7th December 2017
As part of the 16 Days of Action against Gender-based Violence, we’re looking at the Health response to domestic abuse. Communications Officer Ruth went to spend a day with a hospital-based Idsva (Independent domestic and sexual violence advisor) service to find out more about how being located in the hospital helps them to support their clients.
I head to the hospital’s busy main reception and the receptionist pages Punita who comes to meet me. Punita is a Senior Idsva (Independent domestic and sexual violence advisor), and one of two who work at the Bristol 
Royal Infirmary (there is a Bank Idva to cover any outstanding shifts). She leads me to the A&E department, and to the Idsva service’s cosy little office which is a stone’s throw from both A&E and the staff room.
The walls are covered with thank you cards from clients and family photos. There’s also a ‘Wall of Shame’, where Punita sticks up the names and prison sentence of perpetrators who have been successfully prosecuted. “One of our greatest outcomes was a prolific offender pleading guilty to Section 18 GBH and being sentenced to 8 years imprisonment – a really fantastic outcome”.
The BRI Idsva team provide a daily service and receive between 300-350 referrals a year. Punita explains that Mondays can be busy as some patients may have been prevented from seeking medical attention over the weekend. “One lady with a fractured jaw in 3 places had to wait until Monday morning to come to A&E once the perpetrator had left for work – she told me she was in agony over the weekend but her partner would not let her out of the house”.
Punita and her team are NHS staff, which means they have full access to all hospital records. This allows them to look at patient attendance, not just in A&E but Trust-wide, read through patient notes and check for patterns of attendance or any injuries that might be signs of domestic abuse. In this way they can be proactive as opposed to just reactive; they don’t have to wait for referrals to come to them before they take action.
Looking at the cases in the system is a stark reminder that the signs of domestic abuse aren’t just physical; Punita estimates that around 80% of the patients they support disclose mental health problems and may further present in A&E with self-harm or overdose. Part of her work has been to establish structured referral pathways from the Psychiatry Liaison unit in the hospital – including adding a domestic abuse screening question to the Mental Health Matrix (a screening form completed by staff) to prompt a referral to the Idsva team as necessary.
Having access to hospital systems means they can ‘flag’ high risk patients, prompting members of staff to take action - it could say ‘please contact Idsva’, flag that the patient’s partner should be kept away (stipulating current bail conditions or terms of a Restraining Order), or raise any other safeguarding concerns. Punita will also be notified if that patient re-attends in A&E or as an outpatient, so she has the option to follow-up with patients when they are in hospital again or can research for updates, i.e. if patients that are injured need further treatment.
“Health is a vital piece of the Marac puzzle”, Punita says, “Even if the patient doesn’t want to get support from us at this time, we can use the information we have to refer high risk patients to Marac and monitor hospital attendances in the future”. “Repeated screening of high risk patients and the offer of Idsva referral during each A&E attendance is best practice – as a Trust we are sending out the message that domestic abuse is wrong, that hospital is a safe place to disclose and that advisors are on site daily to provide support”.
Hospital Idvas also provide a vital link between the Marac process and clinical staff. “Oh, they’re amazing” says Helen; a nurse in A&E. Helen describes a case where a woman came into A&E in the early hours of the morning, with a fractured wrist. The patient said she slipped and fell, but when Helen looked at her patient record there was a flag from Punita on the system. Seeing this flag prompted Helen to separate the patient from her partner, without raising suspicion, in order to safely ask a few more questions, dig deeper and eventually a referral to the Idsva service was made. Punita tells me that this patient is extremely high risk and had been discussed at Marac every month for the last five months. Helen explains that without them here in the hospital, she wouldn’t always have the confidence to ask – and wouldn’t have anywhere to refer patients to.
Carey, a physiotherapist, agrees that the Idsva team play a vital role in empowering staff: “Having them here, and the training they provide, gives us the confidence to know when it’s ok to let someone go home and when we need to refer them on. And they’re very visible to staff – I’m always popping into their office to ask questions”.
Punita and I take a walk around A&E, which she does every day. She shows me the cubicles where patients are seen by clinical staff – Punita has made sure that these cubicles have posters on the walls, highlighting the signs of abuse and mouse mats at every work station, in case a new member of staff needs guidance on how to “Ask the question” and refer on. “We have a high turnover of junior doctors, so the mouse mats play a key role in getting this information out”.
There are many creative ways that the Idsvas and clinical staff work together to support patients who are experiencing domestic abuse. Patients often come into hospital with their partners, so staff find ways of making sure that the patient can be seen alone in a space where they feel safe to disclose. It’s only by being so deeply embedded in the hospital that the Idsvas can make these links with other departments, and find ways to reach victims of domestic abuse in a safe way.
Back in the staff room I talk to Punita and her colleague about how working in A&E compares to other settings. “It’s totally different, you’re working with clinicians who are trained to see people in terms of their injuries and immediate health needs, whereas we’re trained to see them as a different entity in terms of measuring their current risk and implementing safety plans to keep them and their family safe. So it’s like two worlds merging and learning to work in cohesion”. “Also we’re not trained in terms of the exposure to extreme physical injuries so that’s an adjustment at first”.
Towards the end of the day Punita takes a call from a member of staff about a patient who she knows to be at high risk. She has come into the Gynaecology department for a minor concern, but Punita would like to see her, so they agree that the Consultant will set up a follow-up appointment which Punita will attend.
The service is doing an amazing job of reaching and supporting patients experiencing domestic abuse. From talking to Punita, it’s clear that none of this been achieved overnight. She has been in the hospital for six years, and it’s her sheer tenacity that has enabled the service to become so well embedded.
“You’ve got to make yourself visible in every way you can and just keep pushing to put domestic abuse on everyone’s radar”. She tells me about an Idva working in another hospital, who has no office space and has to sit outside in her car and wait for referrals to come in. “You need to have an equal footing to all other specialisms working in the hospital – domestic abuse isn’t a ‘take it or leave it’ subject – you need the office space, you need the access to hospital systems and you need everyone on board from Trust Leads to Safeguarding teams to nurses and doctors, otherwise you’re not going to reach those vulnerable patients desperate for support – Vital opportunities will be missed”.
Please would you consider making a donation of £25, or a regular gift of £10 a month, or whatever you can afford to help us call for specialist domestic abuse teams in every hospital in the country? You can donate online here or by texting STOP16 followed by the amount you want to give to 70070. Thank you.
