Abuse and violence - Working with our patients in general practice


The White Book
Chapter 3.  Safety and risk assessment
☰ Table of contents


Key messages

  • Health practitioners should express their concern about a patient’s safety and likelihood of risk but it is a woman’s right to decide on her own pathway to safety3
  • Mandatory reporting of child abuse is required throughout Australia (refer to Chapter 6)
  • In the context of intimate partner abuse, where the child or young person does not appear to have directly experienced any violence, you may consider a referral to a vulnerable children’s organisation (see Resources 

 

 

Recommendations

  • Health practitioners should work closely with specialist services including police, to enhance safety for women and children3 Practice point
  • Safety assessments need to be undertaken by health practitioners when seeing any patient experiencing abuse and violence3 Practice point
  • Documenting carefully what a patient has said about the abuse and violence in the record is important for communication with others and potentially for legal processes (refer to Chapter 9 and Chapter 13)3 Practice point

 


Introduction


Chapter 2  outlines issues around identification of intimate partner abuse including how to ask and provide an initial response. This chapter outlines how GPs can provide an initial assessment of risk and safety for women and children. This does not preclude consulting and referring to specialist services including police, women’s and domestic violence services for a more detailed assessment of risk and safety.

 

The role of the GP


Many doctors feel very concerned about women’s welfare and want to stop women returning to an abusive environment, however, women are often the best judge of whether it is safe to go home.54 A series of questions, outlined below, enable us to assess risk and assist women to reflect on their own safety and their children’s safety. In addition, it is important for us to assess directly the level of fear and safety of children if they are old enough to understand.

We need to inform women that whatever they tell us is confidential subject to the legal requirements around child abuse. Doctors working in the Northern Territory need to be aware of the mandatory reporting requirements for domestic and family violence. It is important to inform women that the greatest risk to their lives may be at the time they are leaving or thinking about leaving.55 Documentation may assist with communication with other health practitioners, services and in legal processes.56

 

Assessing the safety of women experiencing intimate partner abuse


Some questions to consider when assessing a woman’s immediate safety include:

  • Does the woman feel safe to go home today?
  • What does she need in order to feel safe?
  • Has the frequency and severity of violence increased?
  • Is he obsessive about her?
  • Has she been threatened with a weapon?
  • Does he have a weapon in the house?
  • Has she been to hospital because of the violence?
  • How safe does she feel?
  • How safe are her children?

Risk assessment

Any assessment of risk to victims of intimate partner abuse must be structured and informed by:

  • the woman’s own assessment of her safety and risk assessment
  • the presence of risk indicators outlined below
  • your own professional judgement.54,57

There are several factors consistently associated with perpetrators of intimate partner abuse. These include age, severity (for example, strangulation) and duration of previous violence, history of arrest and incarceration, violence in the family of origin, drug and alcohol abuse, hostility levels and unemployment.

Risk indicators

Risk indicators of ongoing family violence include:

  • perpetrator history of violent behaviour both within and outside of the household
  • perpetrator access to lethal weapons
  • perpetrator use of alcohol and drugs
  • recent separation or divorce
  • perpetrator stressors such as unemployment or recent loss
  • perpetrator history of witnessing or being the victim of family violence as a child
  • evidence of mental health problems or personality disorder in perpetrator
  • perpetrator resistance to change and lack of motivation for treatment
  • attitude of perpetrator that supports violence towards women.58

Some researchers have developed risk assessment tools,54 for example, danger assessment scale 59 was developed for use by GPs in consultation with women to enhance women’s reflection on safety and self-care.

Women might be feeling unsafe to go home and may need urgent crisis referral (refer to Resources) and an urgent safety plan. Many women feel safe to go home after the consultation that day. For these women further discussion of ongoing detailed safety planning may be delayed until the next follow-up visit.

 

Safety planning


Safety planning is the development of a plan to achieve and maintain safety of women and their children. It includes:

  • compiling a list of emergency numbers
  • helping to identify a safe place for the woman to go to and how she will get there
  • identifying family and friends who can provide support
  • ensuring cash is available
  • providing a safe place to store valuables and important documents.

Devising a safety plan with a patient in case of an emergency may be as simple as identifying where she would go, where to leave a packed bag and where to hide keys and money.

Below is a list of safety behaviours that women might include in their emergency safety plan.
 

Table 7. Safety behaviours

Hide money, an extra set of house and car keys

Ask neighbours to call the police if violence begins

Establish a code with family or friends that signals you need help

Remove weapons

Ensure quick access to the following materials:

  • Medicare and tax file numbers
  • rent and utility receipts
  • birth certificates (woman and children)
  • ID and driver’s licence (woman and children)
  • bank account and insurance policy numbers
  • marriage licence, valuable jewellery
  • important phone numbers, hidden bag with extra clothing


Documenting intimate partner abuse


It is important to document intimate partner abuse in the health record as follows:

  • Enter in the medical record any health complaints, symptoms, and signs, as you would for any other woman, including a history of who injured her.
  • Describe physical injuries, including type, extent, location and age.
  • If you are sure the records will be kept confidential, it may be helpful to note the cause or suspected cause of these injuries or other conditions. This is important for follow-up purposes, to remind yourself or alert another provider at later visits.
  • Some practices use a code, located either on the medical record or an electronic medical system or special coloured sticker, to indicate cases of abuse or suspected abuse.
  • If the confidentiality of records cannot be guaranteed or a woman requests that you not keep notes, it is better not to overtly document actions or interventions, for example, risk, any discussion about onsite or external services, secondary consultation or referral.
  • At the end of the medical record entry, document the plan for the woman, for example, follow-up or referral to services.

It is important to document two things: information the woman has given you in a factually accurate way, and your own observations of injuries, affect, any other health conditions and anything else that is relevant. The notes should be detailed, and include what the patient said using quotation marks. Record any relevant behaviour you observed, for example, ‘patient cried when she spoke about …’ (refer to the toolkit in the PDF version). Documentation is critical for adequate care for the woman, as well as for follow-up should there be a legal process, which is often unknown at the time of medical intervention (refer to Chapter 9  and Chapter 13 ).

To ensure confidentiality of records in the health setting, it is important that neither patients nor their visitors or support persons are able to gain access to the medical records unless this has been formally requested and in adherence to the relevant confidentiality protocol.

 

What to do if the patient is at high risk


Where you reasonably believe a patient is in imminent threat of danger, you should seek their consent to report the matter to the police. If the patient is not capable of giving the consent for any reason, which may include intimidation, the GP is relieved of any obligation to adhere to privacy principles to the extent that disclosure is necessary to safeguard the patient’s immediate wellbeing. You may want to seek legal advice if you are in doubt, but common sense should be applied if the patient is manifestly in danger or threat of physical harm, and the police contacted.

Privacy and imminent threat

Sometimes the patient does not fall under mandatory reporting laws and does not want to go to the police, but you may perceive an imminent threat. This might be a situation such as a patient who is cognitively impaired, or where there has been a life-threatening risk, such as when a gun or knife is involved. The NSW Department of Health recommends in its Domestic Violence Policy discussion paper that health workers notify the police where the victim has serious injuries such as broken bones, stab wounds, lacerations or gunshot wounds (refer to Chapter 13 ). It is wise to get advice from appropriate authorities in these instances, including your medical defence organisation.

Safety of children and mandatory reporting

Children are particularly vulnerable to the impact of intimate partner abuse (refer to Chapter 6 ). In the context of intimate partner abuse, where the child or young person does not appear to have directly experienced any violence, you may consider a referral to a vulnerable children’s organisation (refer to Resources) or a report to Child Protection. The overlap with child abuse and intimate partner abuse is strong.60 Interventions that assist children to realise that their parent’s violence is not their fault and to safety plan for the next episode of violence, are key features of a response for safety.61,62

Referring children to vulnerable children’s or family services may be appropriate where there is a low-to-moderate impact on the child and their immediate safety is not compromised. As an example, the Department of Human Services in Victoria provides useful information for professionals working with vulnerable children, suggesting factors that may trigger a referral to a vulnerable children’s service. This service, upon assessment, may then make a report to Child Protection.

The Victorian Department of Human Services also summarises the circumstances in which a report to Child Protection should be made, together with factors to consider when deciding whether to make such a report.

The Victorian Government has also developed a comprehensive framework for family violence risk assessment.

These principles and guidelines apply to any vulnerable families across Australia and local resources can be found in each state and territory (refer to Tool 7).

 

Dealing with the perpetrator


Chapter 5 outlines how you should approach patients who are using violence against their partners, including how to ask and respond, and referral to services. When both partners are patients, you need to be extra careful with confidentiality and safety issues.63 This includes considering referring the perpetrator to another practitioner or another practice and not communicating about the issue with the perpetrator unless the woman agrees. Ensuring safety protocols are in place in the practice and developing safety plans with the woman are essential.64

 

Conclusion


Within your practice there are a number of steps you can take to assist with dealing with abuse and violence issues. It is important to discuss issues surrounding abuse with all staff and to decide upon a practice policy related to reporting. This will give you a clearer framework within which to operate. Each state and territory police force now has trained domestic and sexual assault teams, including trained domestic violence officers who may be a helpful resource for managing these issues in general practice.

If you suspect that an adult patient is being repeatedly assaulted, and that patient is not willing to approach the police, you should still provide the patient with the appropriate information on, for example, family and domestic violence or sexual assault services (refer to ResourcesChapter 9  and Chapter 13 ). Also consider approaching the police yourself. Remember, if there is a serious and imminent threat to the life and health of an individual, it may be appropriate to provide a report to the police on the basis that there is an overriding duty to disclose information in the public interest. These are often difficult and complex cases and you are encouraged to seek advice from colleagues and/or your medical indemnity insurer if faced with this situation.

 

Resources


Please refer to Tool 7  in the PDF version for resources nationally and in your area.

 

Further information


1800RESPECT is a 24-hour telephone line that provides online and telephone crisis and trauma counselling.

  1. World Health Organization. Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines. Geneva: WHO, 2013. 
  2. Laing L. Risk Assessment in Domestic Violence: Australian Domestic and Family Violence Clearninghouse, 2004. 
  3. Campbell JC. Helping women understand their risk in situations of intimate partner violence. J Interpers Viol 2004;19:1464–77. 
  4. Coker AL, Bethea L, Smith PH, et al. Missed opportunities: intimate partner violence in family practice settings. Prev Med 2002;34:445–54. 
  5. Campbell JC, Sharps P, Glass N. Risk assessment for intimate partner homicide. In: Pinard GF, Pagani L, editors. Clinical assessment of dangerousness: Empirical contributions. Cambridge: Cambridge University Press, 2001. 
  6. Family violence risk assessment and risk management. Department for Victorian Communities, 2007. 
  7. Campbell J. Nursing Assessment for Risk of Homicide with Battered Women. Adv Nurs Sci 1986;8:36–51. 
  8. Renner LM, Slack KS. Intimate partner violence and child maltreatment: understanding intra- and intergenerational connections. Child Abuse Negl 2006;30:599–617. 
  9. Ernst AA, Weiss SJ, Enright-Smith S, et al. Positive outcomes from an immediate and ongoing intervention for child witnesses of intimate partner violence. Am J Emerg Med 2008;26:389–94.
  10. Hardesty J, Campbell JC. Safety planning for abused women and their children. In: Jaffe PG, Baker LL, Cunningham AJ, editors. Protecting children from domestic violence: strategies for community intervention. New York: Guilford Press, 2004. p. 89–101. 
  11. Ferris L, Norton P, Dunn E, et al. Guidelines for managing domestic abuse when male and female partners are patients of the same physician. JAMA 1997;278:851–7. 
  12. Women’s Legal Services NSW. When she talks to you about the violence: A toolkit for GPs in NSW. 2013.