GPs are missing vital opportunities to intervene and potentially save the lives of people experiencing domestic abuse, a leading charity has warned.
Two women are murdered every week in England and Wales by a current or former partner. The latest crime statistics show that 332 women and 78 men were killed by their partners or ex-partners between March 2012 and March 2015. An analysis of 24 domestic homicide reviews (DHRs) from murders committed over the same period show that in more than half of the cases examined, doctors missed vital opportunities to identify risks and seek help for the victim.
The research, by the charity Standing Together, also found that in 25% of cases GPs failed to make inquiries following disclosures or warning signs displayed by the perpetrator. Now it is calling for domestic abuse awareness training to be made compulsory after results from an initiative set up to help GPs spot the signs of domestic abuse found referrals to specialist services increased considerably when doctors’ surgeries had been given appropriate training.
As the only stakeholder group that consistently and actively engages with both victims and perpetrators, GP surgery staff play a crucial role in preventing murders. “Our research shows both parties are more likely to seek help or make disclosures to their GP than any other agency,” says Standing Together’s chief executive, Nicole Jacobs.
DHRs are multi-agency accounts of the circumstances in which the death of a person aged 16 or over has resulted from violence, abuse or neglect by someone they were related to, shared a household with or with whom they were in, or previously in, an intimate relationship. Murders between intimate partners accounted for the DHRs studied as part of a wider sample by the charity in partnership with London Metropolitan University. Of the victims murdered by a partner or former partner, 22 were women. The youngest was 20 and the oldest was 81. “When we use the term ‘missed opportunities’ we are talking about blatant warning signs that are indicative of domestic abuse,” Jacobs explains.
Most frequently observed was a “lack of professional curiosity about relationships with partners or children’s fathers”, according to the report. In one case a woman reported having “an accident or fight” and had been punched, but “also had tenderness in the abdomen”. Another review found that a surgery failed to make inquiries after a patient attended the clinic with an ear injury that she said was not self-inflicted. “In these cases the GPs may have treated the physical injuries, but have not referred the person to specialist support. And they certainly did not note an instance of domestic abuse in the patient’s medical records. So when we say ‘missed opportunities’ we mean quite specific key indicators,” Jacobs adds.
In one case the offender rang the surgery requesting a home visit for an injection to ‘put [the victim] to sleep’
Six DHR reports also noted missed opportunities for GPs to ask the perpetrators about domestic abuse. In one case the offender even rang the surgery requesting a home visit for an injection to “put [the victim] to sleep”. He later presented with a painful shoulder, which he said was the consequence of him trying to “throw a bottle”, yet there was no follow-up. Another man presented injuries following three separate violent altercations, including one that involved assaulting a police officer – yet no further inquiries were made. And while one patient was “impulsive, controlling and had anger issues”, according to his GP, these were not considered to be risk factors in his relationship.
Lack of information sharing between GPs, emergency departments and mental health services was also cited as cause for concern. In one case a man told his GP he “felt angry and felt like destroying things” but was not asked about his family circumstances. Meanwhile, hospital records sent to the GP about the same man stated he had “consumed six cans of lager and phoned police to say he needed help or would kill himself and his girlfriend”. Yet there was no attempt by the GP, hospital or police to follow up.
More than 400 DHRs have been completed since they were made mandatory in April 2011. “These reviews are not intended to be about blame, but exercises in understanding the environments in which people made certain decisions and choices with a key purpose of making the future safer,” says Frank Mullane, founder of Advocacy After Fatal Domestic Abuse, which has guided 160 families through the process of a DHR. Mullane says he regularly sees issues around missed opportunities in GP surgeries. “It seems many GPs are inadequately informed about domestic abuse and may not be spotting the risk indicators. Many don’t know what to do if they suspect abuse, or if it is disclosed to them overtly, or inferred.”
However, there have been marked improvements where specialist training has been provided. The Identification and Referral to Improve Safety – or Iris – project has been commissioned in 34 areas in England and Wales since 2010 and is in more than 1,000 general practices.
Medina Johnson, Iris national director, says research shows patients in practices using the initiative were 22 times more likely to have a discussion about domestic abuse and that resulted in them being six times more likely to be referred to specialist services. They were also three times more likely to have domestic abuse noted in their medical records.
She explains: “GPs always say we are so busy, we only have 10 minutes and now you are asking us to do something additional. And we are, but it could save someone’s life. The simplicity of our message is: ask about domestic abuse, give an understanding response, offer a referral and make a note in the patient’s medical records.”
Under Iris, one specialist full-time worker can support up to 25 general practices, with each named worker conducting training as well as dealing with referrals. Gene Feder, the domestic abuse lead for the Royal College of General Practitioners, admits that some of the failures by GPs are “spine-chilling”. But he points out that the issue is far more complex because most domestic abuse is hidden and the presentation is far more subtle.
“I’m not trying to make excuses for GPs, but it’s hard to blame professionals when most have had zero to one hour of training around domestic abuse as medical students,” he says.
While guidelines from the National Institute for Health and Care Excellence (Nice) now recommend there should be training around domestic violence at every level, it remains minimal or absent in most medical schools.
Feder says that while Iris has good evidence on how doctors can respond safely to women disclosing abuse, the project was still working towards the best model for when patients disclose perpetration abuse. He adds: “The other thing is when you have male victims and female perpetrators – they are a minority, but men can also be victims and suffer serious mental health consequences.”
In some areas where Iris operates, such as Bristol and the east London borough of Hackney, there is sufficient funding for all general practices to be trained, but elsewhere the level of investment is insufficient to cover all surgeries.
The government has recently invested £2.4bn into primary care, part of which is to provide ongoing training for GPs. And last week Theresa May announced she will oversee the creation of a new law, the Domestic Violence and Abuse Act, to increase prosecutions across England and Wales and eradicate a postcode lottery in the way victims are dealt with by police forces. “There are thousands of people who are suffering at the hands of abusers – often isolated and unaware of the options and support available to them to end it,” says May.
But Feder, who is also professor of primary healthcare at Bristol University and the architect of Iris, warns that the impact of any health initiatives on victims of domestic violence is likely to be severely constrained by threats to the funding of domestic abuse services – and GPs who are under huge pressure from the demands of an ageing population. Since 2010, 17% of specialist women’s refuges have closed due to funding cuts.
Domestic abuse charities insist that with hundreds of women being murdered each year by a current or former partner, it is vital to protect the funding needed to keep these important referral pathways open.
‘My stepfather was abusive and should have been sectioned’
Annabella Bell’s mother, Chloe, was murdered in January 2013 by her violent and mentally ill husband, three days before her 81st birthday.
The couple were registered at the same surgery in north London and Bell, a 59-year-old mental health practitioner from Newcastle, had contacted her mother’s GP in the south of England to warn them she was at risk. She explains: “My stepfather was becoming increasingly paranoid and delusional, believing there was a plot to kill him. He missed hospital appointments and my mother was asked to intervene, but this would make him very angry.”
The couple divided the house they were living in and used separate entrances, but Bell’s mother continued to suffer violence at the hands of her husband. Bell says: “I told her doctor I was worried about my stepfather, and my mother also went in to explain, but they continued to involve her in his health matters.”
Then both the hospital and GP failed to make inquiries after her mother presented with a black eye at A&E, a month before she was brutally murdered. Bell’s stepfather killed himself after the fatal attack.
Bell was left so traumatised by her mother’s death that she “struggles every day” and is unable to work. She says more should have been done to protect her mother. “I’m not saying he wouldn’t have killed her if the doctors hadn’t involved her, but I’m saying there should have been some kind of warning.”
She adds: “It’s textbook stuff, but people seem to miss it and then it’s too late because somebody is murdered. My stepfather was abusive and psychotic and should have been sectioned.”
GPs miss chances to save the life of victims of domestic abuse
