Role of hospitals in responding to domestic abuse and mental health

Within East Lancashire Hospitals NHS Trust we have acknowledged the importance of the role we have in responding to domestic abuse. It makes sense that an organisation that serves a population of over 530,000 people will come in to contact with people who are experiencing or at risk of domestic abuse.  And with 8,000 staff who work within our organisation, we need to be sure they can recognise domestic abuse and respond accordingly.

Every hour of every day, 365 days a year, we are providing a service to someone. We have such a diverse range of service provision, from maternity and children’s services to older people’s specialist services, in-patients, out-patients, community clinical teams, and emergency care.

We also work closely with multi-agency partners across East Lancashire, Blackburn with Darwen and beyond, and this includes providers of specialist mental health services and also providers of specialist domestic abuse services.

When SafeLives published ‘A Cry For Health’ in 2016 we saw many parallels between the pilot sites and our own acute hospital trust, and we have used those findings and recommendations to strengthen our approach to recognising and responding to domestic abuse. This has included gaining support to secure the funding for our own full-time Hospital Idva, and she is already making a huge difference with the equivalent of one referral a day in the first three weeks in post.

The role of hospital staff in identifying that people with mental health problems presenting at A&E may be victims of domestic abuse

In addition to direct injuries sustained as a result of domestic abuse, there is good evidence to support the fact that those who experience domestic abuse can suffer significant physical and mental health problems.

We see around 500 people each day in our A&E and Urgent Care Centres. Like any other acute hospital trust we see patients who are predominantly physically unwell, but there are also many people who attend for help, treatment and support for a reason related to mental health.

People may attend A&E with acute exacerbation of a long-standing mental health condition, intentional overdose of medication or other substances, abuse and misuse of alcohol or drugs, self-harm injuries, anxiety, depression, and risk of suicide. As an emergency service we would engage these patients with the specialist mental health teams and services. However, we also recognise there may be serious safeguarding concerns, including historical or current abuse, which could be contributing to the deterioration in the person’s mental health. It is of great concern that, despite referrals to specialist support services, many patients are not actively involved with those services, and we see the same people coming back through our doors time and time again. However, on a positive note, we have seen patients who may agree to access support after many times of declining help previously.

Their role in identifying that people with longer term health issues may be victims of domestic abuse

If we examine the reasons for attendance at hospital for those who have experienced domestic abuse (who are known to us), we can see a picture of poor health including chest pain, recurrent infections, bowel complaints, anxiety and depression.

When people use our services we also see evidence of direct injury where domestic abuse is suspected, and this may be disclosed or not. Unexplained injuries, or injuries where the explanation doesn’t marry with the damage, can be common, and I am confident that safeguarding is well-embedded within the Trust and the clinical staff would seek the opportunity to safely ask the patient about abuse.

We are also in a fortunate position with a number of services where clinicians such as nurses, physiotherapists, psychologists, etc will see patients on a one to one basis. Professional and trusting relationships are established, and we have seen unexpected disclosures of domestic abuse that have come ‘out of the blue’ during an out-patient appointment.  On the whole patients feel safe in a health environment, and confidential, professional relationships are expected across the board.

The Hospital Idva

Over the last few years East Lancashire has established effective partnership working with the local providers of specialist domestic abuse services. Integrating the Hospital Idva role into our Safeguarding team enabled us to raise awareness of domestic abuse across our clinical services, which led to staff recognising the signs of domestic abuse in their patients. There was increased opportunity for patients to disclose domestic abuse, and the Hospital Idva became involved with the daily ward routines, including attending board rounds to assist staff in identifying patients at risk, and improving their knowledge and understanding of domestic abuse. Input from a number of specialist domestic abuse providers has paved the way for us to gain support for our own dedicated Idva based in the hospital.

The recent appointment of Linsey to her role as Hospital Idva has already proved to be not just valuable, but vital. The approach of having the Idva embedded within well-established hospital safeguarding teams makes sense. Already Linsey is seen as part of the safeguarding team by the clinical staff she has worked with.

As Linsey explains, “Previously, as an Idva I was used to going to see clients when they had presented in hospital, but within this new role I am based in the hospital full-time. Because of this, I have found that I am consistently dealing with a complex caseload; the majority being those experiencing some form of mental health problem. Within the first month of being a Hospital Idva, 90% of my caseload has been people with complex mental health issues, including personality disorder, complex PTSD and early signs of psychosis.

Sadly, the majority of the mental health issues are partly due to historic and current domestic abuse. It has been extremely important to work from a multi-professional, interdisciplinary approach due to the complexity of the cases, working alongside nurses, community Idvas, doctors and of course the mental health teams. As well as the clinical teams within East Lancashire Hospitals NHS Trust I have also been working alongside psychologists, psychiatrists, mental health teams and specialist services, making sure our patients, who are some of the most vulnerable people in our society, have all the support they need and are effectively safeguarded”.

The future of Hospital Idvas

We would encourage hospitals to look at what they do to recognise and respond to domestic abuse, and consider what support they can access to bring an Idva into the hospital safeguarding team. We are in a prime position for people to disclose abuse in a safe environment.

As part of a pilot we have gained support for an Isva (independent sexual violence advisor) to join our team from the new year, and we anticipate a high number of referrals to the Isva. In the next 12 months we will hopefully be able to evaluate the impact of having specialist Idvas and Isvas based in hospitals, and we predict now that disclosures of domestic and sexual abuse will be made much sooner than if the opportunity wasn’t there to see a specialist in hospital. We predict in years to come that the numbers of victims at higher risk will reduce in areas where there is a dedicated resource in the hospitals, as they will have disclosed and sought help and support before they reach that level of risk. The more services can do to raise awareness, recognise and respond to domestic abuse, the better the outcomes for those individuals and families.

When all is said and done, safeguarding is a process that relies on close partnership working to protect vulnerable adults and children from abuse or neglect, protecting their health, development and well-being, thus enabling them to live free from harm in a safe environment with the support they require.

About the authors

Kathy is a Registered Nurse and Head of Safeguarding for East Lancashire Hospitals NHS Trust where she has led the Safeguarding agenda for ten years. She works with a dedicated specialist team of safeguarding leads and practitioners, implementing a safeguarding strategy  that addresses all aspects of safeguarding including domestic abuse.

Linsey has worked in the domestic abuse sector for nearly ten years as a refuge support worker, outreach support worker, and Idva. Linsey has worked in Liverpool on a pilot project targeting the co-occurrence of mental health, substance use and domestic abuse. She is a qualified cognitive behavioural therapist and works in private practice, alongside her role for East Lancashire Hospitals NHS Trust as a specialist hospital Idva.