and that reduces the risk of harm. Working together to maximise the health and wellbeing of North Tyneside communities by making the best use of resources.
MARAC continued • Little information is known (and therefore little can be shared with the practice) at the time of the MARAC request – hence the need for a conference to share information • The threshold for requesting a MARAC is based on; • Professional judgement • ‘Visible high risk ‘ – lots of ticks on a risk assessment tool • Potential escalation i. e. 3 or more police callouts in a 12 month period • Seeking consent to share information may put victims a risk – sharing without consent would invariably be supported under these circumstances • MARAC feedback can alert agencies to individuals who may pose a risk to staff Working together to maximise the health and wellbeing of North Tyneside communities by making the best use of resources.
MARAC - Issues arising • • Recommended computer coding Coding child, victim and perpetrator records Storing of reports Sharing information with the team e. g. discussion at PHCT meetings • Taking opportunities to review the situation • Share information if the situation changes Working together to maximise the health and wellbeing of North Tyneside communities by making the best use of resources.
Potential Perpetrators • Coding • Presenting issues – drug or alcohol problems, stress, anxiety, depression, anger management • Ask if safe to do so • Structured perpetrator programmes • DVPP Perpetrator Project (Barnado’s) 2404800 • Don’t refer for relationship counselling Working together to maximise the health and wellbeing of North Tyneside communities by making the best use of resources.
Practice Response (based on CAADA/RCGP Guidance) • • Practice policies – domestic violence, adult and child safeguarding, information sharing Leads for adult and child safeguarding Asking about DVA Signposting to resources Record keeping and coding Referring and responding to MARAC Training Risk assessment Working together to maximise the health and wellbeing of North Tyneside communities by making the best use of resources.
Advice for Primary Care • • Safeguarding leads in practice CCG Safeguarding leads – Riaan Swanepoel, David Jones and Steve Blades riaanswanepoel@nhs. net david. jones 3@nhs. net stephen. blades@nhs. net Safeguarding units Police (dial 101) Protecting Vulnerable People’s Unit Defence Unions Working together to maximise the health and wellbeing of North Tyneside communities by making the best use of resources.
Training for Primary Care • RCGP e-learning http: //www. elearning. rcgp. org. uk • Action on Violence and Abuse (AVA) • http: //www. avaproject. org. uk/our-resources/goodpractice-guidance--toolkits/complicated- matters-stellaproject-toolkit-and-e-learning-(2013). aspx Working together to maximise the health and wellbeing of North Tyneside communities by making the best use of resources.
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