1. Domestic Abuse (DA) & Domestic Homicide Review (DHR) Basic Awareness
Carole Collins RGN BSc(Hons).
Lead Nurse DA & DHR
Across Birmingham CCG’s

2. Why is Domestic Abuse Relevant to GP Practices?
Cost to health services in Birmingham £34 million per annum (2009).
Improved health for the patient & better parenting of any children.
Approximately 1 in 4 women in Birmingham (25,000) will be subject to DA at some point.
30% of DA will start in pregnancy.
Guidance from RCGP, NICE, DOH,HO.

3. What is DA?
“Any incident or pattern of incidents of controlling, coercive or 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. This can encompass but is not limited to the following types of abuse: psychological, physical, sexual, financial, emotional.
Controlling behaviour is: to make a person subordinate and/or dependent by isolating them from sources of support, exploiting their resources for personal gain, depriving them of independence, and regulating their everyday behaviour.
Coercive behaviour is: an act or a pattern of acts of assault, threats, humiliation and intimidation or other abuse that is used to harm, punish, or frighten their victim.”

4. Signs to be aware of. RCGP Domestic violence: the general practitioners role (1998 & 2012)
If the patient presents with or reveals any of the following:
Past abuse.
Unexplained injuries or injuries in various stages of healing. Injury inconsistent with explanation, delay in presentation. Review of records reveal patient has numerous “accidents”.
Patient presents frequently with physical symptoms for which no cause can be found.

5. Patient is in 1st pregnancy, with injuries to breast or abdomen.
Patient has a history of miscarriage.
History of drug dependency, alcohol abuse in patient /partner or seeking treatment for drug/alcohol.
History of psychiatric illness or attempted suicide.
History of depression.
History of behaviour problems.
Partner attends with patient and insists on answering questions, remaining with her etc.

6. Is your professional curiosity aroused?
Do you have enough information to suspect DV?
 Would you ask the question – and if so how?
 If you wouldn’t – why not?
How would you refer on to agencies?
What if the patient refuses to be referred?
Safety planning.    

7. Ask the question (HARKS)
Ask the question (HARKS). GP online (March 2012) Sohal H, Eldridge S, Feder G. BioMed Central, Family Practice 2007; 8(49).
Humiliated?
Afraid?
Raped ?
Kicked?
Safe?
Do not
Ask - unless the woman is alone.
Encourage women to leave, unless they have a clear safety plan – the most dangerous time for them is when they tell their abuser they are leaving, or they leave.

8. What to do once the proverbial can has been opened?
Safety – Police, Safeguarding Children, Birmingham & Solihull Women’s Aid & Refuge line – RIC.
Birmingham Victims Directory.
Document everything for yourself and the victim.
Flag records – have a system in place that is discrete.
Accept that some victims will not leave.
Encourage them to make a safety plan & record everything.

9. Scenarios – To ask or not to ask?
A woman brings her small child for the third time this week saying he is unwell – he is clearly fine.
She is unkempt and concerned that she is a bad mother.

10. A woman attends with her husband she needs a routine smear and he wants to stay with her.
You suggest he waits outside as the nurse will act as a chaperone – he still refuses to leave.

11. A woman says since she has been pregnant she is having trouble sleeping. Her husband has a stressful job and this is causing problems between them. He frequently drinks to unwind and uses cannabis recreationally.

12. A woman says that she slipped on the kitchen floor and banged her head on the table as she fell. It happened a week ago but her neck has become quite sore.
When you examine her you notice that she has fading bruising to her shoulder which she hasn’t mentioned.

13. A young woman comes to see you accompanied by a female relative, she complains of feeling generally unwell with generalised aches and pains this is her third visit with these complaints – she is always accompanied by a female family member.
She speaks very little English.

14. Domestic Homicide Review

15. Domestic Homicide Review (DHR)
Domestic Violence, Crime & Victims Act (2004).
DHR came into force on 13th April 2011.
Looks for good practice & lessons to be learned.
Applies to ALL agencies.
My role is to act as mediator between GP practices and Birmingham Community Safety Partnership (BCSP).
Complete the necessary documentation etc.
Time frame – 6 months.

16. Potential DHR Takes Place – What next?
WM Police – BCSP – Home Office.
Decision is taken if DHR required.
BCSP inform agencies.
I inform GPs.
Panel meets to agree terms of reference (TOR).
I take TOR to GP & complete Chronolator.
Follow up interviews with practices.
Completed report sent to GP & Authorisation Officers for the relevant CCG.
Report submitted to BCSP

17. Common Themes from Birmingham DHR’s.
DA training for Practice Staff.
DA policy for practices.
DA information available for patients.
My observations:
A lack of information sharing.
Everyone thinking that someone else will ask the question.
Lack of information on where to refer victims on to.

18. Identification and Referral to Improve Safety (IRIS).
Programme already running in Bristol & London.
Aimed at increasing the detection rate & management of DV in practices by in house training for all staff.
Involves a dedicated health independent advocate educator working with practices.
Provides direct link to DV agencies; an explicit referral pathway to a named advocate in the domestic violence service.
It also includes a pop-up reminder in automated patient records which appears when particular symptoms associated with domestic violence are entered.

19. Benefits of IRIS (NICE 2013).
Early findings from the randomised controlled trials suggest positive outcomes including evidence that the interventions are cost effective with a cost-effectiveness ratio of £2450.
Improves the safety, quality of life and wellbeing for patients and their children.
- Reduces the recurrence of domestic violence and abuse.
- Provides a preventative solution so that patients do not need to reach critical risk levels in order to get help.
- Provides access to advocacy… with survivors showing improvement in mental health and quality of life.
- Works flexibly and responsively to patient need.
- Offers patients access to specialist services that they identify as safe.

20. Any Questions?