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  • 1. Responding to domestic abuse: a handbook for health professionals
  • 2. Responding to domestic abuse: a handbook for health professionals
  • 3. DH INFORMATION READER BOX Policy Estates HR / Workforce Performance Management IM & T Planning Finance Clinical Partnership Working Document Purpose Best Practice Guidance ROCR Ref: Gateway Ref: 5802 Title Responding to domestic abuse: a handbook for health professionals Author Department of Health Publication Date December 2005 Target Audience PCT CEs, NHS Trust CEs, SHA CEs, Care Trust CEs, Medical Directors, Directors of PH, Directors of Nursing, PCT PEC Chairs, Allied Health Professionals, GPs, Emergency Care Leads Circulation List Foundation Trust CEs, Directors of HR, Allied Health Professionals, Communications Leads, Voluntary Organisations Description Responding to domestic abuse: a handbook for health professionals supersedes Domestic Violence: A Resource Manual for Health Care Professionals (March 2000). The revised handbook gives practical guidance to healthcare professionals on working with service users who have experienced or are experiencing domestic abuse. The Domestic Abuse and Pregnancy Advisory Group, which had representation from the Department of Health, and included the relevant Royal Colleges and domestic violence voluntary organisations, provided advice to Health Ministers on the Children’s NSF Recommendation on the need to provide a supportive and enabling environment within antenatal care for women to disclose domestic violence Cross Ref N/A Superseded Docs Domestic Violence: A Resource Manual for Health Care Professionals Action Required N/A Timing N/A Contact Details Patricia Parris Department of Health Room 212 Wellington House 133–155 Waterloo Road London SE1 8UG For Recipient’s Use
  • 4. Contents Foreword from Caroline Flint, MP Parliamentary Under Secretary of State for Public Health v 1 Using the handbook 1 2 Domestic abuse is a health issue 9 3 Guidance for health professionals 35 4 Guidance for policy-makers and managers 83 Annexes 107 Annex A – Membership of the Inter-Ministerial Group on Domestic Violence 107 Annex B – Action plan drawn up in response to the recommendations of the Domestic Abuse and Pregnancy Advisory Group 108 Annex C – Women with particular needs 112 Annex D – Sample safety plan 120 Annex E – Sample risk assessment 123 Useful contacts 127 Local information 144
  • 5. Contents of CD-Rom 1. Electronic text of the handbook 2. Sample domestic violence strategy, policy and practice guidelines 3. Guidance for Partnerships and Primary Care Trusts (PCTs)
  • 6. Foreword Even though much domestic > prevent future cases of abuse occurs within the privacy domestic abuse. of personal relationships, it’s far Our Inter-Ministerial Group on from being a private issue. Domestic Violence implements Occurring in all parts of society, national strategy and is it accounts for a quarter of all supported by legislation (such violent crime and costs the as the Domestic Violence, taxpayer billions of pounds Crime and Victims Act 2004) every year – £3.1 billion in that strikes at the heart of England and Wales in 2004. the problem. But the greatest cost is to the women and children from all But strategy and legislation social backgrounds who deal alone don’t guarantee results. with its effects on their lives on Success relies on a multi-agency a day-to-day basis, even long approach, so that everybody after they have escaped abuse. plays their part in helping women and children create The extent of the problem is safer lives for themselves. The shocking and intolerable. The NHS has an important role – not Government has responded by only because health making it a priority to: professionals deal with injuries > bring to justice perpetrators caused by domestic violence in of domestic abuse; their daily work, but also because they are often a > support women and children woman’s first or only contact who experience abuse; and
  • 7. Responding to domestic abuse vi with a professional who could > Recognising that many cases provide a lifeline to safety. of domestic abuse start during pregnancy, DH set up The health sector is already the Domestic Abuse and making a significant Pregnancy Advisory Group in contribution: 2005. Its recommendations > The Crime and Disorder Act on how health services could 1998 gave Primary Care meet the needs of pregnant Trusts a statutory duty to women who are work within Crime and experiencing abuse have Disorder Reduction informed this handbook and Partnerships to reduce local will help shape future policy. crime – including domestic > Domestic abuse has been an violence. important consideration in > In collaboration with the health consultations, National Institute for Mental inquiries (Why mothers die, Health in England, the 2000–02 (Confidential Department of Health (DH) Enquiry into Maternal and has established a substantial Child Health 2004)) and programme of work for White Papers (the public 2004/05 and beyond to health White Paper 2004 and alleviate the health and the new Your health, your mental health effects of care, your say, 2005). domestic violence on women and children.
  • 8. A handbook for health professionals vii The Government has an An independent evaluation was evidence base for the work it is also undertaken on a pilot taking forward to respond to project implemented by the domestic abuse. The Crime University of the West of Reduction Programme’s England and North Bristol NHS Violence Against Women Trust, which aimed to equip Initiative was an evidence-led community midwives to enquire programme that aimed to find effectively about domestic abuse out which approaches and during pregnancy. It was found practices were effective in that introducing enquiry about supporting survivors of domestic abuse significantly domestic and sexual abuse opened up opportunities for and in reducing incidents of women to talk about their abuse. Five multi-agency, experiences of abuse during victim-focused projects were pregnancy and led to an based within health contexts increase in the numbers of such as primary care and A&E. women disclosing old and All aimed to encourage and new abuse. support disclosure of domestic Responding to domestic abuse: abuse and facilitate entry into a handbook for professionals is specialist domestic violence a practical tool that answers the support services, and every question ‘What am I supposed project underwent independent to do if one of my patients tells evaluations. me they’re experiencing domestic abuse?’ It takes on
  • 9. Responding to domestic abuse viii board feedback from users of information-sharing amongst Domestic violence: a resource domestic violence agencies. manual for health care As such, it is an important professionals, which was stepping stone towards an published in 2000, and has effective, multi-agency been designed to be easy to response to domestic abuse use, functional and accessible. that will create safer futures It builds on good practice that is and better health for thousands already in place across the of women and children – and country and will enable health for society as a whole. professionals to respond consistently to domestic abuse. The training manual that accompanies this publication can be found on DH’s website. The CD-Rom contains an electronic version of the manual Caroline Flint, MP and key papers with references. Parliamentary Under Secretary The handbook takes a national of State for Public Health vision and puts it into practice. Member of the Inter-Ministerial As well as helping frontline staff Group on Domestic Violence recognise and give appropriate support to women and children who are being abused, it will promote networking and
  • 10. 1 Using the handbook Section 1 Using the handbook In this section: 1.1 Contents 1.2 Target audience 1.3 Responding to domestic abuse: a handbook for health professionals 1.4 How to use the handbook
  • 11. 1.1 Contents A useful reference tool As well as covering work with women, the handbook covers This handbook gives practical the basic information that guidance to healthcare healthcare professionals will professionals on working with need to know to respond patients who may have effectively to children who have experienced or are experiencing experienced or are experiencing domestic abuse. It provides: domestic abuse. > all readers with an insight Healthcare’s contribution to into domestic abuse and its national initiatives effects on individuals, the health service and society; Domestic abuse is a priority across government. Dealing > healthcare professionals with with its effects and trying to practical prompts that they alleviate the problem require a will be able to use in their multi-agency approach – no day-to-day work with one organisation has all the women and children; and answers. But by working > managers and policy-makers together, central and local with advice on creating government, criminal justice strategies for improving the agencies, voluntary sector care given to those who have organisations and the NHS have experienced or are a greater chance of meeting experiencing domestic abuse. women and children’s needs.
  • 12. Responding to domestic abuse 2 Since April 2004, Primary Care experiencing abuse and Trusts have had a statutory duty providing information (once to work with other local staff have received appropriate agencies to reduce crime (in training). The plan is relevant to Crime and Disorder Reduction health services in general and it Partnerships under the Crime has informed many of the and Disorder Act 1998). practical prompts in this Domestic violence forms a handbook. quarter of all violent crime, so A response to genuine need by following the guidance in this handbook, staff are helping The handbook gives very clear the NHS to fulfil its obligations. answers to questions that many healthcare professionals have This handbook is also a been asking: ‘What’s my role?’, response to the Domestic Abuse ‘What am I supposed to do?’ and Pregnancy Advisory Group or ‘Should I tell a woman whose recommendations, August partner has hit her to leave?’ 2005, which we have Thankfully, although domestic incorporated into an action plan abuse is a complicated issue, our (see Annex B). The action plan response doesn’t have to be. sets out how national maternity The guidance in this handbook services can create a supportive sets out clearly what is expected environment for women who of us all. may have experienced domestic abuse – most importantly by routinely asking if a woman is
  • 13. 1.2 Target audience Anybody who works for the For guidance to have maximum NHS – from administrative staff impact, the approaches outlined to clinical staff. But it will be should be adopted at both a especially useful for those who: strategic and a practice-based local level. Trusts should have a > work face-to-face with clearly defined and accessible patients, such as GPs, domestic abuse strategy that is midwives and health visitors; supported by training to ensure > are likely to be the first that health professionals feel point of contact for a woman confident in applying the who may be experiencing approaches set out in this domestic abuse; handbook. > are able to develop a relationship with a woman over time and increase the chance of her disclosing abuse and seeking advice; or > are involved in developing domestic abuse strategy or policy.
  • 14. 1.3 Responding to domestic abuse: a handbook for health professionals This revised edition updates It builds on good practice that Domestic violence: a resource is already in place across the manual for health care country and will enable health professionals, which was professionals to respond published in 2000. It has been consistently to domestic abuse. designed to be easy to use, functional and accessible. Why is the main focus on women’s needs and not men’s? It’s true that men also experience domestic abuse. But about 90% of domestic violence cases are committed by men against women.1 Women are also more likely to experience repeat incidents of abuse, be frightened or be injured after an attack, and they are the lead carers at home, so abuse against them affects their children. Consequently, this handbook focuses on women’s needs. The Home Office is currently examining the needs of men who experience domestic violence. In the meantime, much of the guidance in this handbook can be applied to men who experience domestic abuse, who deserve the same respect and support when they turn to us for help.
  • 15. A handbook for health professionals 5 Similarly, although much of this handbook refers to domestic abuse within heterosexual relationships, it’s important to acknowledge that lesbian and gay relationships are also affected by domestic abuse. Although abuse in same-sex relationships sometimes brings up different issues from those occurring in heterosexual relationships, it merits the same level of concern and the same professional, supportive response from the health service. > The health service is in a > Virtually every woman in unique position to help Britain uses the healthcare people who suffer domestic system at some point. If we abuse get the support they create an environment in need. Individuals and Trusts which women are more likely across the country are to feel safe enough to reveal already doing a lot to help. that they are being abused This handbook formalises our and can therefore access approach so that our work information, we can make a is consistent. real difference for thousands of women and their families.
  • 16. Responding to domestic abuse 6 > If health professionals all follow the same guidance, every woman across the country – from any background – can expect the same standard of response if they turn to us for help. > It makes the job of health professionals easier. If it’s our responsibility to help women who may be experiencing domestic abuse, we need to know the best ways to respond effectively. > The handbook also helps us play our part in bringing perpetrators to justice by giving guidance on the best way to keep records that might be used in future court cases.
  • 17. 1.4 How to use the handbook > The handbook is a flexible > It’s worth remembering that resource. You don’t need to the guidance in the read it from beginning to handbook doesn’t work in end, but can ‘dip into’ it at isolation – it’s part of a any time. national approach that is being implemented locally > But you should familiarise through partnership with yourself with the contents of other agencies. all sections, so that you know the nature and extent of > The CD-Rom that domestic abuse and how the accompanies this publication NHS is contributing to contains electronic text, key supporting women who papers and references. experience it. > If you can’t find the > It has been designed so that information you need or you you can find the information want more information that is most relevant to your about what is being done situation quickly and easily. locally, you can contact the professional leading domestic abuse initiatives in your area. Some Trusts and Strategic Health Authorities have a lead health professional and information on domestic abuse fora.
  • 18. Responding to domestic abuse 8 What’s inside? Section 2 Annexes Domestic abuse is a health issue More details on issues outlined in the guidance. An overview of domestic abuse, its extent and effects, and why Useful contacts it’s a health issue. Where to go to next for more information on domestic abuse Section 3 issues. A list of agencies Guidance for health engaged in multi-agency professionals activities to respond to Practical advice for day-to-day domestic abuse. work dealing with women and Reference children who have experienced 1 BMA, 1998, Domestic violence: a healthcare issue domestic abuse. Section 4 Guidance for policy-makers and managers Advice on creating local policies and strategies that help create safer lives for people experiencing domestic abuse.
  • 19. Section 2 2 Domestic abuse is a health issue Domestic abuse is a health issue In this section: 2.1 Domestic abuse in numbers 2.2 What is domestic abuse? 2.3 Who does domestic abuse affect? 2.4 The effects of domestic abuse 2.5 Understanding abused women 2.6 The cost of domestic violence in 2004 2.7 Domestic abuse is a health issue 2.8 What’s being done to help?
  • 20. 2.1 Domestic abuse in numbers 2 The number of women 70% The percentage of killed every week by a children living in UK current or former refuges who had been partner.1 abused by their father.6 20% The percentage of 75% The percentage of cases women in England and of domestic violence Wales who say they that result in physical have been physically injury or mental health assaulted by a partner consequences to at some point.2 women.7 30% The proportion of cases 90% The proportion of of domestic violence domestic violence in that start during which children are in pregnancy.3 the same or next room.8 52% The percentage of child £1.2bn The cost to the NHS of protection cases dealing with physical involving domestic injuries alone caused by violence.4 domestic violence.9 54% The percentage of UK These are reported - rapes committed by a cases; they will, - woman’s current or therefore, be - former partner.5 underestimates - of the true figures. -
  • 21. 2.2 What is domestic abuse? Many people think of domestic > The term ‘domestic violence’ abuse as a physical assault by a obviously covers a wide man on a woman in their home. range of abuse – physical and But women’s experience of otherwise. It also covers domestic violence extends issues that mainly concern much further than that, and it women from minority ethnic can be difficult to come up with backgrounds, such as forced a simple description. The Inter- marriage, female genital Ministerial Group on Domestic mutilation and so-called Violence (see Annex A) has ‘honour violence’.10 adopted the following Home > Throughout this handbook, Office definition: we use the term ‘domestic ‘Any incident of threatening - abuse’ instead of ‘domestic behaviour, violence or abuse - violence’ wherever possible, (psychological, physical, - because we are concerned sexual, financial or emotional) - that the latter might be between adults who are or - interpreted as physical abuse have been intimate partners - only. We have, however, or family members, regardless - made use of information and of gender or sexuality.’ - statistics on ‘domestic (Home Office) - violence’ and so have kept to that terminology in those instances.
  • 22. A handbook for health professionals 11 Examples of domestic abuse Physical Shaking, smacking, punching, kicking, presence of finger or bite marks, starving, tying up, stabbing, suffocation, throwing things, using objects as weapons, female genital mutilation, ‘honour violence’. Physical effects are often in areas of the body that are covered and hidden (ie breasts and abdomen). Sexual Forced sex, forced prostitution, ignoring religious prohibitions about sex, refusal to practise safe sex, sexual insults, sexually transmitted diseases, preventing breastfeeding. Psychological Intimidation, insulting, isolating a woman from friends and family, criticising, denying the abuse, treating her as an inferior, threatening to harm children or take them away, forced marriage. Financial Not letting a woman work, undermining efforts to find work or study, refusing to give money, asking for an explanation of how every penny is spent, making her beg for money, gambling, not paying bills. Emotional Swearing, undermining confidence, making racist remarks, making a woman feel unattractive, calling her stupid or useless, eroding her independence.
  • 23. Responding to domestic abuse 12 > Most forms of domestic The police in the UK receive a - abuse are crimes that should call to stop domestic violence - never be tolerated in any every minute.11- form or context. Under the Domestic Violence, Crime > Domestic abuse doesn’t and Victims Act 2004, always occur in the home. charges can now be brought Some women who against a perpetrator without experience abuse have never an abused person’s lived with their abuser. permission. > A woman doesn’t have to be > Responsibility for domestic in a relationship with a man abuse always lies with the to experience domestic perpetrator – never with abuse. Some men continue the person who has to assault women after a been abused. relationship has ended. Women are at greatest risk of > We will probably never know being murdered at the point its true extent, because many of separation or after having cases go unreported. It is left a violent partner. difficult – and often dangerous – for women to > Any family member can be a tell somebody that they are perpetrator – but in the vast being abused by somebody majority of cases the abuser close to them. But we do will be male. know it’s common.
  • 24. A handbook for health professionals 13 > Domestic abuse might be a – those who misuse drugs single event, but it’s usually or alcohol; an ongoing behaviour – travellers; pattern that gets worse and more frequent over time. – sex workers such as prostitutes; 35% of households that - experience a first assault will - – asylum seekers; experience a second within - – those with mental health five weeks.12 - problems; > Any woman experiencing – vulnerable adults; domestic abuse can find it difficult to access help. – homeless women; and The problem is made more – the elderly. difficult for women who experience discrimination. Women who might come across stereotyping and prejudice include: – black and Asian women; – older or younger women; – lesbian women; – those with a disability;
  • 25. 2.3 Who does domestic abuse affect? Domestic abuse occurs across Women are at risk when they the whole of society, leave their partner regardless of: Contrary to belief, deciding to > race, ethnicity and religion; leave an abusive partner doesn’t mean a woman is safe. It’s at > age; this point that she’s most at risk > class and income; or of serious injury or being murdered. > where people live. In 2003/04, nearly 40% of all - There may be an increased risk female homicide victims were - for some particularly vulnerable killed by their current or - groups, such as: ex-partner compared with - > women who are transient; about 5% of male homicide - victims.13 - > women with low socio- economic status; and A woman and her unborn child are at increased risk > women with mental health during pregnancy problems. Domestic abuse is more likely We also know that there are to begin or escalate during times when the risk of domestic pregnancy. abuse increases.
  • 26. A handbook for health professionals 15 More than 30% of cases of - Over three-quarters of - domestic violence start during - children-ordered by the courts - pregnancy.14 - to have contact with a violent - parent were abused further - More than 14% of maternal - as a result of contact being - deaths occur in women who - set up.19 - have told their health - professional they are in an - About 750,000 children - abusive relationship.15 - witness domestic violence - every year.20 - 40%–60% of women - experiencing domestic violence- Nearly three-quarters of - are abused while pregnant.16 - children on the ‘at risk’ register- live in households where - 15% report violence during - domestic violence occurs.21 - their pregnancy.17 - Domestic abuse is also a child Children are also at risk protection issue. If a woman is In over half of known - being abused by a current or domestic violence cases, - former partner and there are children were also directly - children in the home, they are abused.18 - likely to have experienced abuse by the same perpetrator. A study of 111 NSPCC cases of child abuse found that domestic violence was present in 62% of cases.22
  • 27. Responding to domestic abuse 16 The risks go further than Under the Adoption and - physical injury. Even when a Children Act 2002, living - child is not directly abused with or witnessing domestic - (physically or sexually), there is violence is identified as a - a risk they will be harmed trying source of ‘significant harm’ - to help their mother. They will for children. So if children are - almost certainly suffer short- or exposed to domestic abuse, - long-term psychological trauma health professionals should - from having witnessed abuse. follow normal child protection - procedures. In such cases, it is - most effective to provide - support and protection to the - abused mother, so that she is - able to protect her children. - Holding her responsible for - failing to protect a child should - not be the approach. It isn’t - helpful to hold her responsible - for failing to protect her child, - if she herself is being abused. -
  • 28. 2.4 The effects of domestic abuse Examples of the effects on women Physical effects Psychological effects Bruising Fear Recurrent sexually Increasing likelihood of misusing transmitted infections drugs, alcohol or prescribed Broken bones anti-depressants Burns or stab wounds Depression/poor mental health Death Wanting to commit or actually committing suicide Gynaecological problems Sleep disturbances Tiredness Post-traumatic stress disorder General poor health Anger Poor nutrition Guilt Chronic pain Loss of self-confidence Miscarriage Feelings of dependency Maternal death Loss of hope Premature birth Feelings of isolation Babies with low birthweight/ stillbirth/injury/death Low self-worth Self-harming behaviour Panic or anxiety Eating disorders
  • 29. Responding to domestic abuse 18 Domestic abuse impacts on a Domestic abuse also affects the woman’s health potential. quality of the relationship a For example, women may: woman is able to have with children. > turn to drugs, alcohol or other substances in an > Domestic abuse can affect a attempt to cope with child’s educational their situation; opportunities, through: > become isolated from friends – developmental delay; and family – important – disrupted schooling or sources of support; truanting; > lose their independence – – concentration difficulties; especially if they are or financially dependent on their abuser; – memory problems. > avoid taking opportunities > It has serious consequences that arise or taking up new on a child’s ability to relate to interests and activities for other people and can affect fear they might provoke their their chances of living a abuser; and healthy, rewarding life – now and in the future. > have problems at work due to increased time off or inability to concentrate.
  • 30. A handbook for health professionals 19 Examples of the effects on children Physical effects Psychological/behavioural effects Bruising Fear, panic, guilt and anxiety Broken bones Depression/poor mental health Burns or stab wounds Introversion or withdrawal Death Thoughts of suicide or running away Neurological complications Post-traumatic stress disorder Tiredness and sleep disturbance Anger, aggressive behaviour and delinquency General poor health Substance misuse Stress-related illness (asthma, bronchitis or skin conditions) Loss of self-confidence Enuresis or encopresis Assumes a parental role Hyperactivity Running away leading to potential homelessness Tension Eating difficulties Low self-esteem Damage following self-harm Sexual problems or sexual precocity Teenage pregnancy Suicide Gynaecological problems Eating disorders Self-harm Difficulty in making and Damage to the unborn child sustaining friendships in pregnancy Truancy and other difficulties at school
  • 31. Responding to domestic abuse 20 > The effects of domestic > For many children, the abuse on children tend to negative effects lessen, and vary according to: in some cases disappear, once the child is safe and – how old they are; secure. Other children may – the levels of violence; only start to show negative effects once they feel safe. – the length of time the abuse has been > But it is important to happening; acknowledge that removal from an abuser doesn’t – whether they are directly automatically mean safety abused; for a child. This is particularly – the extent to which they true if the courts order have witnessed the contact with a man who has violence; and been violent in the past. There have been cases where – how much support they women and children have are getting from other been abused or killed during people. contact visits – sometimes when contact has been ordered by the courts.23
  • 32. A handbook for health professionals 21 There is little evidence to - > 11% of girls who believe - suggest that a child who - it is acceptable to be hit by - experiences or witnesses - a boyfriend have been hit - domestic abuse will grow up - by a parent; - to be a perpetrator or to - > 20% of teenage girls have - experience further abuse in - been hit by a boyfriend; - adult life. Attitudes, however, - and - can be affected by living with - abuse. A recent survey - > 33% say cheating justifies - conducted by the NSPCC and - violence. - Sugar magazine highlighted: - > 31% of girls hit regularly by - their boyfriends have seen - their parents hit each other; - Women are often unable to protect their children Mothers who are living with domestic violence are often unable to protect their children from the direct and indirect effects of abuse, despite their best efforts. As health professionals, we should bear this in mind when planning for child protection.
  • 33. Responding to domestic abuse 22 > Challenging such views is crucial if we are to help avoid future cases of domestic abuse. And, as health professionals, we have an opportunity to show young people that abuse is unacceptable by helping people who have been abused to start to build safer lives. By doing so, we are setting an example that could help shape children’s opinions on what they can expect from current and future relationships.
  • 34. 2.5 Understanding abused women As health professionals supporting those who are experiencing domestic abuse, we have to be able to accept that sometimes women will make decisions that we might find hard to understand. Overcoming our own frustrations and misperceptions forms an important part of providing support. Domestic abuse is always the responsibility of the perpetrator. Never blame the abused woman – it’s not her fault. Why don’t women just leave > suffer chronic post-traumatic an abuser? stress and be unable to make critical decisions; Women always want abuse to end – but not always the > be financially dependent on relationship. They might also: the abuser; > not be safe if they leave an > still love him; abuser. For many women, > have been convinced by an the abuse continues after a abuser that they are relationship has ended; worthless and no-one else > be afraid of the abuser; will care for them; > be anxious about living > think there is a chance their alone, not being able to cope partner will change; or the unknown; > want their children’s father to be around as they grow up;
  • 35. Responding to domestic abuse 24 > want to prevent family > The consequences of talking upheaval (having to move might seem worse than house, children changing staying silent. schools and leaving > Perhaps the perpetrator has established friends); or threatened worse abuse if > feel a ‘trauma bond’ with she talks to someone. their abuser. This is often > Women might be worried referred to as ‘hostage about losing their children if syndrome’.24 social services are involved. Why don’t they just tell > They might worry that someone? nobody will believe them – > They might be worried about particularly if there are no stigma surrounding domestic physical injuries. abuse. > There might be cultural or > Using the label ‘domestic religious barriers. abuse’ might make them > They might be worried about uncomfortable. their immigration status. > They might be afraid of the > The abuser might never leave consequences of telling her alone. someone. > Some women can’t find the > Some women don’t words to describe their recognise their situation experiences. as domestic abuse.
  • 36. A handbook for health professionals 25 > Maybe nobody’s ever asked. supporting them. They may make decisions that we do Always remember that a - not understand, but health woman is the only person - professionals should adopt a who has all the information - non-judgemental approach about her own particular - and women’s decisions circumstances. - should be respected. Continued support and > As with all important life- understanding are crucial changing decisions, women > For a lot of women coping will consider their options with domestic abuse, carefully and over time speaking to somebody about before taking action. It can it and finding ways to create seem frustratingly slow and a safer life can take a long women may return to their time. It’s a long process – abuser on several occasions. not a single event. Pushing them into action is reflective of the abuser’s > Sometimes women try behaviour towards her and different ways of dealing is not helpful. with their problem over a long period of time before finding a way that’s right for them – which is why it’s important to continue
  • 37. Responding to domestic abuse 26 What do survivors of domestic abuse want? To be safe. To be believed, taken seriously and respected. Timely and proactive interventions such as routine enquiry and the provision of information. Independent advocates (from the voluntary sector, for example) to oversee their case and liaise with the different agencies that provide them with support. A single person or agency to get help from so that they don’t have to keep repeating intimate details of their abuse. Options based on their circumstances explained to them clearly. Contact with other survivors. To be kept informed of developments – such as when an abuser is released from a police station or turns up at the child’s school. Support to cope with the effects of abuse on their children. To have their views incorporated into services that are offered to them.
  • 38. 2.6 The cost of domestic violence in 200425 Criminal justice system £ 1 billion Healthcare (including physical and mental health) £ 1.4 billion Social services £ 0.25 billion Housing £ 0.16 billion Civil legal services (injunctions, divorce-related services) £ 0.3 billion Total cost £ 3.1 billion As well as the personal cost to estimated. And the cost of lost those who experienced economic output (due to time domestic violence last year, the off work because of injuries, for financial cost is detailed above. example) is around £2.76 billion a year. These figures are likely to be conservative, as they’re based The total cost to the nation is on the British Crime Survey, and nearly £23 billion, including domestic violence is believed to costs for human and emotional be under-reported. and economic output aspects. Of course, it’s impossible to put See the next page for a price on the pain and suffering health costs. associated with domestic violence, but a figure of over £17 billion a year has been
  • 39. Responding to domestic abuse 28 Health costs NHS/state Patient Total (£’000s) Hospital and ambulance 1,158,053 1,158,053 GP visits 24,672 24,672 Prescriptions 25,779 1,463 27,242 Travel and lost wages for GP visits 10,280 10,280 Sub-total 1,208,504 11,743 1,220,247 Mental health 176,000 176,000 TOTAL 1,396,247 (rounded up to £1.4 billion)
  • 40. 2.7 Domestic abuse is a health issue 1 Health professionals are 2 Women at risk might not often a first point of contact come into contact with any for women, and they deal other professionals who can with the after-effects of offer a lifeline. domestic abuse on an It would be wrong for us to everyday basis. wait for other professionals Women who have to help vulnerable patients experienced abuse use health when we have the perfect services frequently and opportunity to create an require wide-ranging medical environment in which services. They are likely to be women feel comfortable admitted to hospital more and may choose to reveal often than non-abused domestic abuse and ask for women and are issued more much-needed support. prescriptions.
  • 41. Responding to domestic abuse 30 3 A woman’s health records 5 Women say they want us to can play an important part take the initiative. in bringing perpetrators Time and again survivors of to justice. domestic abuse have said They can also be an they wish somebody had influencing factor in housing asked them if they were and immigration decisions. experiencing problems in their personal relationships. 4 Some NHS colleagues will experience domestic abuse. Due to the high prevalence of domestic abuse across society, it’s inevitable that some health professionals will suffer at the hands of someone close to them. Our policies need to be robust enough to give them the support they need. Human Resources (HR) departments can access workplace domestic violence policies via the NHS Employers organisation.
  • 42. 2.8 What’s being done to help? Agencies are joining forces to The Government has prioritised have maximum impact domestic abuse issues For decades women’s It has set up a cross- organisations have responded government group, the Inter- to the needs of women Ministerial Group on Domestic experiencing domestic abuse. Violence, with involvement Now they are supported by from the Department of Health central and local government, (DH), the Home Office and the other voluntary organisations, Cabinet Office. Initially, the the NHS and criminal justice Government wished to address agencies. A multi-agency the prevalence of domestic approach allows the problem abuse in pregnant women. to be approached from various Early in 2005, DH set up the sides simultaneously. It means Domestic Abuse and Pregnancy that women and children who Advisory Group with are dealing with the effects of representation from Royal abuse in their lives can get Colleges and key domestic support that meets their violence voluntary sector individual needs. organisations. The Advisory Group’s remit was to advise Ministers on how services can meet the needs of pregnant women who are experiencing abuse.
  • 43. Responding to domestic abuse 32 DH and the Home Office have, There is a range of support in partnership with the National available Institute for Mental Health in National approaches are flexible England (NIMHE), set up the enough to allow local Victims of Violence and Abuse partnerships to deliver services Prevention Programme. The that meet local need. Although programme seeks to address women in need can still get the health and mental health emergency accommodation if needs of individuals affected by they want to escape a partner, domestic and sexual violence there are now services that can and abuse. Its work will support provide additional safety the implementation of DH measures so that women can, policy on routine enquiry about if they choose to do so, stay in domestic abuse and the their own home. This may provision of information in empower them to make positive antenatal services. and safe changes to their life The Domestic Violence, Crime and can also benefit any and Victims Act 2004 has children in the family. extended the protection There are local and national available in both the civil and helplines for women and the criminal courts to those children experiencing domestic experiencing domestic violence. violence (see page 127 for more information).
  • 44. A handbook for health professionals 33 The NHS is playing an active role As survivors of domestic violence will testify, some health professionals have always played an important role in supporting women who have experienced abuse. Now we are ensuring that this approach is part of our culture and that information and support is available to any woman who wants it from us. It will make a significant difference to the lives of thousands of women and children across the country.
  • 45. Responding to domestic abuse 34 References 1 Ninety-two women (32% of female homicides) were 11 Stanko, B. (2000) The day to count: a snapshot of the killed in 1999 by present or former partners. This impact of domestic violence in the UK. equates to one woman every three days. Criminal 12 World Health Organization (2002) World report on Statistics 1999 (Home Office). violence and health: summary. 2 Home Office (2001) British Crime Survey, England 13 Povey, D. (ed.) (2005) Crime in England and Wales and Wales. 2003/04, Supplementary volume: homicide and gun 3 McWilliams, M. and McKiernan, J. (1993) Bringing it crime, Home Office Statistical Bulletin No. 02/05. out into the open. 14 Lewis, G. and Drife, J. (2001) Why mothers die: 4 Farmer, E. and Owen, M. (1995) Child protection report from the confidential enquiries into maternal policies: private risks and public remedies. deaths in the UK. 5 Walby, S. and Allen, J. (2004) Home Office Research 15 Lewis, G. and Drife, J. (2001) Why mothers die: Study 276: Domestic violence, sexual assault and report from the confidential enquiries into maternal stalking: Findings from the British Crime Survey. deaths in the UK. 6 Bowker, L., Artbitell, M. and McFerron, J. (1998) 16 British Medical Association (1998) Domestic violence: Domestic violence factsheet: children by the a health care issue? Women’s Aid Federation of England. 17 Stark, E. and Flitcraft, A. (1996) Women at risk: 7 Home Office (2001) British Crime Survey, England domestic violence and women’s health. and Wales. 18 Farmer, E. and Owen, M. (1995) Child protection 8 Hughes, H. (1992) ‘Impact of spouse abuse on policies: private risks and public remedies. children of battered women’, Violence Update, 19 Radford, L. and Sayer, S. (1999) Unreasonable fears? 1 August, pp 9–11. 20 9 Department of Health (2002) Women’s mental Walby, S. (2004) The cost of domestic violence, health: into the mainstream. September 2004 (National Statistics, Women and 21 Equality Unit), funded by DTI. Department of Health (2002) Women’s mental 10 health: into the mainstream. Human Rights Watch defines ‘honour killings’ as 22 follows: ‘Honour crimes are acts of violence, usually Hester, M. and Pearson, C. (1998) From periphery to murder, committed by male family members against centre: domestic violence in work with abused female family members who are perceived to have children. brought dishonour upon the family. A woman can 23 Saunders, H. and Barron, J. (2003) Failure to protect? be targeted by her family for a variety of reasons Domestic violence and the experiences of abused including, refusing to enter into an arranged marriage, women and children in the family courts. being the victim of an assault, seeking a divorce – 24 Kirkwood, C. (1993) Leaving abusive partners. even from an abusive husband – or committing 25 adultery. The perception that a woman has acted in a Walby, S. (2004) The cost of domestic violence, manner to bring “dishonour” to the family is September 2004 (National Statistics, Women and sufficient to trigger an attack.’ Equality Unit), funded by DTI.
  • 46. Section 3 Guidance for health professionals 3 Guidance for health professionals In this section: 3.1 Your role 3.2 Creating a supportive environment 3.3 Asking about domestic abuse 3.4 If a woman discloses abuse 3.5 Keeping records 3.6 Confidentiality and information sharing
  • 47. 3.1 Your role > Your role in responding to It is not your role to encourage- domestic abuse should be her to leave her partner, or to - limited to: take any other particular - – focusing on the woman’s course of action. This could - safety and that of her lead to problems, including - children, if she has any; increased danger for her and - her children. - – giving her information and referring her to relevant > Don’t act as a caseworker for agencies; the woman once you have referred her to sources of – making it easy for a help. Remember that there woman to talk about are domestic violence her experiences; agencies that fulfil that role. – supporting and reassuring Of course, you will still need her; and to carry out your usual health duties and provide support – being non-judgemental. that is appropriate to > You should never assume your role. that someone else will take > Practitioners should be aware care of domestic abuse of their own safety needs. issues – you may be Discussions with the woman’s first and management and clinical only contact. supervision provide a framework for support.
  • 48. Responding to domestic abuse 36 > Always be prepared to work implement what you learn in in partnership with other training. For more organisations that have information about policies been set up to ensure a and training in your area, woman’s safety. speak to your Trust’s domestic violence > Always adhere to your Trust’s co-ordinator or lead domestic abuse policy and professional. Looking after yourself Sometimes working with the effects of domestic abuse professionally can bring to the surface personal issues – particularly if you are experiencing or have experienced abuse yourself. Your personal needs are as important as those of the patients you work with. You can ask your managers for confidential help. The NHS doesn’t tolerate domestic violence, and your Trust should have policies for supporting staff who experience it. The NHS Employers organisation is currently drafting a work-based policy that will eventually be put in place in all NHS HR departments. Of course, if you prefer not to disclose domestic abuse to your employers, you can get support by calling the freephone 24-hour National Domestic Violence Helpline on 0808 2000 247 (see page 44 for more information).
  • 49. A handbook for health professionals 37 What you can docan do – an overview What you – an overview Be aware of support support services that are availableand keep suppliessupplies of Be aware of services that are available locally, locally and keep of information to pass on.pass on. information to Help create an environment in whichin which women feel comfortableabout Help create an environment women feel comfortable talking talking abuse. about abuse. Be aware of signs of signs that could indicate domestic abuse is taking place. Be aware that could indicate domestic abuse is taking place. Know how to ask the right questions to let a woman woman know she can talk to Know how to ask the right questions to let a know she can talk to you about abuse. Explain the limits of limits of confidentiality. you about abuse. Explain the confidentiality. Establish whetherwhether there childrenchildren in the household – and how many. Establish there are any are any in the household – and how many. Make an assessment of their needs. needs. Make an assessment of their ValidateValidate and support women who do reveal abuse. and support women who do reveal abuse Pass on Pass on information about relevant support agencies, whether or not a information about relevant support agencies, whether or not a woman woman discloses abuse. discloses abuse. Keep detailed, accurate records about a about a woman’s and what she Keep detailed, accurate records woman’s injuries injuries and what she reveals to you –to you – but never in hand-held records. reveals but never in hand held records. Ensure confidentiality. If you need to need to share information with other agencies, Ensure confidentiality. If you share information with other agencies, follow guidelines. follow guidelines. Carry out your usual the woman’s health needs. Attend to all health duties.
  • 50. 3.2 Creating a supportive environment Domestic abuse is an isolating > By far the most important crime. Many women feel unable factor in creating a to talk about their experiences – supportive environment is even with the people closest to the way that we interact with them. So the idea of asking service users. It’s important health professionals for help to be open to and can be daunting. comfortable with women talking about their abuse. But we do know that many women want an opportunity to ‘My GP was great. I saw him - let somebody know what is again and again and he didn’t - happening so that they can get lose his patience. He guessed - the help they need. The most what was going on, but he - obvious response for the health didn’t try to force me into - service is to ask women more leaving my boyfriend before - openly if they are experiencing I was ready.’ - abuse. But before we even do > Learn as much as possible that, we can help by creating a about the needs of women supportive environment in who experience abuse at the which women feel more relaxed hands of someone close to and open to talking about the them (see Section 2.5). abuse they are experiencing. This should form part of your Trust’s domestic abuse education and training.
  • 51. A handbook for health professionals 39 > Get to know as much as you > Pay particular attention if you can about how domestic are treating a woman who abuse is being responded has attempted suicide or has to locally. How is the self-harmed: domestic abuse partnership working meeting is often a contributing factor. the needs of local women? This is particularly true for Are there activities that you women from minority ethnic could get involved in? As a communities. For example, bare minimum, you should half of women of Asian origin know the domestic abuse who have attempted suicide support agencies in the area, or have self-harmed have so that you can give your experienced domestic patients accurate information. violence.1 > Don’t feel you have to know > Be as comfortable talking everything there is to know about domestic abuse as you about domestic abuse. are talking about other Knowing the basics and health issues (for example admitting that you don’t when taking a social history). know the answer to a Follow your Trust’s guidance woman’s more detailed for routine enquiry (asking all questions is better than not women about domestic talking about domestic abuse abuse – see the guidance in at all. You can provide women Section 3.3, Asking about with relevant information, domestic abuse). including a helpline number.
  • 52. Responding to domestic abuse 40 > Be aware that women will > Make sure that all staff in have different needs, and your workplace are aware of allow them to express them. domestic abuse issues and Just as the female population the importance of creating a is diverse, so are women’s supportive environment. experiences of domestic Would a bad experience with abuse. Don’t assume that a receptionist, for example, you know how they are lessen the likelihood of a feeling, and allow them to woman disclosing? What reveal their own needs based reaction would a woman on their own circumstances. experiencing domestic abuse Annex C contains prompts get if she asked for an that might start increasing emergency appointment but your awareness of the didn’t want to give any potential problems different information at all to kinds of women might have. a receptionist? Diversity should form part of > Be familiar with signs that your Health Authority’s or might indicate domestic Trust’s domestic abuse violence in women – but education and training. don’t jump to conclusions. Be prepared to see signs in any woman.
  • 53. A handbook for health professionals 41 Making it easier for women Never raise the issue of - to talk domestic abuse unless a - Physical environment woman is alone. Even if she is - > Most women aren’t going to with another woman, that - disclose domestic abuse just woman could be the mother - because they are in a more or sister of an abuser. Good - comfortable environment, practice would indicate that a - but it could be an influencing women should be seen alone - factor in their decision about once during her antenatal care. - whether to talk. ‘I thought about saying - > How comfortable is the something to the nurse, - environment you work in for because she was quite friendly - women, particularly those to me. But she kept getting - that are vulnerable? Is it called away – you know how - somewhere they can talk it is with nurses – and she - one-to-one with you without looked stressed. I didn’t want - being overheard? Are there to add to that.’ - quiet rooms you can go to if > Can you improve your you need to? Many health working environment to settings are busy places, with make it more comfortable? people passing in and out of If a woman asks to talk about cubicles and offices, and this a personal issue or gets upset, might not be conducive to how can you put her at ease? revealing vulnerable feelings.
  • 54. Responding to domestic abuse 42 > Do you have access to Getting the message across information on domestic The printed materials you have abuse and support services on display can play an nearby? Is there a phone in important part in letting women the room that a woman can know that they are in a place use to call a helpline if she where it’s safe to reveal needs to in an emergency? domestic abuse. Campaigns, Do you have a supply of posters and leaflets with leaflets or other materials to targeted messages – depending give to women? on their location – can play a significant role. > Do you display posters and leaflets giving information on > Material should be provided domestic violence services? that meets the needs of the local population in a variety of easily accessible formats and media. Support should be available from the start in easy access formats for all, including in different languages, easy read format, tapes and CDs.
  • 55. A handbook for health professionals 43 > If you are going to use posters > The format of the materials and leaflets, remember that you use is also important. some women will attend health Think about how you can services with their partner – create materials that are so choose your message easily hidden in a woman’s carefully. In waiting rooms and shoe or bra, so that her other areas open to the general abuser is less likely to find public, it can be useful to have them. Your instinct might be materials carrying a general to give women as much anti-domestic abuse message information as possible and and a local or national create a large leaflet. But a helpline number. credit-card-sized leaflet carrying helpline numbers > Materials targeting women might be more useful directly are best placed where to them. perpetrators can’t see them – in women’s toilets, for > Don’t overburden women example. A woman is more with information. Remember likely to respond to a poster or that somebody at the end of pick up a leaflet if her abuser, a helpline can always give the and other people, can’t see detail you don’t. As a bare her. A national helpline minimum, give vital safety number on the back of a toilet information (see page 65) cubicle door or leaflets near a and helpline numbers. hand drier are useful ways of disseminating information.
  • 56. Responding to domestic abuse 44 Freephone, 24-hour National Domestic Violence Helpline Run in partnership between Women’s Aid and Refuge. 0808 2000 247 The National Domestic Violence Helpline provides information and emotional and practical support to women experiencing domestic abuse, and to those seeking help on a woman’s behalf. Helpline staff – all of whom are women – will discuss the available options to enable women to make an informed choice. If appropriate, they may refer them to a refuge, outreach services or other sources of help and information. All calls are taken in the strictest of confidence. The helpline is a member of Language Line and can provide access to an interpreter for non-English speaking callers. Helpline staff can also access the BT Type Talk Service for deaf callers. If all lines are busy, there is a voice mail system that enables callers to leave a message, which will be responded to as soon as possible.
  • 57. A handbook for health professionals 45 Good practice example Nottinghamshire Domestic Violence Forum (NDVF) information card NDVF’s domestic violence information card measures only 8.5cm x 5.5cm. It contains: > information on domestic violence; > a reminder that the woman isn’t to blame; > a brief description of NDVF; > safety information for women in need; > national helpline numbers. Printed on sturdy but flexible paper, the card can easily be folded and hidden on a woman’s body.
  • 58. Responding to domestic abuse 46 Diversity > Consider what alternative > As much as possible, your formats you might need to materials should reflect the use to meet the varying diversity of your service needs of service users. For users. If you are using example, you might need to photography, for example, produce a Braille or recorded will you show women from version of a leaflet for blind minority ethnic backgrounds, patients. Or you might need women of all ages and to produce a version that is women with disabilities? written in basic English, so It’s important to that it is accessible to patients acknowledge that domestic with learning difficulties. abuse can happen to women > Do you need to provide from any section of the translated versions of your population. printed materials (see further guidance on page 109)? Bear in mind that actual or perceived racism can be a barrier to women from minority ethnic backgrounds seeking help. Ignoring their needs can worsen the feelings of isolation that many abused women already feel.
  • 59. A handbook for health professionals 47 Visits > If you are giving local > If you are visiting a woman in helpline numbers, always her own home, keep a supply include a national one as of domestic abuse materials well. Local helplines might on you. But be very careful not operate 24 hours a day, about when you choose to and a woman might find hand them over – and ask herself without help if she the woman if she wants the needs support in the middle materials first. Question of the night, for example. whether leaving information on domestic violence services behind or amongst other materials could provoke a perpetrator. It might be better to communicate the information face-to-face rather than rely on printed materials. Leave your contact details.
  • 60. 3.3 Asking about domestic abuse Possible signs of domestic abuse in women Frequent appointments for Frequent missed appointments vague symptoms Multiple injuries at different Injuries inconsistent with stages of healing explanation of cause Patient appears frightened, Woman tries to hide injuries or overly anxious or depressed minimise their extent Woman is submissive or afraid Partner always attends to speak in front of her partner unnecessarily Partner is aggressive or Woman is reluctant to speak in dominant, talks for a woman or front of partner refuses to leave the room Suicide attempts – particularly Poor or non-attendance at with Asian women antenatal clinics History of repeated Injuries to the breasts or miscarriages, terminations, still abdomen births or pre-term labour Recurring sexually transmitted Repeat presentation with infections or urinary tract depression, anxiety, self-harm infections or psychosomatic symptoms Early self discharge from Non-compliance with treatment hospital None of the above signs automatically indicates domestic abuse. But they should raise suspicion and prompt you to make every attempt to see the woman alone and in private to ask her if she is being abused. Even if she chooses not to disclose at this time, she will know you are aware of the issues, and she might choose to approach you at a later time. If you are going to ask a woman about domestic violence, always follow your Trust’s or Health Authority’s guidance. Or follow the guidance in Section 3.3 of this handbook.
  • 61. A handbook for health professionals 49 We know from the evidence Selective enquiry that women find it difficult to > If you are working with a raise the subject of domestic woman and see something abuse themselves. Health that indicates a woman professionals should be might be experiencing prepared to take a proactive domestic abuse (see Possible approach. signs of domestic abuse in For health services to function women, page 48), take the as a vital lifeline for women and initiative and ask specific children, talking about domestic questions. abuse needs to become part of > Never assume that our daily work. Evidence shows somebody else will ask that direct questions get more about it. positive results than vague queries. They also show a > Always be guided by the woman that you have some need to keep a woman – and understanding of the issue her children – safe. of domestic abuse.
  • 62. Responding to domestic abuse 50 > Never ask about domestic standard practice, another abuse when anybody else is possibility would be when present – this includes the woman is providing a partners, children and other urine sample or using the members of the family. The lavatory. There may well be only exception to this is other opportunities and you when you have a will need to think creatively professional interpreter about these. present. But even then you > Ensure privacy – make sure should follow the guidance that you can’t be overheard. on page 53. > Take the phone off the hook, > You should find a way of switch off mobile phones seeing the woman alone, and ask not to be disturbed, even if she insists on so that the woman doesn’t someone else staying with get the impression that you her. Health professionals have ‘more important things often say this is the most to deal with’. difficult part of talking about abuse. Seeing a woman > Don’t rush a woman – be alone at some stage of her patient. You might have other care should be standard appointments waiting, but practice and should be remember that it might be included in good practice very difficult for a woman to guidelines. If it feels difficult talk. She may feel ashamed. to organise this as part of Allow her to talk about her
  • 63. A handbook for health professionals 51 experiences at a pace that > Aim to have a supportive suits her. Arrange another conversation. Your role is to appointment to see a woman let her know she can talk to you’re concerned about. you if and when she’s ready. Many health professionals > Avoid pushing her into worry that routine enquiry revealing domestic abuse. about domestic abuse and It might not be the right time providing information will for her. Respect her choice. take too much time. But research shows that it can be > Think of your conversation incorporated into everyday as the start of a process, not clinical practice (such as a one-off event. Not all taking a social history) and women are going to open up can quite literally take a the first time they realise you few minutes. think they are being abused. Try to make a woman feel > Understand that the woman comfortable about coming may also have time back to see you again. She pressures. A reluctance to might not want to talk about engage mid-afternoon might her problems now, but at be because she needs to least she knows you’re there leave the interview to collect if she needs you in the future. children from school. Provide your contact details. Encourage the woman to rearrange for a time that suits her.
  • 64. Responding to domestic abuse 52 > Never accept culture as an > Might you need an advocate? excuse for domestic abuse. You might consider ensuring Every woman being abused that the woman has access to by someone close to her is an advocate from a specialist the subject of a crime. Every agency to assist her. woman deserves the same > Might children be involved? attention from you – even if Establish how many children you feel you might be live in the household. Bear in crossing cultural boundaries. mind the close link between Your fear shouldn’t stand in domestic abuse and child the way of getting a woman neglect. If you think that a the support she needs. woman is being abused, > Ask if the woman would like always think about the to talk to someone else. possible implications for her If you’re male, perhaps she children – including the would like to speak to a possibility that the children woman? But don’t assume themselves might be subject that a woman will always to domestic abuse. Similarly, want to talk to someone of if you suspect that a child is the same race. Some women being abused, be alert to the think that it is dangerous for possibility of domestic abuse them to speak to someone in the family. The involvement who is part of their of the NSPCC with a family community, while others feel is often an indicator of safer doing so. Always ask. domestic abuse.
  • 65. A handbook for health professionals 53 Using an interpreter? > You should always use a professional interpreter. > Never use a woman’s partner, her child or another family member. Do not use friends. Do not use your colleagues who speak the same language. > Try to get a female interpreter where possible. Using a man might preclude discussion of certain subjects. > Arrange for a interpreter in advance. Ideally all interpreters should have attended an education programme on domestic abuse. > Your interpreters should sign a confidentiality agreement. > An alternative to an interpreter would be an advocate from a specialist organisation. > Look at your patient and speak directly to them – not the interpreter. > Give every woman effective outcome. Knowing information on support that a professional is services, regardless of the interested and takes domestic reply to your questions. abuse seriously provides the Disclosure is not the only opportunity for a woman
  • 66. Responding to domestic abuse 54 to talk if she chooses. Or, if whether or not they show she isn’t experiencing abuse signs of it. An appropriate herself, she might be able time to do so would occur as to pass the information to you take a social history, somebody who is. when you are asking about other factors that have a Routine enquiry negative impact on a > Routine enquiry and woman’s health. Asking all providing information involve women helps avoid stigma asking all women if they are and inappropriate experiencing domestic abuse, judgements. Routine enquiry In response to the evidence provided by the University of the West of England and North Bristol NHS Trust project (see Foreword, page vii), all Trusts should be working towards routine enquiry and providing all women with information on domestic abuse support services. If your Trust has already adopted this approach, you should receive training before applying it. You might also like to see the guidance given to managers and policy-makers in Section 4 of this handbook. If you aren’t familiar with your Trust’s position on routine enquiry and the provision of information, it’s a good idea to speak to the domestic violence co-ordinator or lead professional, who will be able to advise you.
  • 67. A handbook for health professionals 55 > It’s important to take the > It’s important to understand initiative and be proactive. that routine enquiry and the Evidence suggests that some provision of information is women minimise or deny not a cure – it contributes to domestic abuse as a way of helping women access coping. Women have also support if they choose. said that they found the Be confident asking the subject too difficult to raise questions themselves – even when they wanted to. > Asking women about domestic abuse should go > All health professionals will hand in hand with providing be given training before them with a small credit- changing from selective to card-sized card carrying routine enquiry and the helpline numbers and safety provision of information. advice. This should occur Those health professionals regardless of a woman’s who have already been response to your questions. trained in their role and the It would be rare for a woman limits of their responsibilities to disclose abuse on initial quickly become confident in enquiry. If someone isn’t the new approach. ready or chooses not to disclose, their privacy should be respected. Some women might want the information to pass on to a friend or
  • 68. Responding to domestic abuse 56 family member. Supplying > A woman might deny or play information also gives out a down domestic abuse as part powerful public health of a coping mechanism. message about safer lifestyle > Don’t be afraid to ask direct choices and helps create a questions such as: supportive environment for patients who are – Has your partner ever experiencing abuse. hit you? > It’s not always easy to ask – Are you ever afraid questions about domestic at home? abuse. So it’s important to – Have you been forced to take time to put a woman at do anything sexually that ease before you start asking you did not want to? direct questions. Don’t assume that you will get a > Be supportive and express hostile response. Women your concern. Don’t accuse who have been abused say or patronise. they were glad when > It’s OK to be honest. If you somebody asked them about think a woman’s injury is their relationships. inconsistent with her > Always put the woman’s explanation, explain that you safety first. are concerned. > Ask your questions in a sensitive, supporting manner.
  • 69. A handbook for health professionals 57 > Be prepared that even if a woman is being abused, she might deny it. Accept ‘no’ as an answer and continue to be supportive if you have future appointments. Offer her a discreet domestic abuse card or leaflet carrying helpline numbers.
  • 70. 3.4 If a woman discloses abuse If a woman reveals that Never advise a woman to - someone close to her is leave her partner. Women - assaulting her, it’s important to are at high risk of injury or - know how to respond so that murder when they leave a - she can get the help she needs. violent partner, so leaving - Your role is to: immediately might not be the - > provide support and best option. Supporting her, - information to help her assessing whether she’s in - make a decision on what immediate danger and - to do next; referring her to sources of - help are the best things you - > encourage her to have a can do for her. If you have - safety plan; and serious concerns for her - > help assess the risk to her and safety, speak to a manager - any children she has. or domestic abuse lead on - what you can do to help – - The flowchart on pages 72–73 for example, discussing the - gives a diagrammatic overview situation with the relevant - of the appropriate issues to police domestic violence - raise. Many of them are liaison officer. - questions you might already ask in the cases you come across on a daily basis.
  • 71. A handbook for health professionals 59 Providing support and > Don’t try to make decisions information for her. It’s crucial that she decides herself what it is she > Give the woman information wants to do next. You might on local and national support like to talk through different agencies and helplines. You options with her, but it would should give information on be better for her to speak to domestic abuse services to a specialist domestic violence all women, regardless of agency about what support is whether they disclose currently available. domestic abuse. Freephone, 24-hour National Domestic Violence Helpline Run in partnership between Women’s Aid and Refuge. 0808 2000 247 UK Gold Book The UK Gold Book is a UK-wide directory of refuge and domestic abuse services. To order it, see page 127.
  • 72. Responding to domestic abuse 60 Know what’s going on locally It’s important that you know what services are offered locally to women experiencing domestic abuse. And it’s a good idea to keep a chart of contact details, so that you can easily refer to them in an emergency. Try to have contact details for: > the National Domestic Violence Helpline; > local domestic violence services, including refuge services, outreach, advocacy and counselling services (public contact numbers are listed in the UK Gold Book, available from Women’s Aid or online at www.womensaid.org.uk); > your local police station domestic abuse unit or community safety unit; > your local authority homelessness office; > social services; > local authority child protection co-ordinator; > the children’s service director; > legal services, including the Crown Prosecution Service; > drug and alcohol treatment services; > Victim Support; and > any other relevant support services.
  • 73. A handbook for health professionals 61 > Let the woman know that > Ask her what she wants you you believe her and make it to do. Be clear about what’s clear that the abuse is not her possible, but explain that fault. Tell her that abuse is other agencies might be able unacceptable and she has the to help in areas where right to safety. you can’t. > Let her know that she is > Never be tempted to act as a not alone – a quarter of go-between. This includes all women will have never helping her partner experienced abuse at some locate her if she has left him. time in their lives. Don’t pass on letters or messages or facilitate contact > Encourage her to see that – you could put yourself and there is life after abuse and the woman in danger. that she deserves to be safe. Other women have created ‘All I needed was that bit of - safer lives for themselves – so encouragement to phone the - can she. helpline. All those years - thinking they only helped - > Emphasise and explain young women. A quick word - confidentiality – but be clear from a nurse when my - about its limits, such as if a husband stepped out for a - child is involved. moment put an end to that.’ -
  • 74. Responding to domestic abuse 62 > Attend to all the woman’s > Don’t make assumptions. health needs. The woman For example, if your patient may have injuries that need is from a minority ethnic treating, for example. Or a background, don’t assume referral to social services or that she will only accept help mental health services may from culturally-specific be appropriate. agencies. This might limit her options, as specialist agencies Ongoing support might not have the capacity > Support the woman in to respond immediately. whatever decision she > Allow the woman to do makes. You might not things for herself. If she understand her decision. wants to phone a helpline, She might decide to stay with allow her to use your phone or return to an abuser – and rather than make the call for not just because she is afraid her – unless she feels unable to leave him. Sometimes to do so. women still love their abuser, believe he can change or > If you have ongoing contact want their children to grow with the woman, continue to up with their father. provide support each time you see her.
  • 75. A handbook for health professionals 63 Talking about options Unfortunately, patients who experience domestic abuse don’t have a set list of options. The opportunities that are open to them will depend on their personal circumstances, the risks they face and what capacity domestic violence agencies have at a particular time. It’s important that a woman reaches her own decision about what she does next – possibly through calling a helpline. But options might include: > seeking advice from a helpline; > getting support from domestic violence agencies; > contacting the police; > getting legal advice about obtaining a civil injunction or a restraining order; > taking additional safety measures (such as changing locks) to make her home more secure after the abuser has left; > seeking emergency refuge accommodation; or > returning to her abuser after making a safety plan.
  • 76. Responding to domestic abuse 64 Safety issues Don’t take on sole responsibility for creating the In most cases, domestic abuse plan or create the plan on a occurs repeatedly. So it’s woman’s behalf. It’s important important that a woman who that her plan is based on her discloses that she is being needs, and these will change abused has a safety plan for depending on her background what to do when abuse starts. and circumstances. There might Annex D contains a sample also be local agencies (such as safety plan, but your patients domestic violence voluntary don’t have to have a written organisations, eg Women’s Aid plan – in many cases it’s safer or Refuge) that can help her for them not to write down a create a safety plan. plan and take it away. You can help them by prompting them to think about what they can do to reduce the risks in emergency situations.
  • 77. A handbook for health professionals 65 What should a safety plan cover? Safety in the relationship > Places to avoid when abuse starts (such as the kitchen, where there are many potential weapons). > People a woman can turn to for help or let know that they are in danger. > Asking neighbours or friends to call 999 if they hear anything to suggest a woman or her children are in danger. > Places to hide important phone numbers, such as helpline numbers. > How to keep the children safe when abuse starts. > Teaching the children to find safety or get help, perhaps by dialling 999. > Keeping important personal documents in one place so that they can be taken if a woman needs to leave suddenly. > Letting someone know about the abuse so that it can be recorded (important for cases that go to court or immigration applications, for example). Leaving in an emergency > Packing an emergency bag and hiding it in a safe place in case a woman needs to leave in an emergency.
  • 78. Responding to domestic abuse 66 > Plans for who to call and where to go (such as a domestic violence refuge). > Things to remember to take: documents, medication, keys or a photo of the abuser (useful for serving court documents). > Access to a phone. > Access to money or credit/debit cards that a woman has perhaps put aside. > Plans for transport. > Plans for taking clothes, toiletries and toys for the children. > Taking any proof of the abuse, such as photos, notes or details of people who know about it. Safety when a relationship is over > Contact details for professionals who can advise or give vital support. > Changing landline and mobile phone numbers. > How to keep her location secret from her partner if she has left home (by not telling mutual friends where she is, for example). > Getting a non-molestation, exclusion or restraining order. > Plans for talking to any children about the importance of staying safe. > Asking an employer for help with safety while at work.
  • 79. Risk assessment framework Is the abuse Does the woman How worrying is Is the abuser becoming more have a disability? the abuse using a weapon? frequent, intense history? or severe? Is the woman Are children pregnant? being harmed? Is the woman Is the abuser about to leave Risk? stalking or her partner? harassing? How much does Is there a threat of the woman feel suicide or self-harm at risk? from either party? Does either party Does the abuser Is there Does the abuser Has the abuser have a mental misuse drugs emotional have a criminal threatened to health problem? or alcohol? abuse? history? kill/attempted strangulation?
  • 80. Responding to domestic abuse 68 Assessing risk a woman or child has serious injuries, but you should try to It’s important to determine the determine the extent of the extent of the danger faced by a risk in every case. woman and her children. This is a staged process for which you > If there is an immediate risk of don’t have full responsibility. harm (for example, a woman’s But you do play an important partner is in reception and part, particularly in assessing becoming aggressive) you whether somebody is at risk of should call the police. Never immediate harm. take on responsibility yourself for dealing with high-risk There are three stages to situations. assessing risk: > If somebody has already 1 A risk assessment between sustained injuries, accurate you and your patient documentation is important. > This doesn’t necessarily have A referral for further to be a written assessment. assessment, treatment, You might be in a situation specialist advice or counselling where you need to make an might be required. emergency decision about 2 An organisational framework whether a woman, her children or you and your > Your Trust or Health colleagues are at risk of Authority will have its own immediate harm. This will be guidelines for assessing risk more obvious in cases where around domestic abuse.
  • 81. A handbook for health professionals 69 It might have formal > Bringing together the documentation that you expertise of a range of need to fill in. A sample agencies (such as the police, organisational risk assessment health professionals and is included in Annex E. domestic violence agencies), these assessments offer the > You should follow guidance best opportunity for from your Trust or Health safeguarding women Authority. and children. > Discussion with your > In some areas, such as Cardiff, manager and clinical MARACs are the norm. Each supervision are tools which agency attending a MARAC are there to assist in accepts responsibility for improving your risk contributing to the risk assessment skills. assessment and providing the 3 A broader, multi-agency most suitable response for the response woman and child being discussed. Information from a > Certain areas are developing risk assessment might also feed strong local partnerships into the work of the local where multi-agency risk multi-agency public protection assessment conferences panel (MAPPP), which might (MARACs) are taking place. be considering whether a perpetrator is a risk to the community.
  • 82. Responding to domestic abuse 70 > If you are taking part in a As well as following multi-agency risk safeguarding children assessment, always follow procedures, you can support the information-sharing children by working in guidance provided by your partnership with agencies such Trust or Health Authority. as Sure Start, Early Years and schools, which can as part of If there are children in the their usual service: household > make early interventions with Local safeguarding guidelines pregnant women, new should be followed if there are mothers and children who children in the family. It may be have educational and necessary to refer to social behavioural problems services. It would be preferable resulting from domestic abuse; to seek a woman’s consent but this may not always be possible. > teach children about healthy If you have particular concerns, relationships; discuss these with your > use local education authority manager or child protection/ child protection co-ordinators domestic violence lead. to help protect children; and Your initial approach should - > provide education and never be to blame a woman - support for children who are for failing to protect her - affected by domestic abuse. children. Aim to provide her - with support and protection. -
  • 83. A handbook for health professionals 71 All areas are establishing the > children’s Trusts – currently following: being introduced following Lord Laming’s Inquiry into > children’s boards – all the death of Victoria Climbié. authorities should have Local Children’s Trusts will bring Safeguarding Children together health, social care Boards (LSCBs) by April and educational 2006. These provide health organisations in the interest professionals with the of vulnerable children. opportunity to help safeguard and promote the welfare of children; and Online support for children The Hideout (www.thehideout.org.uk) is an online resource aimed at children and young people who are witnessing or experiencing domestic violence. It provides information about what constitutes domestic violence, helps children to explore their feelings about what’s happening at home and lets them know what they can do to deal with their situation – including tips for staying safe.
  • 84. Responding to domestic abuse 72 What to do following a disclosure Are there children in the household? Yes No Assess risks. How serious is the incident? Is there a previous history? Is a report or referral to social services needed? Child in need/safeguarding procedures activated
  • 85. Responding to domestic abuse professionals 73 A handbook for health 73 Woman reveals she is experiencing domestic abuse Reassure, support and give national helpline numbers and information on local specialist domestic violence services Is there an immediate danger to physical or mental health or to life? No Yes Outline the need for safety. Discuss a safety plan and provide information on support agencies Document accurately in all cases. Take photographs if possible. Store all information confidentially Consider the need to share information safely, where necessary (see guidance)
  • 86. Is it necessary to involve manager/admit to hospital for treatment/involve police? Follow local multi-agency guidelines No
  • 87. 3.5 Keeping records Health records play an Keep detailed, accurate and - important role in responding to clear notes to indicate the - domestic abuse – and not just in harm that domestic abuse has - a health setting. The records caused. This can ultimately - you keep can be used in: assist women in living a safer - > criminal proceedings if a life. Perpetrators will be more - perpetrator faces charges; likely to be charged and - sentenced.- > obtaining an injunction or court order against Improving record keeping a perpetrator; > Always keep a detailed record > immigration and deportation of what you have discussed cases; with a woman – even if your suspicions of domestic abuse > housing provision; and haven’t led to disclosure. > civil procedures in family They might in the future. courts to assess the risks > You don’t need a patient’s associated with granting a permission to record a abusive parent contact with disclosure of domestic abuse children. or the findings of an examination. Make clear to a woman that you have a duty to keep a record of her disclosure and injuries as a duty of care.2
  • 88. A handbook for health professionals 75 > Keep records as detailed as explanation for it are possible (for example, consistent. ‘patient states she was kicked > If possible, use drawings or twice in stomach by husband’ body maps to show injuries rather than ‘patient (an example is provided in assaulted’). Diagnostic codes the training manual on the for domestic violence will be Department of Health included in electronic patient website). Photographs records (for which a template as proof of injuries should is currently being developed). be taken with a ‘The solicitors said there just - Polaroid camera. wasn’t enough evidence on - > To ensure confidentiality, you my health records. Nothing to - should record domestic abuse suggest my ex was to blame - separately from the main for my injuries. I was so let - patient record and ensure down. I thought my doctor - that the record can only be had written down everything - accessed by those directly I said.’ - involved in the woman’s > Use the patient’s own words care. Domestic abuse should (with quotation marks) rather never be recorded in hand- than your own. held notes, such as maternity notes. > Document injuries in as much detail as possible, and record if an injury and a woman’s
  • 89. Responding to domestic abuse 76 > For medical legal reasons, it is causing serious physical or - necessary to identify a person mental harm to the - experiencing abuse, her wife/partner.- relationship with the abuser and the name of the abuser. > In general practice, domestic abuse records should be seen in Data Protection Regulations - the context of the whole health (SI 2000/413 – Regulation 5 - record to get a clear – www.opsi.gov.uk/si/ - understanding of repeat si2000/20000413.htm) - consultations for health exempt information from - problems connected to the being released as a result of - abuse. However, practices that a subject access request which - encourage hand-held records ‘would be likely to cause - should record abuse separately. serious harm to the physical - or mental health or condition - > If your organisation has of the data subject or any - computerised records, ensure other person’. Even if an - that nothing about domestic abuser was able to sustain - abuse is visible on the a right of subject access, - opening screen (which could information provided by their - be seen by a perpetrator or a wife/partner that they had - member of staff who doesn’t abused them could still be - need to see information withheld on the grounds that - about the abuse). If routine it would be likely to result in - enquiry is practised, devise a further abusive behaviour - code to indicate whether the question has been asked and
  • 90. A handbook for health professionals 77 information provided, when > You should adhere to the it was carried out and what processes and the outcome was – to alert documentation for recording staff to potential risks. domestic abuse that your Trust has put in place. What to include in notes Your notes on domestic abuse should include: > ethnicity; > whether routine enquiry has been undertaken; > response to routine or selective enquiry – if used; > relationship to perpetrator, name of perpetrator; > whether the woman is pregnant; > the presence of children in the household; > nature of abuse and injuries – if any exist; > description of all kinds of domestic abuse experienced and reference to specific incidents; > whether this is the first episode. If not, how long has it been going on and how regularly? > presence of enhanced risk factors; > indication of information provided on local sources of help; and > indication of action taken (for example, direct referrals).
  • 91. 3.6 Confidentiality and information sharing Keeping information > Confidentiality is confidential particularly important in general practice, where > It is vitally important that health professionals might information on domestic treat other members of a abuse is kept confidential. woman’s family – including Without confidentiality, the perpetrator, who can use women are less likely to talk information to track down a about their experiences. partner who has left him. Their physical safety can depend on it. > But it’s important to understand – and to explain In 1998, Gina McCarthy’s - to women who reveal that husband had been refused - they are experiencing contact with his baby son - domestic abuse – that there following their separation. - are limits to confidentiality. The courts had ordered Gina - For example, if there is to send her husband monthly - reason to suspect children progress reports via social - are at risk, safeguarding and services. Using the - protection should always information from the monthly - take precedence over reports, Gina’s husband - confidentiality. identified her home, tracked - her down and killed her in - front of their son, whom he - then abducted.3 -
  • 92. A handbook for health professionals 79 Safe information sharing > You will need to make an informed decision about > There will also be occasions whether you need to share when information about a information in a given domestic abuse case should situation. It’s not always easy be made available (see to balance confidentiality Safety and justice: sharing against the interests of personal information in the disclosure. Never make a context of domestic violence decision on your own. www.homeoffice.gov.uk/rds/ pdfs04/dpr30.pdf) – either > Be particularly wary of because it is required by law situations in which (if records are being used as confidentiality could evidence in a court case, for accidentally be broken. example) or to help support For example, if a child who agencies tailor services to is staying at a refuge spends meet a family’s needs (for time in hospital and the advocacy or carrying out a father visits the child, you risk assessment, for should take care that records example). that are on display do not include a contact address or any other information that could help a perpetrator track down people he has previously abused.
  • 93. Responding to domestic abuse 80 > In some instances, failure to > Your Trust or Health share information can be as Authority should have dangerous as breaking information sharing policies confidentiality in place to help inform health inappropriately. professionals in their decisions about sharing In 1999, Mark Goddard was - information. convicted of the murder of his - wife, Patricia. In the five - > Only ever consider giving months before Patricia’s death,- information to reputable her employer and six different - agencies – never to agencies (including health, - individuals making enquiries housing and police services) - about a woman’s were aware of her problems - circumstances. and abuse. None of the - > The only acceptable reason agencies informed anyone else- for sharing information is to about their concerns. We don’t- increase a woman’s safety know that information sharing- and that of her children. could have saved Patricia’s life,- Even then, only share but it would have at least - information that is relevant. enabled a comprehensive risk - assessment to be carried out.4 - > Always follow local multi-agency guidelines for sharing information about domestic abuse.
  • 94. A handbook for health professionals 81 > Respect deadlines. If you are being allowed to stay in the late giving information to country. Take time to ask solicitors who are dealing when information is needed with a woman’s immigration if you haven’t been given application, for example, you a deadline. will jeopardise her chances of Can you share information without permission? > Always seek a woman’s permission to share information. > But given current legislation (section 115 of the Crime and Disorder Act 1998) it is permissible to pass information to another agency in situations where: – the courts request information about a specific case; or – there is significant risk of harm to the woman, her children or somebody else if information isn’t passed on. If you do pass on information without permission, you should be completely sure that your decision doesn’t place somebody at risk of greater violence. You will need to be able to justify your decision. See guidance in the Home Office’s Safety and justice: sharing personal information in the context of domestic violence, which is available online at www.homeoffice.gov.uk/rds/pdfs04/dpr30.pdf.
  • 95. Responding to domestic abuse 82 References 1 Chantler, K. et al. (2001) Attempted suicide and self- harm: South Asian women (Manchester Metropolitan University Women’s Studies Research Centre); Newham Asian Women’s Project (1998) Young Asian women and self-harm: a mental health needs assessment of young Asian women in East London. 2 Nursing and Midwifery Council (2002) Guidelines for records and record keeping; Nursing and Midwifery Council (2005) NMC code of professional conduct: standards for performance and ethics. 3 Home Office (2004) Safety and justice: sharing personal information in the context of domestic violence. 4 Home Office (2004) Safety and justice: sharing personal information in the context of domestic violence.
  • 96. Section 4 Guidance for policy-makers and managers In this section: 4.1 Your role 4.2 Working together 4.3 Supporting staff 4 Guidance for policy-makers 4.4 Education and training and managers 4.5 A multi-agency approach 4.6 Monitoring and data collection 4.7 Confidentiality and information sharing
  • 97. 4.1 Your role As a policy-maker or manager in > participate fully in multi- the NHS, you play a pivotal role agency initiatives; and in making sure services respond > monitor, evaluate and audit to domestic abuse effectively. health services’ domestic Your role should be to: abuse initiatives and collect > create strategies and policies appropriate data. for delivering local service provision which reflect national guidance; > place at the heart of decision making the safety of women and children who have experienced abuse;
  • 98. Responding to domestic abuse 84 What should be included in domestic abuse policy? As a bare minimum, policy should include: > a description of the principles underpinning the policy; > a definition of domestic abuse; > information on the national and local context; > an outline of expectations of policy; and > the Authority’s or Trust’s approach – to include reference to who has responsibility for asking a woman about domestic abuse. By saying that everybody needs to take responsibility for asking about domestic abuse, you might risk nobody doing so. The main responsibility should lie with the person with primary responsibility for a woman’s care. It is of paramount importance that your policy is underpinned with education and training, supervision and support for staff.
  • 99. 4.2 Working together The NHS can best respond to supplied with this handbook domestic abuse by co-operating contains a sample strategy, with other organisations in policy and guidance document multi-agency partnerships. (for Ashfield and Mansfield NHS Trust). Strategic Health Authorities and Trusts should have policies for The principles below should responding to domestic abuse underpin all local domestic effectively. The CD-Rom abuse policy. The safety of women and children is the primary concern in any initiative. Patients should be listened to with respect and dignity and without judgement. Health professionals should empower women to make their own decisions and not make decisions on their behalf. They should not extend their role to include in-depth support where other agencies might have more experience. Information sharing is beneficial if carried out appropriately and safely. Appropriate levels of confidentiality should be respected. Staff should not put themselves or their colleagues at risk in a potentially violent situation.
  • 100. Responding to domestic abuse 86 Introducing policy guidance ‘I was asked and it opened up - on routine enquiry and the a whole catalogue of services, - provision of information because I eventually decided - > Your domestic abuse policy that I was not going to lie. The- should outline how your hospital had already worked - organisation is working out what was going on - towards routine enquiry and because of the nature of - the provision of information my injuries.’ - – asking questions about > You should handle the domestic violence to every introduction of routine woman who fits set criteria. enquiry with care and ensure Local policy will probably it is always coupled with start with pregnant women provision of information, and then be rolled out to irrespective of disclosure. other women. Staff should be properly > In areas where routine trained in how to use enquiry enquiry has been tested, the tools and interview majority of women have said techniques as well as that they don’t mind being responding appropriately. asked about domestic abuse Allowing untrained staff to if they know that everybody discuss domestic abuse could is being asked the same increase the risk of abuse for questions. women or make them less likely to reveal that they are being abused.
  • 101. A handbook for health professionals 87 > You should never introduce who develop a relationship routine enquiry and the with health professionals provision of information during a pregnancy might be without having in place more open to choosing to guidelines, referral processes disclose abuse once the and robust clinical relationship is well supervision. established. > Health professionals who > More information on have primary responsibility training, awareness raising for a service user’s care and the general principles/ should be trained in routine issues around domestic enquiry and the provision of violence can be found on the information. Eventually, CD-Rom that accompanies domestic abuse should this handbook and the be an integral part of educational and training undergraduate and materials on the Department professional training for of Health’s website. health professionals. > The domestic abuse > Routine enquiry should never guidelines should make clear be treated as a one-off that health professionals see activity. Enquiry at specified a woman alone if they are intervals increases the going to speak about likelihood of a woman feeling domestic abuse. They should safe enough to talk about her never raise the subject if abuse. For example, women anybody else – including
  • 102. Responding to domestic abuse 88 friends or family members – a lead health professional? is present. The one exception Some Trusts and Health to this would be a Authorities already have professional interpreter (see lead health professionals. Using an interpreter? on It’s important that your page 53 of this handbook). employees have someone to turn to for guidance and that > Your domestic abuse domestic abuse initiatives are guidelines should outline the drawn together to provide a response you expect from comprehensive response to staff to whom women local need. disclose domestic abuse. This should include > How will your Trust meet information on your Trust’s or its obligation to keep staff Health Authority’s approach informed of legislative to risk assessment – changes that impact on particularly multi-agency risk their practice? assessments, which offer the > How will your organisation best protection for women raise awareness about the and children experiencing nature and prevalence of domestic abuse. domestic abuse? Further considerations > What support will you give > Has your Trust recognised to staff with personal domestic abuse as a core experience of domestic health issue and appointed abuse? Ensure that all staff
  • 103. A handbook for health professionals 89 are familiar with the NHS > How will you identify Employers organisation’s opportunities for multi- workplace policy on domestic agency working? One of abuse and are able to access your priorities should be their Human Resources (HR) contacting local domestic department, where it is violence organisations to recommended a domestic discuss how you could work abuse workplace policy together. You should should be in place. also ensure that a senior Primary Care Trust (PCT) > How can your staff share representative is a member of information appropriately the local Crime and Disorder and safely with other Reduction Partnership organisations? Adhere to (CDRP) and the Domestic guidance in Safety and Violence Forum or Domestic justice: sharing personal Abuse Forum, if one exists. information in the context of domestic violence, which is ‘You just don’t realise how - available online at: much help is out there. - www.homeoffice.gov.uk/rds/ I thought I’d go to a refuge - pdfs04/dpr30.pdf. and that would be it. But so - many people were involved. - I’m just grateful that I didn’t - fall through cracks in the - system.’ -
  • 104. Responding to domestic abuse 90 Good practice Women who experience domestic abuse are often worried about going to hospital. They are concerned about having to wait in public places and about the level of domestic abuse training staff receive. Some Trusts have a midwife or nurse consultant who has strategic responsibility for a co-ordinated response to domestic abuse. They educate health professionals in domestic violence issues and represent the Trust in multi-agency partnerships. Indicators of good practice in domestic abuse 1 Developing a definition of domestic abuse in conjunction with appropriate service provision. 2 Overarching domestic abuse policies and guidelines which include vulnerable adult and child protection issues. 3 Prioritising safety. 4 Awareness raising, education and training. 5 Evaluation, auditing processes and data collection. 6 A multi-agency strategy.
  • 105. 4.3 Supporting staff Supervision and guidance – safe information sharing – within health agencies and > Staff working with women with other organisations. and children who might have been abused should have > Some staff might feel that clinical supervision to support they are expected to be the them in delivering good only source of support for practice. women experiencing domestic abuse. It should be > Guidelines should be in place made clear that this isn’t the to set out the procedures case. Policies and guidelines staff need to follow. should stress that a major The most important issues benefit of multi-agency to cover are: working is the alleviation of – routine enquiry and pressure on health staff to provision of information; ‘case manage’ service users trying to create a safer life. – considering safety issues; Personal experience of – clear referral pathways; domestic abuse – confidentiality; Domestic abuse is prevalent – record keeping and the across all sections of society. significance of compiling As the largest employer in an evidence base; and Europe, the NHS is bound to employ people who have been or are currently experiencing
  • 106. Responding to domestic abuse 92 domestic abuse and > It should create an perpetrators of domestic abuse. environment in which staff Having domestic abuse can disclose abuse and ask responsibilities introduced as for confidential support. part of their job can > Health services should consequently trigger painful demonstrate zero tolerance emotions. of perpetrators in the > The NHS should support staff workplace. who are experiencing > Authorities and Trusts should domestic abuse or who are have domestic abuse still dealing with the long- workplace guidelines. term effects of past abuse. What to include in an HR policy: > a statement of commitment to provide support, advice and information; > an overview of the legal basis for the policy; > what the organisation will provide for those experiencing domestic abuse; > how the organisation will respond to perpetrators; > how policy will be implemented and monitored; and > what training will be made available to line managers.
  • 107. A handbook for health professionals 93 What can your organisation offer those experiencing domestic abuse? Confidentiality Nominated Information contact for staff about domestic affected by abuse abuse Support Practical measures Access to specialist to ensure the support services safety of those affected Flexible working and supportive measures
  • 108. Responding to domestic abuse 94 Demonstrating zero tolerance The NHS Employers - to perpetrators in the health organisation is a member of - service the Corporate Alliance, a - > Make employees aware that group of commercial and - domestic abuse is government organisations - unacceptable and can lead committed to developing - to criminal convictions. domestic abuse workplace - policies and good practice. - > Inform staff that conduct In September 2005, it - outside of work can lead to produced a draft domestic - disciplinary action at work: abuse workplace policy which - domestic abuse undermines will eventually be put in place - your confidence in them and in all NHS HR departments. - harms the organisation’s reputation. > Have a policy that reported incidents of abuse from a partner who also works for the NHS may lead to suspension or redeployment of the alleged perpetrator pending a disciplinary investigation.
  • 109. 4.4 Education and training > Successful implementation of > Education and training in policy and guidelines relies domestic abuse needs to start on a comprehensive at undergraduate level and education and training continue in specialist training programme. and continuous professional development programmes. > All staff who have contact with patients should be > It is not advisable to trained in domestic abuse introduce new approaches issues – this includes until all relevant staff administrative and reception are trained. staff. > Education and training > All health professionals should be relevant to staff’s should be given basic working environment. information and taught Aims of training about the nature and prevalence of domestic abuse > improving awareness and and the steps that they need understanding; to take to provide > increasing sensitivity to information, support potential signs of domestic disclosure and prevent abuse; further abuse. > improving awareness of possible signs and symptoms of child abuse;
  • 110. Responding to domestic abuse 96 > increasing health > improving awareness of local professionals’ confidence in specialist services and providing support; resources. > implementing new It is sometimes beneficial to approaches, such as routine have multi-agency contributors enquiry about domestic and participants at training. abuse as part of taking a Obviously, for those aspects of social history; training that refer solely to healthcare, only healthcare staff > establishing core principles should attend. for responding to women experiencing domestic abuse; > ensuring an appropriate response when abuse is disclosed; > developing communication skills to improve empathetic responses; > improving communication and information sharing between stakeholders; > ensuring a co-ordinated response at strategic and individual levels; and
  • 111. 4.5 A multi-agency approach > A multi-agency approach is – actively promoting advice widely accepted as the best on information sharing in way to approach domestic line with the Home abuse issues. It is strongly Office’s Safety and justice: recommended by sharing personal Government. information in the context of domestic violence; > In April 2004, PCTs were given the statutory duty to – displaying or giving out work in partnership with information about support other agencies in CDRPs to services for those who reduce crime (see the CD have experienced Rom accompanying this domestic abuse; handbook, Guidance for – developing and Partnerships and Primary implementing a domestic Care Trusts (PCTs). This abuse policy; includes: – training staff to – providing anonymised understand and data for the CDRP audit; implement the domestic – signing up to local abuse policy; and information-sharing – developing domestic protocols; abuse services – either alone or in partnership with other agencies.
  • 112. Responding to domestic abuse 98 > Working in partnership with > Partnerships are a means to other organisations isn’t an end, and not an end in always easy. Decisions in one themselves. Aims, objectives organisation can affect how and plans should be clearly services are delivered in stated and progress another. Conflicting monitored regularly. pressures can act as a barrier > For more information on to success. But it’s important working in partnerships, that all agencies – including see the Home Office those in the healthcare publication Developing sector – work together to domestic violence strategies: overcome obstacles. a guide for partnerships > Partnerships should focus on (available online at: action for improving safety www.crimereduction.gov.uk/ for women and children. domesticviolence46.htm). They should not be ‘talking shops’ where decisions are not made and outcomes not achieved. > Staff attending partnership meetings should have the authority to contribute to decisions that need to be made.
  • 113. 4.6 Monitoring and data collection Monitoring > The criteria used to monitor local initiatives will vary > To assess whether domestic depending on specific goals abuse initiatives are and objectives adopted by improving the safety of healthcare providers or women and children, they partnerships. But the diagram need to be monitored below provides a framework regularly. for setting monitoring > Every agency involved in criteria. domestic abuse initiatives > The results of monitoring will should be able to: help shape services and will – describe the work they provide valuable data for the are doing; CDRP’s crime reduction audit and strategy. – measure the services they provide; – detail how their services are being used; and – demonstrate how their existing resources are being spent.
  • 114. Framework for setting monitoring criteria Improvements in the safety of women and children Development and Improvements in implementation of service provision comprehensive domestic abuse strategies 100 Criteria for monitoring domestic abuse initiatives Responding to domestic abuse Monitoring levels Service user of disclosure and consultation and repeat incidents of satisfaction domestic abuse Concrete changes in policy and practice
  • 115. A handbook for health professionals 101 Collecting data > The inclusion of domestic abuse diagnostic codes in the > Recording information and new electronic patient developing a case history records will make it easier to of how initiatives are collect data in future. developing is a vital part of NHS domestic abuse > You should share the results initiatives. of data analysis with colleagues within the NHS > Managers should monitor and in domestic abuse and respond to data that are partnerships – as regularly collected. Gathering as possible. anonymous information from individual records will enable > Internally, the results of data us to paint a picture of: analysis are a good opportunity to remind staff – the size of the NHS of the importance of detailed domestic abuse workload; record keeping. – how effective our > Externally, it gives a more response is; and accurate and detailed – where there are gaps in assessment of local service delivery that need prevalence of domestic to be filled and how abuse and the associated commissioning can be need for services. improved.
  • 116. Responding to domestic abuse 102 Making it count: a practical - guide to collecting and - managing domestic violence - data, published by NACRO in - 2003, contains useful - information on data collection. - It is accessible online by - clicking on ‘Online resources - and links’ in the quick links list - on the NACRO website at: - www.nacro.org.uk. -
  • 117. 4.7 Confidentiality and information sharing > Confidentiality is a > Staff should be made aware foundation stone for building that they should usually only the conditions in which share information after a women feel comfortable woman has given her disclosing domestic abuse. permission. They should It should inform all policy also be aware of the and protocol and should be circumstances under which included in training for information can be shared health professionals. without permission. Managers should be able > The transfer of anonymised to advise their staff on data poses no problem. But these issues. for personalised data, the guidance in Section 3.6 of > Information sharing guidance this handbook outlines the should inform health main considerations for professionals on how to frontline staff. share information safely. > Authorities and Trusts should acknowledge the difficulty of balancing the need for confidentiality with an assessment of whether information sharing will put a woman and her children at increased risk of abuse.
  • 118. Responding to domestic abuse 104 Safety and justice: sharing - > Health organisations should personal information in the - contribute to multi-agency context of domestic violence is- guidelines on confidentiality. a Home Office publication - Special attention should be which will be useful when - paid to situations in which producing policy on or facing - confidentiality could be decisions about confidentiality - broken inadvertently. Your and information sharing. - guidelines should contain It is available online at: - practical examples relating www.homeoffice.gov.uk/ - to specific health service rds/pdfs04/dpr30.pdf. - environments. The Crime Reduction website > If organisations are to share has an easy-to-use interactive information effectively, all tool, which asks simple yes/no organisations concerned questions to help staff should share data sets. determine if confidential Signing up to an agreed information can and should be definition of domestic shared with other agencies. violence and abuse (see the It can be found at: Government’s definition in www.crimereduction.gov.uk/ Section 2.2 of this handbook) isp01.htm. will be a first step. > Support measures should be in place for staff facing difficult decisions about information sharing.
  • 119. A handbook for health professionals 105 > Authorities and Trusts will want to determine their own local data requirements and to consider subsequent IT implications. Suggested data requirements include: – the number of recorded, and repeated, incidents of domestic violence in a year (broken down by age, sex and ethnicity). Electronic patient records will assist in data collection and provide a robust evidence base; – the proportion of local child protection cases involving domestic abuse; and – findings from any local research into domestic abuse.
  • 120. Annexes, useful contacts, local information In this section: Annex A – Membership of the Inter-Ministerial Group on Domestic Violence Annex B – Action plan drawn up in response to the recommendations of the Domestic Abuse and Pregnancy Advisory Group Annex C – Women with particular needs Annex D – Sample safety plan Annex E – Sample risk assessment Useful contacts Local information local information Annexes, useful contacts,
  • 121. Annex A Membership of the Inter-Ministerial Group on Domestic Violence Government action on domestic > Department for Work violence is led by the Inter- and Pensions Ministerial Group on Domestic (www.dwp.gov.uk) Violence, set up in 2003. > Office of the Deputy The group is chaired by Home Prime Minister Office Minister Baroness (www.odpm.gov.uk) Scotland, QC. It includes > Northern Ireland Office ministers from the key (www.nio.gov.uk) departments below to provide a joined-up and robust > The Solicitor General programme of work: (www.lslo.gov.uk) > The Home Office > National Assembly for Wales (www.homeoffice.gov.uk) (www.wales.gov.uk) > Department for Education The Government’s strategic and Skills (www.dfes.gov.uk) approach to tackling domestic violence was set out in the > Department for consultation paper Safety and Constitutional Affairs Justice. The approach has led to (www.dca.gov.uk) the Domestic Violence, Crime > Department of Health and Victims Act 2004, the (www.dh.gov.uk) largest piece of legislation on domestic violence in over > Department of Trade 30 years. and Industry (www.dti.gov.uk)
  • 122. Annex B Action plan drawn up in response to the recommendations of the Domestic Abuse and Pregnancy Advisory Group The terms of reference the nature and frequency of domestic violence, that those The Advisory Group’s terms of affected need not suffer in reference were: silence and will be listened to ‘to advise Ministers on the sympathetically, and all women practicalities of taking forward are given information on how the commitment in the to access local and national Children’s, Young People’s and sources of support and advice’. Maternity NSF [National Recent NHS reforms were Service Framework] to provide designed to meet the needs of a supportive and enabling patients more effectively. One environment within antenatal outcome has been a shift of care for women to disclose emphasis from Whitehall to the domestic violence’. NHS frontline. It is now the Definition of enabling responsibility of local environment authorities, managers and professionals to set priorities in The group proposed the following the light of their resources and definition of an enabling the needs of their populations. environment, which may make it The role of the Department of easier for women to seek help Health (DH) is to set out a clear about personal violence: national framework whilst ‘an environment which ensures, providing resources, setting at the very least, that all standards and looking at pregnant women know about accountability.
  • 123. A handbook for health professionals 109 Action points: national activity 6 Regularly update relevant national DH publications 1 Ensure wider promotion of such as the Domestic the new number for the violence resource manual national telephone helpline. for health professionals, 2 Develop a single common Pregnancy book and Birth website portal for all to five. enquiries about violence. Action points: local activity 3 NHS Direct staff to be 7 Material should be - trained in issues relating to provided that meets the - domestic violence and be needs of the local - able to refer callers to the population in a variety of - relevant services. easily accessible formats - 4 National telephone number and media. Support should - and website address to be be available from the start - displayed on all national in easy access formats for - documents relating to all, including in different - maternity and postnatal languages and easy - services. read format. - 5 A possible national 8 The numbers and website campaign to raise awareness addresses of the national amongst women attending and local helplines should be clinics or GP practices. automatically printed at the bottom of all NHS
  • 124. Responding to domestic abuse 110 appointment cards and any foods etc, but which will other locally produced also include the domestic information. violence helpline numbers. 9 The national and local 11 The national helpline helpline numbers should be number and website address printed on local hand-held should be printed on a maternity and child health standardised credit-card- records as well as being sized leaflet that should be made available in clinics by made freely available in means of posters, videos etc. clinics or elsewhere. These may be adapted for 10 New mothers to receive, local use. as part of their baby record book, a laminated card with 12 Regular surveys should be a complete list of useful carried out to ascertain how national and local numbers many women recalled seeing of organisations that can the information, if they help them and their babies, understood it and such as access to breast modifications made feeding advice, welfare accordingly. UK Gold Book The UK Gold Book is a UK-wide directory of refuge and domestic abuse services. To order it, see page 127.
  • 125. A handbook for health professionals 111 13 Policies should be audited DH intends to produce generic locally as part of the materials to raise awareness monitoring process tracking amongst women attending implementation of the clinics or GP practices and is Maternity Standard of the considering use of the National Children’s, Young People’s Electronic Library for Health for and Maternity NSF. callers to access agencies addressing domestic violence. 14 NHS maternity services DH is also investigating the should move to include a incorporation of a question on routine question as part of domestic violence in a the social history taken survey/surveys related to the during pregnancy, but this implementation of the should be introduced at a Maternity Standard of the measured pace, and with Children’s, Young People’s and appropriate training. Maternity NSF.
  • 126. Annex C Women with particular needs Women experiencing domestic abuse will all have their own circumstances to relate, and it’s important to approach each case without assumptions and prejudice. Culture and lifestyle are important influencing factors in how a woman relates to her abuse – and to how it is seen by the wider community. The prompts in this section are not exhaustive. It would be impossible to provide a comprehensive list to cater for the varying health needs of the whole community. However, by giving prompts for some minority communities, we hope to demonstrate the importance of allowing a woman to describe her own experiences of abuse and enabling her to make her own decision of how she wants to deal with it, based on her own circumstances. Issues for minority ethnic or > Minority ethnic women migrant women might feel that they have too much to lose by leaving an > Some women don’t speak abusive partner. For example, English as their first religious or cultural beliefs language. This is a barrier might forbid divorce. Culture when they try to access should never be accepted as services. All staff should have an excuse for abuse. access to professional interpreters.
  • 127. A handbook for health professionals 113 > They might be wary of Issues for older women involving the police or other > Older women might find it services, because of actual or difficult to reveal their abuse perceived racism. to a young person. > Migrant women might fear > Some older women might be losing the right to stay in this embarrassed that they have country if they separate from put up with the abuse for so an abusive partner. Their long, and they might ‘talk partner might use this threat down’ the extent of their as part of the abuse. They experiences. might also fear that their partner’s immigration status > Older women might might be threatened. experience abuse from a partner who is also their > Some women have ‘no carer. Like women with recourse to public funds’ disabilities, they might be because of their immigration afraid of losing their home, status. They will be unable support, independence – to support themselves and especially if institutional care their children if they leave is the only option. their husbands.
  • 128. Responding to domestic abuse 114 Issues for disabled women > Some refuges have adapted facilities, including full > Women with disabilities wheelchair access, and there might feel dependent upon is one refuge in London that the person abusing them and caters for women with their home, which might learning difficulties. have been adapted to meet their care needs. This makes Issues for lesbians and leaving an abuser a very bisexual women difficult option – and it is > It’s important to understand important to give women that abuse between women information about alternative brings up different issues sources of care. than that between a man and > They might be afraid of being a woman. For example, an left alone at home or being abusive woman might not put in institutional have the same status and accommodation. It is power as an abusive man, important to acknowledge but she might be more able that there are few alternative to access women-only sources of support. services to trace her partner.
  • 129. A handbook for health professionals 115 > Women are often reluctant Issues for young women to report that they have been > Young women have special experiencing abuse at the needs if fleeing abuse from hands of a female partner, their father, brother or other because of heterosexual- male relative. Evidence on centred assumptions about child sexual abuse suggests domestic abuse, anti-lesbian that as the age of the child attitudes and the fear of not increases, so does the being believed. likelihood of the abused child > Lesbians and bisexual being a girl. If the young women may be reluctant to woman is under 18, report abuse by a female safeguarding children partner to the police as they measures should be fear they might be subject to followed. discrimination because of > There are some specialist their sexuality. agencies to support young > The Domestic Violence, women, but housing options Crime and Victims Act 2004 are usually very limited. will ensure that same-sex Specialist housing projects couples have the same legal and refuges do exist. It is rights under the Family Law important to remember that Act as heterosexuals. if a young woman is leaving home for the first time, she will need extra support.
  • 130. Responding to domestic abuse 116 > In some cases, young women > They might seek legal help – will have several such as an injunction – or professionals supporting families with more than one them at the same time. The caravan might be able to various agencies involved divide the property. should work together to > Traveller women sometimes ensure that the multi-agency find it hard to stay in refuges approach isn’t – perhaps due to prejudice disempowering a from other residents. young woman. > Within the travelling Issues for traveller women community, marriage is seen > Travellers are not very likely as being for life. If a woman to approach the police to ask leaves her husband, she for help, because they worry often has to leave the whole that they will not be treated community, having lost the with respect. They might also status of a married woman. worry about how a Leaving the community perpetrator will be treated by means losing contact with the police and courts, if her culture and way of life charged. Or they might be and facing the prejudice of concerned about how their the settled population. community will respond to them if they contact the police.
  • 131. A handbook for health professionals 117 Issues for middle-class women Issues for women who misuse drugs and alcohol > Middle-class women might be less familiar with services > Women who misuse drugs or available to assist them. alcohol might fear that they will not be taken seriously or > They might be uncertain that they will be treated in about coping financially, terms of their drug or especially if they are alcohol use. dependent on their partner’s income. > They might think that agencies won’t take women > They might be afraid that who misuse drugs or alcohol no-one will believe that their and are in chaos. Or they outwardly successful partner might think agencies don’t could also be an abuser. have services that meet > Research shows that middle- their needs. class women are far less likely > Their abuser might also be to involve the police. their supplier, or they might be scared of losing their supply and having to face withdrawal.
  • 132. Responding to domestic abuse 118 > The abuser might be > The financial pressures they controlling her through her face might stop them leaving drug or alcohol misuse. He an abuser, who might have might have threatened to tell immense power over a other people about her number of women. misuse. > They might fear facing the > They might be afraid that attitude that women who they will lose their children work in the sex industry if their drug or alcohol misuse should expect assault is revealed. and rape. > Women sometimes misuse > Sex workers often have drugs and alcohol to cope difficulty in finding with domestic abuse. employment, due to a lack Dual diagnosis should be of references, qualifications recognised by both by and training. Drug Action Teams and > Women who have been health professionals. trafficked might have Issues for sex workers and additional fears about their women who are trafficked status as an illegal immigrant. They might also have > Sex workers might not want language difficulties and not to approach agencies for know where to turn for help. help because of perceived or actual disrespect from authorities.
  • 133. A handbook for health professionals 119 > Trafficked women might feel version of materials or a sense of helplessness or explain the contents clearly shame at their situation. face to face. Being forced into sex work > Women with learning might transgress their own disabilities might find it cultural values and make it difficult to describe their difficult for them to reveal experiences or might express their situation. their feelings differently to > Sex workers who have other women. experienced domestic abuse > A perpetrator might exploit a have multiple needs. When woman’s learning disability treating a sex worker, genito- to make her feel responsible urinary clinics need to be for the abuse or to aware that she might face normalise it. additional risks. > Women with learning Issues for women with disabilities might fear that learning disabilities they won’t be believed if > Women with learning they disclose their abuse. disabilities might find it Or they might fear not difficult to understand being able to cope with or information you give them understand the about domestic abuse. You consequences of disclosure. might have to produce a simplified and/or recorded
  • 134. Annex D Sample safety plan This safety plan can be used by > What code word or phrase women experiencing domestic can she use in an emergency abuse, but the questions are to let her children know that meant as a guide or prompt she wants them to get to rather than as a form to be filled safety immediately? in. Remember that it might not > Ask her to think of four be safe for women to fill in places she can go to if she safety plans and take leaves her home. them away. > Who can she leave extra Increasing safety in the money, car keys, clothes and woman’s relationship copies of documents with? > Where can the woman keep > What will she take with her if important phone numbers so she leaves? that they are always accessible to her and her > Where can she leave an children? emergency bag? > Ask her to think of the names > Where can she hide of two people she can tell emergency money and about the abuse and ask important documents? them to listen out for strange noises from her home, so that they can call the police if she is being assaulted.
  • 135. A handbook for health professionals 121 > What parts of the house > Who will she ask to call the should she avoid when the police if they see her partner abuse starts? Where is there near her home or children? no exit? Where are there > Advise her that she should things that can be used as tell the people who care for weapons? her children who is allowed Increasing safety when a to pick them up, and give relationship is over them the names of the people she has given > Things that she might need permission to. to do straight away: > Who can she tell about her – change locks; situation at work and ask – get smoke detectors; them to screen her calls? – get a security system; > What shops, banks and other places that she used to use – get stronger (metal) doors; with her partner does she – get an outdoor lighting need to avoid? system; > Who can she call if she’s – change landline and feeling down and is tempted mobile numbers. to return to her partner? > Who will she tell that her partner no longer lives with her?
  • 136. Responding to domestic abuse 122 Important phone numbers > Make a list of numbers including the police, a helpline, friends and a refuge or outreach centre. Advise the woman that she - should always dial 141 before - calling out, so that her number - can’t be traced. -
  • 137. Annex E Sample risk assessment Metropolitan Police Service risk assessment for domestic violence cases From their in-depth analysis of domestic violence homicide cases in London, Laura Richards and Professor Betsy Stanko have identified six high-risk factors for domestic violence: High-risk factors: SPECSS Present?- Separation (child contact) Pregnancy/new birth Escalation: the attacks becoming worse and happening more often Cultural issues and sensitivity Stalking Sexual assault
  • 138. Responding to domestic abuse 124 Separation Cultural issues and sensitivity Those experiencing abuse trying Needs may differ with ethnic to leave relationships are minority people experiencing frequently murdered. Many domestic abuse. This might be incidents happen as a result of in terms of issues of perceived child contact or disputes over racism, language, culture, residence and contact. insecure immigration status and accessing relevant support Pregnancy/new birth services. Domestic abuse may Domestic abuse can start or take on different forms within get worse in pregnancy. specific communities. For Escalation example, women and girls may There is a very real need to even be killed for their actual or identify repeat incidents of perceived immoral behaviour in abuse and escalation. Those some communities. This is experiencing abuse are more sometimes termed an ‘honour likely to experience repeat killing’, whereby the family or incidents than any other type community try to restore their of crime: as abuse is repeated honour and respect by killing it gets more serious. the woman or girl concerned. Immoral behaviour may take the form of perceived or actual infidelity, refusing to submit to marriage, separating, flirting with men or ‘allowing herself to be raped’.
  • 139. A handbook for health professionals 125 Stalking Sexual assault Persistent and consistent calling, Analysis of domestic sexual texting, sending letters, assaults for the first four months following, etc. Stalkers are more of 2001 in London show that likely to be abusive if they have those who are sexually had an intimate relationship assaulted are subjected to more with the person experiencing serious injury. Those who report abuse. Furthermore, stalking a domestic sexual assault tend and physical assault are to have a history of domestic significantly associated with abuse, whether or not it has murder and attempted murder. been reported previously. One in twelve of all reported domestic sexual offenders were considered to be very high risk and potentially dangerous offenders.
  • 140. Responding to domestic abuse 126 Risk management Accept the risk by continued A crucial part of risk assessment reference to the RARA model, is risk management. Officers continual multi-agency should refer to the interventions intervention planning, support options document and in doing and consent of the person so adhere to the RARA model experiencing abuse, and when compiling safety plans offender targeting within for people experiencing abuse. pro-active assessment and tasking pro-forma (PATP) and Remove the risk by arresting the multi-agency public protection suspect and obtaining a remand panel (MAPPP) format. in custody. Avoid the risk by re-housing the person experiencing abuse/ significant witnesses or placement in refuge/shelter in location unknown to suspect. Reduce the risk by joint intervention/safety planning for the person experiencing abuse, target hardening and use of protective legislation.
  • 141. Useful contacts This section provides contact Wales Domestic Abuse details for the main Helpline organisations and resources that Helpline 0808 80 10 800 might be useful when Web supporting women and children www.welshwomensaid.org who are experiencing, or who Scottish Domestic Abuse have experienced, domestic Helpline abuse. For additional useful Helpline 0800 027 1234 websites, books, articles and Web policy papers, please see the www.scottishwomensaid.co.uk CD-Rom that was supplied with this handbook. Northern Ireland Women’s Aid 24-hour Domestic National helplines Violence Helpline Freephone 24-hour National Helpline 0800 917 1414 Domestic Violence Helpline Web www.niwaf.org Run in partnership between Key domestic abuse resources Women’s Aid and Refuge. Helpline 0808 2000 247 The UK Gold Book, published Web www.womensaid.org.uk/ by Women’s Aid and updated www.refuge.org.uk annually, is a UK-wide directory of refuge and domestic abuse services for women and children, as well as professionals and the general public. The UK Gold Book has been developed
  • 142. Responding to domestic abuse 128 through the UKrefugesonline Agencies supporting those partnership project of leading who have experienced domestic violence service domestic abuse providers: Women’s Aid Action on Elder Abuse Federation of England, Scottish Information and support for Women’s Aid, Welsh Women’s older people experiencing abuse Aid, Northern Ireland Women’s or people who have witnessed Aid and Refuge. abuse. Helpline operates To order The UK Gold Book Monday to Friday, 10.30am contact Women’s Aid on to 4.00pm. tel 0117 944 4411, or email Address Astral House, info@womensaid.org.uk. 1268 London Road, London SW16 4ER A list of public contact details Helpline 0808 808 8141 for all domestic abuse services is Email available at: enquiries@elderabuse.org.uk www.womensaid.org.uk/ Web www.elderabuse.org.uk network/index.htm. Akina Mama wa Africa Advice, information and counselling for African women on domestic violence, AIDS, HIV and mental health. Address 334– 336 Goswell Road, London EC1V 7LQ Tel (020) 7713 5166 Email amwa@akinamama.org Web www.akinamama.org
  • 143. A handbook for health professionals 129 Asian Women’s Resource Black Association of Women Centre Step Out (BAWSO) Advice and information, Support for black women in counselling, English classes, Wales who have experienced parenting, women’s support domestic abuse. There are groups, multi-lingual separate offices in Swansea, translation service. Cardiff and Newport. Address 108 Craven Park, Address 9 Cathedral Road, Harlesden, London NW10 8QE Cardiff CF11 9HA Tel (020) 8838 3462 Tel (02920) 644633 Email Fax (02920) 644588 asianwomencentre@aol.com Email info@bawso.org.uk Web Web www.bawso.org.uk www.asianwomencentre.org.uk Broken Rainbow Barnardo’s Advice and support for gay and Helping families overcome the lesbian people who have problems of homelessness, experienced domestic abuse. poverty and abuse. Helpline runs from Monday to Address Tanners Lane, Friday, 9am to 1pm and 2pm to Barkingside, Ilford, 5pm. Essex IG6 1QG Address c/o HGLC, 40 Borough Web www.barnardos.org.uk High Street, London SE1 1BS Helpline 08452 60 44 60 Email mail@broken- rainbow.org.uk Web www.lgbt-dv.org
  • 144. Responding to domestic abuse 130 Careline Chinese Information and Telephone counselling for Advice Centre (CIAC) children, young people and Advice on domestic violence, adults. immigration and general Tel (020) 8514 1177 family issues. Web www.carelineuk.org Address 53 New Oxford Street, London WC1A 1BL ChildLine Domestic violence helpline Freephone helpline for children (020) 7462 1281 and young people. Email info@ciac.co.uk Address Freepost 1111, Web www.ciac.co.uk London N1 0BR Helpline 0800 1111 Domestic Violence Tel (administration) Intervention Project (020) 7239 1000 Services for male perpetrators Web www.childline.org.uk of domestic violence living or working in west London. Childline (Wales) Support services for female Freephone helpline for children partners of men in the and young people. programme and other women. Address 9th floor, Alexander Tel (for men) (020) 8563 House, Alexander Road, 7983/(for women’s support Swansea SA1 5ED service) (020) 8748 6512 Helpline 0800 1111 Email info@dvip.org Tel (administration) Web www.dvip.org (01792) 480111 Web www.childline.org.uk
  • 145. A handbook for health professionals 131 EACH (Asian and Minority Foreign and Commonwealth Group Counselling Service) Office Forced Marriage Unit Counselling service for alcohol Advice on forced marriages. and mental health issues for Tel (020) 7008 0135/ women from minority ethnic (020) 7008 0230 communities living in Harrow, Email fmu@fco.gov.uk Hounslow, Brent, Ealing and Web www.fco.gov.uk Barnet (the latter two boroughs Get Connected are by satellite status only). General advice service Address Signal House, (telephone, web and email) for Ground Floor, young people aged between 16 16 Lyon Road, and 25. Helpline open every day Harrow HA1 2AG from 1pm to 11pm. Tel (020) 8861 3884 (Harrow); Tel 0808 808 4994 (020) 8577 6059 (Hounslow); Email (020) 8795 6050 (Brent) help@getconnected.org.uk Email info@eachharrow.gov.uk Web www.getconnected.org.uk Family Matters Counselling support for sexual abuse survivors aged eight and over. Address 5 Manor Road, Gravesend, Kent DA12 1AA Tel (01474) 536661 Web www.charitynet.org/~family- matters
  • 146. Responding to domestic abuse 132 The Greater London Domestic Irish Women’s Aid Violence Project Advice and support for those Working to end domestic who have experienced domestic violence in Greater London by abuse who live in Ireland. supporting direct service Address 47 Old Cabra Road, providers and promoting joint Dublin 7, Ireland working. Also hosts the Stella Freephone helpline for those Project, which promotes good living in Ireland: 1800 341 900 practice and supports direct Tel (administration) service providers across the +353 1 868 4721 drug, alcohol and domestic Email info@womensaid.ie violence sectors in Greater Web www.womensaid.ie London. Provides guidelines for Jewish Women’s Aid (JWA) working across these sectors. Works to break the silence Address 1 London Bridge, surrounding domestic violence The Downstream Building, through education and London SE1 9GB awareness-raising programmes Tel (020) 7785 3862; (020) Address PO Box 2670, 7983 4238 (the Stella Project) London N12 9ZE Email info@gldvp.org.uk Helpline 0800 591 12 03 Web www.gldvp.org.uk/ Tel (administration) www.lat.org.uk (020) 8445 8060 Email info@jwa.org.uk
  • 147. A handbook for health professionals 133 Mothers of Sexually Abused NSPCC Asian child protection Children (MOSAC) helplines Voluntary organisation Bengali 0800 096 7714 supporting all non-abusing Gujurati 0800 096 7715 parents and carers whose Hindi 0800 096 7716 children have been sexually Punjabi 0800 096 7717 abused. Helpline is open Urdu 0800 096 7718 Wednesday 10am to 2pm and English-speaking Asian advisor Friday 7.00pm to 9.30pm. 0800 096 7719 Address 141 Greenwich High NCH Action for Children Road, London SE10 8JA Advice and information for Helpline 0800 980 1958 families and children. Web www.mosac.org.uk Address 85 Highbury Park, National Society for the London N5 1UD Prevention of Cruelty to Tel (020) 7226 2033 Children (NSPCC) Web www.nch.org.uk Specialising in the protection Northern Ireland Women’s Aid of children and prevention of For those who have cruelty to children. experienced domestic abuse Address Weston House, living in Northern Ireland. 42 Curtain Road, Address 129 University Street, London EC2A 3NH Belfast BT7 1HP Helpline 0808 800 5000 Helpline 0800 917 1414 Textphone 0800 056 0566 Web www.niwaf.org Welsh helpline 0800 917 1414 Helpline email help@nspcc.org.uk Web www.nspcc.org.uk
  • 148. Responding to domestic abuse 134 Refuge Respect Accommodation and support Respect is a national services to women who have organisation which has experienced domestic abuse. developed principles and Address 2–8 Maltravers Street, minimum standards of practice London WC2R 3EE for domestic violence Helpline 0808 2000 247 (run in perpetrator programmes and partnership between Refuge associated women’s services. and Women’s Aid) It has a service for men who are Web www.refuge.org.uk looking for advice on how to stop their abusive or violent behaviour towards their partners. A phone interpreting service is available to those who don’t speak English. The helpline is open Monday, Wednesday and Friday, 10am to 12pm, and Tuesday, 2pm to 5pm. Address PO Box 34434, London W6 0YS Helpline 0845 1228609 Textphone (020) 8748 9093 Email info@respect.uk.net Web www.respect.uk.net
  • 149. A handbook for health professionals 135 Rights of Women Survivors of Lesbian Abuse Advice on family law matters, (SOLA) including domestic violence. Helpline offering support, Free legal advice for women advice and information to by women. survivors of lesbian abuse. Address 52–54 Featherstone Open Tuesday to Friday, 10am Street, London EC1Y 8RT to 5pm. Legal Advice Line Helpline (020) 7328 7389 (020) 7251 6577 Email solalondon@hotmail.com Textphone (020) 7490 2562 Southall Black Sisters Sexual Violence Legal Advice Advice, emotional support Line (020) 7251 8887 and help for black and Web Asian women. www.rightsofwomen.org.uk Address 52 Norwood Road, Scottish Women’s Aid Southall, Middlesex UB2 4DW Advice and support for those Helpline (020) 8571 9595 who have experienced domestic Web abuse who live in Scotland. www.southallblacksisters.org.uk Scottish Women’s Aid runs the Victim Support Scottish Domestic Abuse Information and support to Helpline. victims of crime. Address 2nd floor, 132 Rose Address Cranmer House, Street, Edinburgh EH2 3JD 39 Brixton Road, Helpline 0800 027 1234 London SW9 6DZ Web Helpline 0845 3030900 www.scottishwomensaid.co.uk Web www.victimsupport.org
  • 150. Responding to domestic abuse 136 Women’s Aid Welsh Women’s Aid Women’s Aid Federation of Welsh Women’s Aid is the England is the nationwide national umbrella organisation network of over 500 local for Wales, and the leading services, working to end provider of services offering violence against women and support and advice to women children, and supporting over and children who are 200,000 women and children experiencing domestic violence each year. Women’s Aid and abuse in Wales. provides a package of vital 24- Cardiff National Office 38–48 hour lifeline services through its Crwys Road, Cardiff CF24 2NN publications, websites for Tel (02920) 39 08 74 women and children, and runs Aberystwyth National Office the freephone 24-hour National 4 Pound Place, Aberystwyth Domestic Violence Helpline in SY23 1LX partnership with Refuge. Tel (01970) 612748 Address PO Box 391, Wales Domestic Abuse Bristol BS99 7WS Helpline 0808 8010 800 Helpline 0808 2000 247 Web www.welshwomensaid.org Tel (general enquiries) Women and Girls Network (0117) 944 4411 London-wide multicultural Web www.womensaid.org.uk counselling and healing centre www.thehideout.org.uk for women and girls overcoming experiences of physical, sexual or emotional violence. Helpline (020) 7610 4345 Tel (administration) (020) 7610 4678 Email info@wgn.org.uk
  • 151. A handbook for health professionals 137 The Woman’s Trust Other useful agencies Provides free one-to-one Issues concerning children, counselling and weekly support babies and pregnancy groups for women who have been abused. Self-referrals or Children’s Legal Centre referrals from professionals for Free legal advice on law and London women experiencing policy affecting children and domestic violence. The young people. Woman’s Trust also offers an Address University of Essex, advocacy service, currently for Wivenhoe Park 1, Colchester, abused women in the Essex CO4 3SQ Westminster area, which is also Tel (01206) 873820 free of charge. Email clc@essex.ac.uk Address Top Floor, Web Kensington Cloisters, www.childrenslegalcentre.com 5 Kensington Church Street, Gingerbread London W8 4LD Support for lone parent families. Tel (020) 7795 6444/ Address 1st floor, 7 Sovereign (020) 7795 6999 Close, Sovereign Court, Email wtrust@onetel.net.uk London E1W 3HW Web www.womanstrust.org.uk Tel 0800 018 4318 Email office@gingerbread.org.uk Web www.gingerbread.org.uk
  • 152. Responding to domestic abuse 138 The Hideout Parentline Plus Women’s Aid’s award-winning Provides a helpline support and website provides help and parenting courses to anyone support for children and young looking after a child. people who are living with Helpline 0808 800 2222 domestic violence. Textphone 0200 783 6783 Web www.thehideout.org.uk Web www.parentlineplus.org.uk Miscarriage Association Advice and support to women Reunite who have suffered a miscarriage For parents of abducted or an ectopic pregnancy. children. Address c/o Clayton Hospital, Address International Child Northgate, Wakefield, Abduction Centre, PO Box West Yorkshire WF1 3JS 24875, London E1 6FR Helpline 01924 200799 Helpline 0116 2556 234 Web Email reunite@dircon.co.uk www.miscarriageassociation. Web www.reunite.org org.uk Immigration and asylum National Association of Child Asylum Aid Contact Centres Advice for refugees on asylum Arranges supported or applications and welfare rights. supervised contact at neutral Tel (administration) places for separated families. (020) 7377 5123 Address Minerva House, Legal Advice Line Spaniel Row, Nottingham (020) 7247 8741 NG1 6EP Web www.asylumaid.org.uk Tel 0845 4500 280 Email contact@naccc.org.uk Web www.naccc.org.uk
  • 153. A handbook for health professionals 139 Joint Council for Welfare Refugee Women’s Association of Immigrants Empowering refugee women Advice on immigration and in London. asylum. Address Print House, 18 Address 115 Old Street, Ashmin Street, London E8 3DL London EC1V 9RT Tel (020) 7923 2412 Tel (administration) Email info@refugeewomen.org (020) 7251 8708 Web www.refugeewomen.org Advice Line (020) 7251 8706 Women from minority ethnic Email info@jcwi.org.uk backgrounds Web www.jcwi.org.uk Language Line National Asylum Support 24-hour immediate interpreter Service (NASS) provision in 100 languages. Support for professionals only – Please see the guidance on no support services for page 53 of this handbook about members of the public. using interpreters. Tel 0845 602 1739 Tel (020) 7520 1430 Web www.asylumsupport.info/ nass.htm Muslim Women’s Helpline Listening, counselling and Refugee Council information for Muslim Information and referral to local women and girls. refugee councils. Tel (020) 8904 8193/ Address 240–250 Ferndale Road, (020) 8908 6715 London SW9 8BB Tel (020) 7346 6777/ Somalian Women’s Centre (020) 7346 6700 Advice on housing, immigration Web and benefits for Somalian www.refugeecouncil.org.uk Women in West London. Tel (020) 8752 1787
  • 154. Responding to domestic abuse 140 Turkish Community Project MIND Services to men and women in The national association for Lewisham, Lambeth, Southwark mental health. and Bromley: translation, Address 15 –19 Broadway, advocacy, housing and Stratford, London E15 4BQ welfare advice. Mind infoline 08457 660 163 Address 44 Campushill Road, Typetalk (for callers with London SE13 6QT hearing or speech problems Tel (020) 8318 2864 who have access to minicom) 0800 959 598 Health and mental health Email contact@mind.org.uk Drinkline Web www.mind.org.uk Telephone support for adults MIND Cymru (Mind in Wales) and young people with The national association for alcohol problems. mental health in Wales. Tel 0800 917 8282 Address 23 St Mary Street, DrugScope Cardiff, CF1 2AA The UK’s leading independent Information line centre of expertise on drugs. 0845 766 0163 Address 32–36 Loman Street, Web www.mind.org.uk London SE1 0EE National Self Harm Network Tel (020) 7928 1211 Provides advice, advocacy and Email info@drugscope.org.uk an information sheet on Web www.drugscope.org.uk self-harm. Address PO Box 7264, Nottingham, NG1 6WJ Email info@nshn.co.uk Web www.nshn.co.uk
  • 155. A handbook for health professionals 141 NHS Direct Housing Confidential 24-hour helpline See also entries under ‘Agencies on all matters relating to health. supporting those who have Access to Language Line experienced domestic abuse’. interpreters. Helpline 0845 4647 Eaves Housing for Women Web www.nhsdirect.nhs.uk Housing support in the London area for vulnerable women, Samaritans including those experiencing Confidential and emotional domestic violence. Also funds support to people in crisis. the Poppy Project, for women Helpline 08457 909090 wanting to leave prostitution Web www.samaritans.org.uk and who have experienced Women’s Therapy Centre being trafficked. Counselling and psychotherapy Address 2nd floor, services for women in the Lincoln House, London area. Kennington Park, Address 10 Manor Gardens, 1–3 Brixton Road, London N7 6JS London SW9 6DE Tel (020) 7263 6200 Tel (020) 7735 2062 Email Poppy Project information line enquiries@womenstherapy (020) 7840 7129 centre.co.uk Web www.eaves.ik.com Web www.womenstherapy Shelter centre.co.uk 24-hour information and advice on homelessness and housing. Helpline 0808 800 4444 Web www.shelter.org.uk
  • 156. Responding to domestic abuse 142 Sexuality National Association of Citizens’ Advice Bureaux London Lesbian and Gay (NACAB) Switchboard General and legal advice. 24-hour helpline offering Address Middleton House, information, support and 115 –123 Pentonville Road, referral services for lesbians London N1 9LZ and gay men. Tel (020) 7833 2181 Helpline (020) 7837 7324 Web Web www.llgs.org.uk www.citizensadvice.org.uk; Welfare and legal www.adviceguide.org.uk Benefits agency helplines National Debtline Department for Work and Advice on debt, with free Pensions public enquiry line. self-help packs. Tel (020) 7712 2171 Tel 0808 808 4000 Textphone 0800 243 355 Email Web www.dwp.gov.uk: advice@nationaldebtline.co.uk provides information on all state Web benefits, alphabetically, with www.nationaldebtline.co.uk links to www.jobcentreplus.gov.uk when appropriate. You can download information leaflets and claim forms from the website.
  • 157. A handbook for health professionals 143 Rights of Women Advice on family law matters, including domestic violence. Free legal advice for women by women. Address 52–54 Featherstone Street, London EC1Y 8RT Legal Advice Line (020) 7251 6577 Textphone (020) 7490 2562 Sexual Violence Legal Advice Line (020) 7251 8887 Web www.rightsofwomen.org.uk
  • 158. Local information This section has been provided for you to keep a record of local domestic violence agencies and other partners. Having a list of local contacts to hand will help you give women the information they need as soon as possible after disclosing domestic abuse.