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Distressed patient who says they have been assaulted

Dr Melanie Wynne-Jones offers advice on what you should ­ and should not ­ do with assaulted patients

Patients may or may not tell you immediately that they have been assaulted, although the pattern of injuries may alert you to the possibility. Male patients may suggest they have been fighting.

You have several tasks to complete in a consultation with a patient who claims to have been assaulted.

The first is to decide what medical treatment is required. Patients often attend A&E first, and their GP practice later, because they need dressings changing, stitches removing or a sicknote. Under nGMS1, GPs are no longer automatically responsible for dealing with minor injuries sustained in the previous 48 hours, unless this has been agreed with the PCT as a local enhanced service attracting additional payment.

This can put GPs in a dilemma (unless the situation is clearly an emergency requiring an instant response). Even if GPs are willing to work for nothing, this will incur costs, as their nurses and receptionists will certainly expect to be paid. Yet many GPs feel uncomfortable sending needy or vulnerable patients away with instructions to go to A&E, and will treat them anyway.

This ethical/financial conflict may cause dissent within the practice or between the practice, A&E or the PCT. It may also spark patient complaints. Follow-up medical treatment and medical certification may also fall to the GP.

The next issue is documentation. Clearly GPs must keep good, clear records of all their consultations, which in the case of injury may include diagrams, technical terms such as 'laceration', or comments about the likely age or cause of an injury. You may subsequently be asked to provide a medical report as a witness of fact.

But unless you are trained in forensic examination, your observations are unlikely to be of sufficient standard for use as evidence in criminal prosecution.

This responsibility belongs to police surgeons (who may be suitably qualified GPs), and anyone who tells you they have been assaulted should be advised to report the assault to the police who should arrange proper forensic examination. You could also, however, suggest they take some good-quality photographs of their injuries.

Unfortunately the police themselves often tell victims of common assault to go to their GPs 'to get their injuries documented', presumably to reduce police workload and costs.

But this increases our workload and costs instead, and the Government has made it clear this is not the role of the GP. 'Making a Difference ­ Reducing GP Paperwork'2 estimated that removing the obligation to record injuries for police purposes would save 87,000 GP appointments plus 2,000 GP hours annually. The Association of Chief Police Officers subsequently wrote to all Chief Constables advising that the documentation of minor injuries for police purposes was not an appropriate use of GPs' time.

Patients should be advised that a GPs' evidence may not be accepted in court and that they should go back to the police, with their solicitor if necessary, and ask to see the police surgeon.

Being a victim of crime is usually distressing, and some patients present for this reason alone, often at the suggestion of relatives or Victim Support. They may be acutely anxious, repeatedly go over the episode, ask 'why me?', blame themselves or worry about what might have happened or that the perpetrator may return.

Listening, normalising, empathising and inquiring about other sources of support may need to be supplemented with a sicknote or a short course of anxiolytics/ hypnotics. Some may find it difficult to return to normal activities, especially if a prosecution or compensation claim is pending. Occasionally, the victim may develop full-blown post-traumatic stress disorder.

The assault may also be a pointer to an underlying problem, such as domestic violence, mental health problems, previous childhood abuse or alcohol/ substance dependence in the victim or assailant.

Tactful questioning and a risk-assessment ­ including any children who may be at risk ­ may reveal the true problem and enable it to be addressed.

Patients who have (or allege

they have) been assaulted

turn up to GPs in several ways

·With a fresh injury, often as emergency 'extras'

·With a recent injury, sometimes following attendance at A&E

·With persisting physical problems from a previous injury

·With psychological sequelae

·When they are at the end of

their tether in an abusive relationship

·Looking for medicolegal support

Resources and references

1 BMA New Contract Website www.bma.org.uk/ap.nsf/Content/

Hubthenewgmscontract

2 Making a Difference ­ Reducing GP Paperwork: Cabinet Office (2002) www.cabinetoffice.gov.uk/

regulation/docs/pst/pdf/redgppaptxt.pdf

3 Department of Health 2000. Domestic violence: a resource manual for health professionals. www.doh.gov.uk/domestic.htm

4 NSPCC www.nspcc.org.uk/html/home/

needadvice/domesticviolence.htm

5 Women's Aid Federation England

Tel: 0845 7023 468 www.womensaid.org.uk

Support, advice, information and referrals for women experiencing domestic violence. Makes direct referrals to refuges throughout England.

Melanie Wynne Jones is a GP in Marple, Cheshire

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