Case of domestic abuse
Emotions may run high when you are consulted by a victim of domestic violence.
Dr Melanie Wynne-Jones explains what your role is
Mrs Walker is in tears and clinically has at least one broken rib. You notice various other bruises on her body and, avoiding eye contact, she tells you her husband hit her while he was drunk and asks you to record the injuries 'just in case'.
In a case like this it is important to deal with your own emotions quickly; as yet you do not know what the dynamics are, and she may back off quickly if you ride in like the white knight trying to save her.
Show empathy: 'that looks very painful' or 'you must have felt very frightened', but you need to find out more and there are several tasks to accomplish:
lrecording and managing each injury
lestablishing the circumstances
ldiscussing whether she should report it to the police
lassessing her continuing risk
lfinding out whether any children may be at risk
ldiscussing her options.
If Mrs Walker is sufficiently composed you need to ask what actually happened and about the circumstances leading up to the assault. Was it a sustained attack or over in a few seconds?
How drunk (or drugged) was her husband, and was she drunk also? What were his 'reasons' and what does she think about them?
What is their relationship usually like: does he regularly abuse her verbally or is he usually the 'perfect husband'? Has he said he is sorry or expressed a desire to seek help for his drinking or his behaviour?
You should also assess and record her current mental state: is she suffering from anxiety or depression, unfit to make her own decisions or at risk of suicide?
It's important to remember that you may get a selective story she may be embarrassed, want to protect him despite what has happened, take the blame for angering him or be worried that you will try to take the children away or even be falsely accusing her husband. It is often difficult to work out what exactly is going on in patients' lives.
Your clinical notes should include her account of how the injuries were caused and a description of each injury's size, location, type (contusion, laceration and so on), approximate age, and a comment on whether the injuries are consistent with the story. Record your management plan (including 'no action required') for each, and suggest she takes photographs of her external injuries before they fade.
Unless you have been trained in forensic examination you should point out that the proper person to record her injuries is the police surgeon; if you suspect uncomplicated rib fracture then there is no more clinical need to X-ray her than if the injury had been accidental. Ask what her 'just in case' comment means: is she worried about future assaults, or trying to place her evidence on record?
She may be reluctant to go to the police because of her fear of reprisals (from relatives, if he is locked up), by her love for him, or by fear that she will not be able to manage on her own (many violent partners undermine their victim's self-belief).
Some doctors experience violence in their own families; if this is a personal issue that could affect you or your patient care, talk to a trusted colleague or your own GP.
She could, however, speak to police officers from the domestic violence unit (DVU) before or instead of making a formal complaint; they will advise, offer support and place her statement on record.
They can also make arrangements for her to move into a refuge (a safe house with a secret address) and put her in touch with a social worker.
If she does decide to report the assault, DVU officers will accompany her to court if she wishes, identify attempts at intimidation and provide access to witness protection if necessary. If Mrs Walker will not go to the police, she may agree to consult a solicitor (many do pro bono work, providing a free initial consultation) or move in with a relative or friend.
She must be made aware of the possible risks of staying in the marital home, although leaving has to be her own decision. This may have been the first attack of its kind or another
episode in an ongoing violent relationship, and the level of violence may escalate.
If there are children in the house they may also be at risk (just seeing their mother attacked is a form of abuse). How does he behave towards them, and have there been any previous concerns?
Even if she assures you that he 'adores them and would never lay a finger on them' it would be wise to check their records later, and discuss the family with your trainer and other members of the primary care team. If there is any doubt, this may become a child protection issue.
At the end of the discussion she is quite likely to reject all your suggestions and decide to do nothing. If there is no medicolegal imperative for you to act, you may at least have provided some support, now and for the future.
If Mr Walker consults on his own behalf, broaching his drinking or violent behaviour without breaching confidentiality will need careful handling.
Melanie Wynne-Jones is a GP trainer in
1 Department of Health 2000.
Domestic violence: a resource manual for health professionals.
3 Women's Aid Federation England
Support, advice, information and referrals for women experiencing domestic violence. Makes direct referrals to refuges throughout England.
Tel: 0845 7023 468
4 Women's Aid Helpline, Northern Ireland
Tel: 028 9033 1818
Advice, information, listening, support and referrals.
Also runs refuges.
5 Welsh Women's Aid
For referrals to local Women's Aid offices in Wales
Tel 029 2039 0874
6 Scottish Women's Aid National Office
Offers information, support, and referrals to local groups.
Tel: 0131 475 2372