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Child health Women's health Men's health

Domestic abuse

Last revised in September 2023

Domestic violence and abuse is a serious and common problem

Domestic abuse: Summary

  • Domestic abuse is defined as abusive behaviour of a person towards another person, who are each aged 16 years or over and are 'personally connected' to each other, which may be a single incident or a course of conduct, and may consist of any of the following:
    • Physical or sexual abuse.
    • Violent or threatening behaviour.
    • Controlling or coercive behaviour.
    • Verbal abuse.
    • Emotional, psychological, or other abuse.
    • Harassment or stalking.
    • Economic abuse.
    • Technology-facilitated abuse.
    • 'Honour'-based abuse, including forced marriage or female genital mutilation.
  • A child is defined as a victim of domestic abuse if they see, hear, or experience the effect of the abuse.
  • Domestic abuse is common. It occurs across the whole of society, regardless of age, sex, sexual orientation, gender identity, ethnicity, religion, socioeconomic status, disability, or belief.
  • Risk factors for experiencing domestic abuse include being female, being a young adult, having a comorbid mental health problem or long-term illness, separating from a partner, being pregnant, or being socio-economically disadvantaged.
  • Indicators of possible domestic abuse include:
    • Inconsistent health-seeking behaviour, including frequent attendances, vague symptoms, missed appointments, and delayed presentations.
    • Traumatic injuries; functional disorders; or stress-related conditions including irritable bowel syndrome, unexplained fatigue, and chronic pain syndromes.
    • Unexplained gynaecological symptoms, unintended pregnancy or termination, and delayed pregnancy care.
    • Depression, anxiety, sleep disorders, self-harm, and drug or alcohol misuse.
    • Intrusive 'other person' present in consultations.
  • If a person is experiencing possible domestic abuse, management should include:
    • Allowing them to make a disclosure alone, in private, asking open or direct questions sensitively and non-judgementally.
    • Advising that any discussion is confidential, subject to practice policy on adult and child safeguarding.
    • Assessing whether the person (and any other adults or children) are at immediate or significant risk of harm, and providing a basic safety plan.
    • Information sharing and arranging referral to the police, a local specialist domestic abuse service, or other agencies, depending on the level of risk and the person's wishes and needs.
    • Advising on sources of information and support, including for affected children.
    • Offering follow-up and continuity of care, including if a person is unwilling or unable to make a disclosure at this time.
    • Documenting any discussion with the person clearly, accurately, and safely in the primary care health record.
  • If a person is a possible perpetrator of domestic abuse, management should include:
    • Assessing personal safety and the safety of the person being abused (and any other adults or children), including asking open or direct questions relating to risk factors for immediate risk of harm.
    • Advising that any discussion is confidential, subject to practice policy on adult and child safeguarding.
    • Information sharing and arranging referral to the police, a local specialist domestic abuse service, or other agencies supporting perpetrators, depending on the level of risk and the person's needs.
    • Advising on sources of information and support.
    • Documenting any discussion with the person clearly, accurately, and safely in the primary care health record.

Have I got the right topic?

From age 16 years onwards.

This CKS topic covers the recognition and management of domestic abuse in primary care.

This CKS topic does not cover domestic abuse perpetrated on children by adults in detail, but includes recommendations on how to support children who are affected by domestic abuse. It also does not include detail on the recognition and management of suspected female genital mutilation.

There are separate CKS topics on Child maltreatment - recognition and management, Conduct disorders in children and young people, Depression, Depression in children, Generalized anxiety disorder, and Post-traumatic stress disorder.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

August to September 2023 — reviewed. A literature search was conducted in July 2023 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. The topic name has been changed from 'Domestic violence and abuse' to 'Domestic abuse', and the content has been updated in line with current evidence in the literature. The topic has undergone minor restructuring to improve clarity and navigation. 

Previous changes

February 2023 — minor update. The word 'woman' in the section on recognizing domestic violence and abuse has been replaced with the word 'person'.

July 2018 — new topic. The evidence base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 July 2023.

HTAs (Health Technology Assessments)

No new HTAs since 1 July 2023.

Economic Appraisals

No new economic appraisals relevant to England since 1 July 2023.

Systematic reviews and meta-analyses

No new systematic reviews or meta-analysis which reach the CKS threshold for inclusion since 1 July 2023.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 July 2023.

New policies

No new national policies or guidelines since 1 July 2023.

New safety alerts

No new safety alerts since 1 July 2023.

Changes in product availability

No changes in product availability since 1 July 2023.

Goals and outcome measures

Goals

To support primary healthcare professionals to:

  • Recognize the signs of possible domestic abuse.
  • Facilitate disclosure of domestic abuse sensitively and safely.
  • Assess whether the person and any other adults or children are at immediate risk of harm, provide a basic safety plan, and refer or signpost to specialist support services.
  • Assess the person for any physical injuries or mental health conditions, and offer appropriate management.
  • Provide advice and support for children who are affected by domestic abuse.
  • Provide advice and support to people who disclose that they are perpetrators of domestic abuse.
  • Document domestic abuse in a person's primary care health record clearly, accurately, and safely.
  • Share information appropriately with other agencies and specialist support services.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

Domestic violence and abuse

  • People presenting to frontline staff with indicators of possible domestic violence or abuse are asked about their experiences in a private discussion.
  • People experiencing domestic violence and abuse receive a response from level 1 or 2 trained staff.
  • People experiencing domestic violence or abuse are offered referral to specialist support services.
  • People who disclose that they are perpetrating domestic violence or abuse are offered referral to specialist services.

[NICE, 2016]

Background information

What is it?

  • The Home Office Domestic abuse statutory guidance defines domestic abuse as the presence of abusive behaviour of a person towards another person, who are each aged 16 years or over and are 'personally connected' to each other, which may be a single incident or a course of conduct, and may consist of any of the following [NICE, 2014] [Home Office, 2023]:
    • Physical or sexual abuse.
    • Violent or threatening behaviour.
    • Controlling or coercive behaviour.
    • Verbal abuse.
    • Emotional, psychological, or other abuse.
    • Harassment or stalking.
    • Economic abuse — a substantial adverse effect on a person's ability to acquire, use, or maintain money or other property, or obtain goods or services.
    • Technology-facilitated abuse.
    • 'Honour'- based abuse — a crime or incident committed (or possibly committed) to protect or defend the perceived 'honour' of an individual, family, or community against alleged or perceived breaches of the family or community's code of behaviour. This may also include:
      • Forced marriage — a marriage in which one or both spouses do not (or, in the case of some adults with learning or physical disabilities, cannot) consent to the marriage, but are forced into it using physical, psychological, financial, sexual, or emotional pressure. It is distinct from an arranged marriage, in which both partners enter freely.
      • Female genital mutilation — a procedure where the female genital organs are injured or changed for non-medical reasons.
    • Note: 'personally connected' refers to people who are, or have been, married to each other or have agreed to marry one another; civil partners of each other or have entered into a civil partnership agreement; in an intimate personal relationship; have or have had a parental relationship in relation to the same child; or are relatives. It often occurs in private, is subtle, and may be sustained [Home Office, 2023]. Domestic abuse may occur both during a relationship or after it has ended [SafeLives, 2019].
    • See the section on Initial assessment for full details of what each type of abuse may involve.
  • The Home Office Domestic abuse statutory guidance defines a child as a victim of domestic abuse if the child sees, hears, or experiences the effect of, the abuse [Home Office, 2023].

How common is it?

Domestic abuse is common. It occurs across the whole of society, regardless of age, sex, sexual orientation, gender identity, ethnicity, religion, socio-economic status, disability, or belief [Home Office, 2020] [Home Office, 2023]. Statistics are likely to be underestimated, as all types of domestic abuse are under-recognized and under-reported [NICE, 2014] [Home Office, 2023].

  • The Crime Survey for England and Wales (CSEW) data on people's experiences of crime for the year ending March 2022 estimated that [ONS, 2022]:
    • 5.0% of adults (6.9% women and 3% men) aged 16 years and over experienced domestic abuse, which equates to an estimated 2.4 million adults (1.7 million women and 699,000 men).
    • Approximately 1 in 5 adults aged 16 years and over (10.4 million) had experienced domestic abuse since the age of 16 years, which equates to a prevalence rate of 21.9%.
    • A higher percentage of adults experienced domestic abuse by a partner or ex-partner (3.5%) than by a family member (2.1%) in the last year. Of those who experienced partner abuse, 84.3% experienced non-physical abuse, 12.9% experienced any sexual assault, and 20.8% experienced stalking.
    • The number of police recorded domestic abuse-related crimes in England and Wales increased by 7.7% compared with the previous year, to 910,980 in the year ending March 2022. This follows increases seen in previous years and may reflect increased reporting by victims. The police recorded a total of 1,500,369 domestic abuse-related incidents and crimes over this time period.
  • The CSEW police data for the year ending March 2023 (based on 8 months of data collection) reported [ONS, 2023]: 
    • 702,604 violence against the person offences in England and Wales were flagged as domestic abuse-related.
    • 32,721 sexual offences in England and Wales were flagged as domestic abuse-related.
  • The Home Office Domestic abuse statutory guidance notes that domestic abuse-related offences represent 18% of all offences recorded by the police, but less than 1 in 5 victims report their abuse to the police [Home Office, 2023].
  • The Childhood Local Data on Risks and Needs (CHLDRN) 2019 childhood vulnerability report estimated that 831,000 children and young people lived in households that reported domestic abuse [Children's Commissioner, 2019].
  • The National Institute for Health and Care Excellence (NICE) public health guideline notes that [NICE, 2014]:
    • Domestic abuse is more commonly inflicted on women by men, especially severe and repeated violence and sexual assault.
    • Partner abuse is the most prevalent form of domestic abuse among adults.
    • Men are less likely to report abuse to the police, and are more likely to say this is because they consider it too trivial or not worth reporting.
    • Partner abuse is also prevalent in young people's relationships, and young people in same-sex relationships were at greater risk than those in heterosexual relationships.
    • Domestic abuse in which a parent is abused with children in the household is the most frequently reported form of trauma for children.
    • Abuse of parents by their children (aged 16 years and older) is under-reported, and is more commonly experienced by mothers than fathers and by single parents.
  • An Age UK report notes that domestic abuse has no age limit, and older people can experience domestic abuse from their partner, grown-up child, or people in a trusted position such as a friend, or paid or unpaid carer [Age UK, 2019].
    • It notes that CSEW data do not collect statistics for people over the age of 74 years in England and Wales, so there are no reliable data on the prevalence of domestic abuse for people over this age.

What are the risk factors?

  • The risk of experiencing domestic abuse is increased if a person is:
    • Female — more women than men are affected by domestic abuse [Home Office, 2023].
    • Age — aged 16–24 years (women) or 16–19 years (men) [NICE, 2014].
    • Sexual orientation and gender identity — about 80% of 'trans people' (including cross-dressers, transgender and transsexual people, and other gender-variant people) experience emotional, physical, or sexual abuse from a partner or ex-partner, and 38.4% of bisexual, gay, and lesbian people class themselves as having experienced domestic abuse [NICE, 2014].
    • Affected by long-term illness, disability, or mental health problems — the odds of being a victim of domestic abuse were two-fold higher for those with a physical disability and three-fold higher for those with a mental illness [BMA, 2014]. Mental health problems can be a risk factor for perpetration and victimisation of domestic abuse [SafeLives, 2015; Keynejad, 2021; Home Office, 2023].
    • Separated or in the process of separating from a partner — there is a higher risk of abuse around the time of separation including increased risk to physical safety, due to the perpetrator's perceived lack of control [SafeLives, 2019; Home Office, 2023].
    • Pregnant or has recently given birth — although pregnancy appears to offer protection for some women, it increases the risk for others [Home Office, 2023].
    • Socio-economically disadvantaged — although domestic abuse is experienced across all socio-economic classes, there is increased risk if a person is low income or under financial strain, or has reduced access to social support [Home Office, 2023].
  • The immediate risk of harm is increased if there is [SafeLives, 2015] [SafeLives, 2019] [Keynejad, 2021] [Home Office, 2023]:
    • Escalating violence — previous domestic abuse is the clearest indicator that further domestic abuse will occur, and the number of police callouts to the victim in the past 12 months can indicate a risk of potential escalation.
    • Substance misuse — some studies have found a significant relationship between alcohol and drug use and intimate partner violence and risk of escalation.
    • Mental health problems of the perpetrator and/or the victim.
    • A history of stalking.
    • Credible threats to kill.
    • Assault or threatening with a weapon.
    • Controlling or excessive jealous behaviour.
    • Assault during pregnancy.
    • Strangulation.

What are the consequences?

The experience of domestic abuse can adversely affect the physical, psychological, emotional, and social health and wellbeing of the victim, children, and other affected adults [DH, 2017] [Keynejad, 2021].

Physical

  • May include repeated traumatic injury (for example bruises, burns, bites, lacerations, abrasions, or fractures) or in extreme cases, homicide [NICE, 2014; Home Office, 2023].
    • The Home Office Domestic abuse statutory guidance cites Office for National Statistics (ONS) data that [Home Office, 2023]:
      • The majority of domestic homicide victims are women. Data for the period March 2018 to 2020 found 276 women were victims of domestic homicide and in 97% of cases, the suspect was male. Over the same period, 86 men were killed in domestic homicides. In 62% of the cases, the suspected perpetrator was male, and in 38% of the cases the suspect was female.
      • In the year ending March 2021, 57 women and 10 men were recorded as being victims of homicide by a current or ex-partner.
  • Children may present with bed-wetting and unexplained abdominal pain [Home Office, 2023].

Reproductive and sexual health

  • May include adverse reproductive outcomes, including multiple unintended pregnancies or terminations, delayed pregnancy care, miscarriage, premature labour, stillbirth, concealed pregnancy, recurrent sexually transmitted infections, and other urogenital conditions [NICE, 2014; Keynejad, 2021].

Emotional and psychological

  • May include depression, fear, anxiety, post-traumatic stress disorder, eating disorders, sleep disorders, drug and alcohol misuse, self-harm, suicidal ideation, or suicide attempts [NICE, 2014; RCGP/SafeLives/IRIS, 2014; SafeLives, 2019; Keynejad, 2021; Home Office, 2023].
  • There may be feelings of anger, guilt, low self-esteem and confidence, inability to trust others (especially in intimate relationships), fear of intimacy, emotional detachment, isolation, feelings of dependency, and loss of hope [DH, 2017; SafeLives, 2019].
  • Children may experience anxiety, depression, adjustment difficulties, behavioural problems, difficulties forming healthy relationships, risk-taking, aggression, and sleep problems including nightmares [SafeLives, 2019; Keynejad, 2021; Home Office, 2023].

Social and economic

  • There is an increased risk of financial dependency on the perpetrator, and homelessness and poverty if a person leaves a perpetrator, due to the effects of economic abuse [Home Office, 2023].
  • Children may have reduced educational attainment, truancy, and risk of expulsion from school [Home Office, 2023].
  • A Home Office report has estimated the social and economic costs of domestic abuse to be over £66 billion for victims identified in England and Wales within the year 2016 to 2017 [Home Office, 2019].
    • This is likely to include healthcare costs, time lost at work, reduced productivity at work, and costs of other support services including social and housing support, voluntary agencies, and police and criminal legal system involvement.
  • The cost per family where there is domestic abuse is estimated to be £18,730 according to a SafeLives report [SafeLives, 2015].

Recognition

When should I suspect domestic abuse?

All healthcare staff should be trained to recognize possible signs of domestic abuse at an early stage, to enquire sensitively and safely, be aware of patient confidentiality, and know how to respond to a disclosure.

  • Indicators of possible domestic abuse include:
    • Inconsistent health-seeking behaviour
      • Frequent attendances for vague symptoms.
      • Frequently missed appointments, including at antenatal clinics or children not brought to appointments.
      • Non-concordance with treatment or unplanned/early discharge from hospital.
      • Repeated health consultations with no clear diagnosis. The person may describe themselves as ‘accident prone’ or ‘silly’ and provide a vague explanation for injuries.
      • Delay in presentation of injuries. 
    • Physical symptoms and signs
      • Traumatic injury, especially if repeated, and with vague, inconsistent, or implausible explanations (for example bruises, burns, bites, lacerations, abrasions, or fractures).
      • Physical injuries may be inflicted on areas of the body that are covered by clothing, such as the neck, thorax, breasts, and abdomen. The person may try to hide or minimize the extent of injuries.
      • Functional disorders or stress-related conditions such as irritable bowel syndrome and other unexplained chronic gastrointestinal symptoms; fibromyalgia; chronic headache; and other chronic pain syndromes; unexplained fatigue; and unexplained cognitive problems.
    • Reproductive and sexual health symptoms and signs
      • Unexplained gynaecological symptoms, including chronic pelvic pain, sexual dysfunction, and genital injuries. 
      • Adverse reproductive outcomes, including multiple unintended pregnancies or terminations.
      • Delayed pregnancy care, miscarriage, premature labour, stillbirth, or concealed pregnancy.
      • Vaginal bleeding and recurrent sexually transmitted infections or urinary tract infections.
    • Emotional and psychological symptoms
      • Depression, fear, anxiety, post-traumatic stress disorder, eating disorders, and sleep disorders.
      • Adjustment difficulties, behavioural problems, risk-taking, aggression, sleep problems, and bed-wetting (particularly in children).
      • Self-harm, suicidal ideation, or suicide attempts.
      • Alcohol or drug misuse.
    • Intrusive ‘other person’ present in consultations:
      • Partner or spouse, parent, or grandparent (or, for elder abuse, a partner or family member or carer) always attending appointments unnecessarily.
      • The person is submissive or afraid to speak in front of the partner or relative, escort, or spouse.
      • The escort is aggressive, dominant, or over-attentive, talking for the person, or refusing to leave the room.
      • Note: the escort may intentionally present as charming, pleasant, and agreeable, which may make the person experiencing domestic abuse seem difficult and/or disordered in their thinking.

Basis for recommendation

The recommendations on recognizing domestic abuse are largely based on the National Institute for Health and Care Excellence (NICE) public health guideline Domestic violence and abuse: multi-agency working [NICE, 2014], the Home Office publication Domestic abuse: statutory guidance [Home Office, 2023], the Department of Health (DOH) guideline Responding to domestic abuse. A resource for health professionals [DH, 2017], the British Medical Association (BMA) report Domestic abuse [BMA, 2014], the SafeLives and IRIS publication Responding to domestic abuse: guidance for general practices [RCGP/SafeLives/IRIS, 2014], a survey of public perceptions of domestic abuse [Sivarajasingam, 2022], and expert opinion in a review article on identifying and responding to domestic abuse [Keynejad, 2021].

  • The NICE guideline recommends that health and social care managers and professionals should ensure frontline staff are trained to recognize the indicators of domestic abuse, and can ask relevant questions to help people disclose past or current experiences of violence or abuse [NICE, 2014].
    • The NICE guideline highlights that there is an ongoing debate about the effectiveness and desirability of screening and routine or targeted enquiry to identify people who are experiencing domestic abuse. Although there is currently insufficient evidence to recommend this practice in healthcare settings, asking people routinely about domestic abuse in some specialized healthcare settings is considered good practice by professionals in those fields. The expert opinion of a previous external reviewer of this CKS topic also recommended a low threshold for enquiry about domestic abuse.
  • A survey of public perceptions of domestic abuse notes that people experiencing domestic abuse may have unnecessary investigations and medications for a wide variety of physical and/or mental health problems, and may be frequent attenders to healthcare service [Sivarajasingam, 2022].

Management

Scenario: Managing domestic abuse

From age 16 years onwards.

How should I assess a person experiencing possible domestic abuse?

All healthcare staff should be trained to recognize possible signs of domestic abuse at an early stage, to enquire sensitively and safely, be aware of patient confidentiality, and know how to respond to a disclosure. If a person presents with indicators of possible domestic abuse:

  • Allow the person to make a disclosure alone in private with no third parties present.
    • Ensure that the person feels safe, is given time and space to talk, and questions are asked in a kind, sensitive manner. Listen closely, with empathy, and without judgement.
    • Use gender-neutral terms such as partner/ex-partner.
    • Ask the person for safe contact details.
    • Ask about where the perpetrator and any children are.
    • Ask about who they are frightened of, and who they are frightened for.
    • Ask what they would like to happen.
    • Use a professional interpreter or an advocate from a local specialist domestic violence and abuse service. Do not use the person's child, relative, or friend as an interpreter.
  • Advise the person that any discussion is confidential and that the information provided will be shared only with their consent, subject to practice policy on adult and child safeguarding.
    • If it is believed that withholding information puts a child or another adult at risk of significant harm, then disclosure may be justified in the public interest and/or in order to protect the vital interests of the third party.
    • If there is any uncertainty about ongoing management, discuss with colleagues or seek specialist advice. See the sections on Confidentiality and information sharing and Multi-agency working for more information.
  • Ask open or direct questions about domestic abuse, depending on clinical judgement.
    • Consider asking open questions, such as 'How are things at home?', 'Sometimes symptoms can be triggered by stressful events in our relationships, has anything like that happened to you?', 'We know violence at home can be a problem, is there anyone who is hurting you?'.
    • Consider asking direct questions, such as 'Do you feel safe at home?', 'Does anyone make you feel afraid?', 'Do you feel safe in your relationship?', 'Is there anything that worries you about your relationship?', 'These injuries are more than I would expect following a fall, I'm wondering if someone else might have hurt you?'.
    • Try and establish the range of abuse, if the abuse is getting worse, or happening more often, or the incidents themselves are getting more serious.
      • Suggest the person keeps a diary of incidents or threats, when and where they happen, if anyone else was with them, and if they were frightened.
    • Try and establish if the abuse is affecting other people in the household or elsewhere, such as children (including ages, school or nursery), siblings, or relatives.
    • Ask about emotional, physical, social, and practical needs and concerns, and any risk factors for domestic abuse.
  • Consider asking specific questions relating to different forms of domestic abuse, depending on clinical judgement. These may include:
    • Emotional or psychological abuse
      • Does your partner, or former partner, repeatedly belittle you, put you down, or say you are worthless? Blame you for the abuse or arguments? Deny that abuse is happening, or play it down? Isolate you from your family and friends? Stop you going to college or work? Make unreasonable demands for your attention? Accuse you of flirting or having affairs? Tell you what to wear, who to see, where to go, and what to think? Control your money, or not give you enough to buy food, medication, pay bills, or pay for other essential things?
    • Threats and intimidation
      • Does your partner, or former partner, ever threaten to hurt or kill you? Destroy things that belong to you? Stand over you, invade your personal space? Threaten to kill themselves or the children? Read your emails, texts, or letters, monitor your internet or social media use, or limit your use of technology? Harass or follow you? Threaten to deny access to medical aids or equipment?
    • Controlling or coercive behaviour
      • Does your partner, or former partner, ever control or monitor your daily activities and behaviour? Control your access to finances and how you spend your money? Control who you see or isolate you from family, friends, and professionals? Refuse to interpret or hinder your access to communication including preventing you learning a language or making friends? Prevent you from taking medication or prevent access to medical aids or equipment? Threaten to expose sensitive information?
    • Physical abuse
      • Does your partner, or former partner, threaten to or ever slap, hit, punch, scratch, or pinch you? Push or shove you? Bite, spit on, or kick you? Burn or scald or poison you? Choke or strangle you or hold you down? Throw things at you or in the direction of you? Use or threaten to use weapons including knives or irons? Harm pets or damage furniture?
    • Sexual abuse
      • Does your partner, or former partner, ever touch you in a way you don't want to be touched? Make unwanted sexual contacts or demands? Hurt you during sex including non-fatal strangulation? Pressure or trick you to have unsafe sex – for example deception over the use of contraception such as condoms? Intentionally expose you to STIs? Threaten, intimidate, or pressure you to have sex, or sexual acts, including with other people? Force you to to make or watch pornography? Restrict your access to contraception or refuse to use contraception? Force you to get a termination or pregnancy, or assisted reproductive procedure?
    • Economic abuse
      • Does your partner, or former partner, ever control the family income or not allow you to earn or spend money unless 'permitted'? Refuse to contribute to household income or costs? Prevent you claiming welfare benefits or interfere with your training, employment, or career so you are economically dependent on them?
  • If talking to a child about possible domestic abuse:
    • Talk sensitively, and ask simple and direct questions to allow opportunities for a disclosure.
      • Do not interrogate the child. Ask questions such as 'Is there something you are sad or worried about?'.
      • Be aware that some children may not want to talk at all, whilst others disclose indirectly (not sharing the details without being prompted) or in a roundabout way, for example 'Sometimes my stepdad upsets my mum'.
  • If the person is unwilling or unable to disclose domestic abuse at this time:
    • Assess whether the person (and any other adults or children) are at immediate risk of harm. See the section on Responding to a disclosure by the victim if there is an immediate risk of harm.
    • Offer follow-up and continuity of care, where possible. Advise that you are available to talk if and when they are ready.
    • Be aware of possible reasons for non-disclosure, such as:
      • Fear of the perpetrator; fear of retribution from the perpetrator; or fear of not being believed.
      • Pressures from family or the community. Fear of causing a family breakdown or bringing dishonour to the family; fear that the children will be taken into care; fear of an unsympathetic response; or fear of repercussions related to insecure immigration status.
      • Shame or embarrassment, cultural stigma, economic barriers, or communication difficulties.
      • Not identifying their experience as abuse.
      • Not believing that anything can be done to help them; believing that the experience is ‘too trivial’ to mention; or having had a negative past experience of services.
  • Document any discussion with the person clearly, accurately, and safely in the primary care health record, even if the person is unwilling or unable to disclose domestic abuse at this time.
    • Explain the need to document the consultation. Explain that, as a duty of care, healthcare professionals have a responsibility to record a disclosure or the findings of an examination (including any injuries).
    • Record any health problems, symptoms, and signs, including a description of any injuries, whether this is a first disclosure, or any previous disclosures, timescales, and actions taken.
      • Use the person's own words (with quotation marks) rather than your own. Describe exactly what happened, for example, patient states 'my husband kicked me twice in the stomach' rather than 'patient assaulted'.
      • It may be helpful to note the cause or suspected cause of injuries or other conditions, including the person who caused the injury.
      • Consider taking photographs of any physical injuries. Drawings or body maps can also be used.
    • Ensure that the medical record can only be accessed by those directly involved in the person’s care.
      • Make use of the online visibility function in the electronic medical record, and consider use of a code or special mark to indicate cases of (or suspected) domestic abuse in the person's (and children's) medical notes. Ensure that documentation of domestic abuse is hidden from accessible online records.
      • Do not document anything where it can be seen by those who do not need to know, for example, on an X-ray request or in hand-held notes (such as maternity notes).
  • Following a disclosure of domestic abuse, see the section on Responding to a disclosure by the victim for more information on management and follow-up.

Multi-agency working

GP practices should ensure staff are given relevant training in multi-agency working with other statutory agencies and third sector organisations, including local authorities, community-based agencies, children's services, schools, housing, mental health services, drug and alcohol services, specialist domestic abuse agencies, and the police and criminal justice system, in order to share information appropriately to support and protect victims of domestic abuse [RCGP/SafeLives/IRIS, 2014] [SafeLives, 2019] [Keynejad, 2021] [Home Office, 2023]. This may include:

  • Referral to an IDVA (Independent Domestic Violence Advisors) service
    • This may act as a victim's point of contact, supporting people who are at high risk of harm from perpetrators. They help assess risk levels, discuss options, and create safety plans. The IDVA is a specialist practitioner who works in partnership with other agencies to implement the action plan, mobilising resources on behalf of the victims, including children, to increase their safety.
  • MARAC (Multi-Agency Risk Assessment Conference)
    • This is a non-statutory process that brings together statutory and voluntary agencies to jointly support adult and child victims of domestic abuse who are at a high risk of serious harm or homicide, and to disrupt and divert the behaviour of the perpetrator(s).
    • The SafeLives national charity website (www.safelives.org.uk) has useful resources for healthcare professionals, including how to complete MARAC GP information requests, information sharing for MARAC, and the other agencies involved, such as police, probation, health, child safeguarding, housing, and IDVAs.
  • Use of the SafeLives DASH (Domestic Abuse, Stalking, Harassment and 'Honour'-based Violence) risk assessment tool
    • This can be used by front-line practitioners, alongside professional judgement, as a framework to identify adults at high risk of serious harm or homicide whose cases should be referred to a MARAC meeting, and help decide what other support may be needed.
  • IRIS (Identification and Referral to Improve Safety) programme
    • This is a model for professional support providing specific domestic abuse in-house training, support to practice teams, referral, and recording for general practices, by having a domestic abuse specialist embedded in practice.

Confidentiality and information sharing

  • If it is felt necessary or desirable to share information with other agencies:
    • Obtain consent from the person to share information, if possible.
  • If the person does not consent to information sharing:
    • Be aware of the lawful grounds for sharing without consent, including:
      • Where there is a risk of harm to the person, any children involved, or somebody else if information is not passed on as a referral.
      • To inform a risk assessment (where the definition of ‘harm’ to a child includes impairment caused by seeing or hearing the abuse of another person).
      • When the courts request information about a specific case.
    • The decision to override the duty of confidentiality must be justifiable and proportionate, based on the potential or actual harm to adults or children at risk. 
      • For an adult, a relatively high risk is necessary before considering overriding the duty of confidentiality.
      • For children, careful consideration should be given to disclosure even about low risks.
  • If a decision is made to share information:
    • Record the decision and the reasons for that decision.
    • The process must be compliant with the UK General Data Protection Regulations (GDPR) 2018 and Data Protection Act 2018 and the common law duty of confidence. The Information Sharing Protocol and Caldicott Principles must be adhered to, and the decision to share must be recorded as being both proportional and relevant in relation to the risks.
  • If a decision is made to share information without consent, or if consent is refused:
    • Be completely sure that the decision does not place the person(s) at risk of greater abuse or violence.
    • Record your reasons to be able to justify your decision, and document confirmation that the information you passed on has been received and understood.
    • If safe and appropriate, discuss what will be disclosed and why you are doing so with the person. Note when and whether the person was informed about the disclosure, and reasons why if not informed (for example, places the person at increased risk).
    • Consider seeking specialist advice, for example, from the local Caldicott Guardian or the Information Commissioner’s Office.
  • If a decision is made not to share information, record the decision and the reasons for that decision.
  • Professional resources about information sharing which may be useful include:

[BMA, 2014; NICE, 2014; RCGP/SafeLives/IRIS, 2014; DH, 2017; Home Office, 2023] 

Sources of victim support

  • Useful sources of information and support for people experiencing domestic abuse include:
    • General
      • Police — 999 in an emergency.
      • National Domestic Abuse Helpline — 0808 2000 247 (www.nationaldahelpline.org.uk), a freephone, 24-hour, non-judgemental, and confidential advice run by Refuge to keep victims safe and provide information to make informed choices.
      • Bright Sky mobile app and website provide practical support and information on how to respond to domestic abuse.
      • Samaritans — 116 123 www.samaritans.org (available 24 hours a day to provide confidential, emotional support for people who are experiencing feelings of distress or despair).
      • Victim Support — 0808 1689 111 www.victimsupport.org.uk (free and confidential support for victims and survivors of any abuse or crime, regardless of when it occurred or if the crime was reported to the police).
    • Women
    • Men
      • Men’s Advice Line run by Respect — 0808 801 0327 www.mensadviceline.org.uk.
      • Men’s Aid — 0333 567 0556 www.mensaid.co.uk (provides practical advice and support to primarily men, but also seeks to represent the views and support anyone, regardless of gender or sexual orientation).
      • Mankind — 01273 911680 www.mkcharity.org (a specialist organisation for men in England and Wales affected by unwanted sexual experiences, including self-help resources, counselling, and other forms of therapy).
      • ManKind Initiative — 01823 334244 www.mankind.org.uk (provides a confidential helpline for male victims of domestic abuse, as well as information, support, and a signposting service).
      • Respect — 0808 802 4040 www.respectphoneline.org.uk (offers information and advice to male victims of domestic abuse, their partners, ex-partners, friends, family, and front-line workers).
      • Survivors UK — 0203 598 3898 www.survivorsuk.org (provides support and advocates for men and non-binary people who have been affected by rape or sexual abuse).
    • Children
    • Specific groups
      • Galop — 0800 999 5428 www.galop.org.uk (provides the national LGBT domestic abuse helpline, and can also advise on other issues such as hate crime, so-called conversion therapies, and sexual violence).
      • There are multiple additional resources on the GOV.UK website section on specialist support services including for lesbian, gay, bisexual, trans+ people; older people; refugee groups; disabled people, and ethnic minority groups.
    • Legal advice
      • National Centre for Domestic Violence — 0800 970 2070 www.ncdv.co.uk (provides a fast, free emergency injunction service to survivors of domestic abuse, regardless of their financial circumstances, race, gender, or sexual orientation).

Basis for recommendation

These recommendations are largely based on the National Institute for Health and Care Excellence (NICE) public health guideline Domestic violence and abuse: multi-agency working [NICE, 2014], the Home Office publications Domestic abuse: statutory guidance [Home Office, 2023] and Domestic abuse: recognise the signs [Home Office, 2020], the Department of Health guidance Responding to domestic abuse: A resource for health professionals [DH, 2017], the British Medical Association (BMA) report Domestic abuse [BMA, 2014], the SafeLives and IRIS publication Responding to domestic abuse: guidance for general practices [RCGP/SafeLives/IRIS, 2014], the SafeLives document SafeLives DASH risk checklist. Quick start guidance [SafeLives, 2019], the Age UK report No age limit. The hidden face of domestic abuse [Age UK, 2019], a survey of public perceptions of domestic abuse [Sivarajasingam, 2022], and expert opinion in review articles on identifying and responding to domestic abuse [Keynejad, 2021] and on the impact of domestic abuse [Walker-Descartes, 2021].

Allowing a person to make a disclosure
  • These recommendations are based on the NICE public health guideline [NICE, 2014], the Home Office statutory guidance [Home Office, 2023], the Department of Health guidance [DH, 2017], the SafeLive publications [RCGP/SafeLives/IRIS, 2014; SafeLives, 2019], the BMA report [BMA, 2014], and expert opinion in a review article [Keynejad, 2021].
    • Despite the hidden nature of domestic abuse, healthcare professionals are in a key position to identify it and to provide support and safety for people experiencing it [BMA, 2014; DH, 2017].
    • The recommendation to never ask about domestic abuse in front of a verbal child, partner, relative, or other adult is based on the fact they may share that information with the perpetrator, placing the person at greater risk [Keynejad, 2021; Home Office, 2023].
    • The recommendation to use gender-neutral terms is to encourage a safe, accessible environment where lesbian, gay, bisexual, or trans (LGBT) victims feel able to disclose both domestic abuse and their sexual orientation or gender identity [SafeLives, 2019].
    • The recommendation to use a professional interpreter is based on the fact there is a significant risk that people experiencing domestic abuse may be less likely to disclose with someone they know in the room. It may increase the risk to the victim if they disclose in front of the perpetrator or someone who could share that information with the perpetrator [Home Office, 2023].
Advising on patient confidentiality and sharing information
  • These recommendations are based on the NICE public health guideline [NICE, 2014], the Home Office statutory guidance [Home Office, 2023], the SafeLives guidance [RCGP/SafeLives/IRIS, 2014], and the BMA report [BMA, 2014].
    • The NICE guideline notes that information sharing without consent risks losing the person's trust and may endanger a person's safety.
    • The BMA report recommends that healthcare professionals emphasize that any discussion about domestic abuse will be confidential, as reassurance could affect whether or not a person chooses to disclose information. It also highlights the importance of the person being involved in all stages of the decision-making process and retaining as much control as possible over disclosures of information. They may feel threatened by the thought of others knowing about their situation, and may be concerned that disclosure may lead to further violence and abuse.
    • The BMA report notes, however, that there are limits to confidentiality in exceptional circumstances, such as risk of serious harm to a third party such as a child or vulnerable adult. The decision of a professional to disclose is based partly on balancing the risk and likelihood of harm if no disclosure is made, the risk and likelihood of harm if a third party disclosure is made, and the need to maintain the trust of the person.
Asking open and direct questions about domestic abuse
  • These recommendations are based on the SafeLives checklist publication [SafeLives, 2019] and expert opinion in review articles [Keynejad, 2021; Walker-Descartes, 2021].
    • Expert opinion in a review article recommends using closed questioning in specific situations, such as if remote consulting, to stop the content of a discussion being understood by someone else in the room [Keynejad, 2021].
    • Expert opinion in another review article highlights that asking questions about domestic abuse can identify abuse which would not otherwise be detected, can help to prevent future abuse, can lessen the impact of abuse, and can improve the person's future functioning. It notes that many victims may not disclose unless directly questioned under safe and respectful conditions [Walker-Descartes, 2021].
    • The SafeLives publication recommends assessing the nature, frequency, and severity of abuse, and suggests keeping a diary of incidents or threats to have an objective record.
Asking specific questions about different forms of abuse
Asking a child about possible domestic abuse
  • These recommendations are largely based on the Department of Health guidance [DH, 2017], and expert opinion from a previous external reviewer of this CKS topic, who highlighted that clinicians often find it difficult to talk to children about domestic abuse, as it can be upsetting to imagine what the child may be going through, and frustrating if they feel disempowered to help. They note a child may disclose important information requiring child safeguarding procedures to be followed, and/or it may be necessary to involve other professionals, such as the health visitor or school nursing teams.
Responding to non-disclosure of abuse
  • These recommendations are based on the NICE public health guideline [NICE, 2014], the Home Office statutory guidance [Home Office, 2023], the Department of Health guidance [DH, 2017], the BMA report [BMA, 2014], the Age UK report [Age UK, 2019], a qualitative survey [Sivarajasingam, 2022], and expert opinion in a review article [Keynejad, 2021].
    • The recommendation to offer follow-up and continuity of care is based on the fact that survivors report being more likely to disclose domestic abuse if they have a trusting relationship with their healthcare professional [DH, 2017; Keynejad, 2021; Home Office, 2023]. The BMA report suggests thinking of the conversation as the start of a process rather than a one-off event.
Ensuring clear and accurate documentation
  • These recommendations are based on the Home Office statutory guidance [Home Office, 2023], the Department of Health guideline [DH, 2017], the BMA report [BMA, 2014], the SafeLives publications [RCGP/SafeLives/IRIS, 2014; SafeLives, 2019], and expert opinion in a review article [Keynejad, 2021].
    • Healthcare professionals should record and share information about suspected and actual abuse accurately to better support victims [Home Office, 2023].
    • The BMA report notes that the primary care health record may be required as evidence, for example, during the prosecution of a perpetrator, if the victim was obtaining protection through an injunction or court order, in cases where the person is at risk of deportation due to immigration laws, for housing provision applications, and to assess possible risks to children.
    • The expert opinion of a previous external reviewer of this CKS topic notes various challenges associated with recording domestic abuse information in the electronic medical record of people experiencing or perpetrating abuse (and any children). It is essential to avoid increasing the risk of harm to the person being abused (and any children), for example due to an accidental discovery of disclosure by a perpetrator.

How should I respond to a disclosure made by a victim?

All healthcare staff should be trained to recognize possible signs of domestic abuse at an early stage, to enquire sensitively and safely, be aware of patient confidentiality, and know how to respond to a disclosure following initial assessment.

  • Reassure the person that they have made an important step by making the disclosure.
    • Tell them you believe them, that the abuse is not their fault, and that they (and any children) have a right to safety.
  • Assess whether the person (and any other adults or children) are at immediate risk of harm.
    • If there is an immediate risk, ring 999 and refer to the local adult and/or child safeguarding teams and/or IDVA (Independent Domestic Violence Advisors) service, ideally with the person's consent.
    • If there is no immediate risk, provide a basic safety plan.
      • Manage any presenting physical injuries and arrange admission or referral, depending on clinical judgement.
      • Do not advise the person on what action they should take, such as to leave their partner if they are not ready and without appropriate support in place.
      • Be aware that a person's situation and risk are dynamic and can change quickly.
  • Advise the person that any discussion is confidential, and that the information provided will be shared only with their consent, subject to practice policy on adult and child safeguarding.
  • If there is a significant risk to the person (or other adults or children), share information with other agencies and services appropriately, depending on clinical judgement.
    • If it is believed that withholding information puts a child or another adult at risk of significant harm, then disclosure may be justified in the public interest and/or in order to protect the vital interests of the third party.
    • See the sections on Multi-agency working and Confidentiality and information sharing for more information.
  • Advise on sources of information and support to enable the person to make their own decisions.
  • Arrange referral, liaise with, or signpost to local agencies and services, depending on clinical judgement.
    • These may include specialist services for domestic abuse; maternity services; sexual health services; a sexual assault referral centre (SARC) and the police for medical and legal investigations if there is reported sexual abuse; mental health services and/or substance misuse services; housing support; financial advice; counselling; and advocacy, depending on the level of risk.
    • Ensure that children and young people affected by domestic abuse are offered referral to age-appropriate specialist domestic abuse services, which may include psychoeducational support, counselling, specialist children's victim support workers, or an Independent Domestic Violence Adviser (IDVA).
  • Provide ongoing support and follow-up for the person (and other adults or children) with continuity of care, where possible.
    • Ensure the person is seen alone at future appointments. 
    • Monitor for possible indicators of further, or increased, domestic abuse.
    • Follow existing safeguarding, risk assessment, and referrals processes and procedures for vulnerable adults and children. See the CKS topic on Child maltreatment - recognition and management for more information.
    • Monitor their physical, mental and/or emotional wellbeing and need for ongoing support, treatment, and/or referral.

Basis for recommendation

These recommendations are largely based on the National Institute for Health and Care Excellence (NICE) public health guideline Domestic violence and abuse: multi-agency working [NICE, 2014], the Home Office publications Domestic abuse: statutory guidance [Home Office, 2023] and Domestic abuse: recognise the signs [Home Office, 2020], the Department of Health guideline Responding to domestic abuse: A resource for health professionals [DH, 2017], the British Medical Association (BMA) report Domestic abuse [BMA, 2014], the SafeLives and IRIS publication Responding to domestic abuse: guidance for general practices [RCGP/SafeLives/IRIS, 2014], the SafeLives document SafeLives DASH risk checklist [SafeLives, 2019], and expert opinion in a review article on identifying and responding to domestic abuse [Keynejad, 2021].

Providing validation and reassurance
  • This recommendation is based on expert opinion in a review article [Keynejad, 2021]. In addition, the expert opinion of a previous external reviewer of this CKS topic notes that it can sometimes take years for people to disclose domestic abuse due to a number of reasons, including feelings of shame, vulnerability, fear, and low self-esteem. The immediate response from a healthcare professional is therefore very important.
Assessing for immediate risk of harm
  • These recommendations are based on the NICE public health guidance [NICE, 2014], the Home Office statutory guidance [Home Office, 2023], the Department of Health guideline [DH, 2017], the BMA report [BMA, 2014], the SafeLives publications [RCGP/SafeLives/IRIS, 2014; SafeLives, 2019], and expert opinion in a review article [Keynejad, 2021].
    • The Department of Health guideline highlights that a thorough risk assessment can guide safety planning, referrals to appropriate specialist support services, and aid any police investigation.
    • Engagement with specialist services including the IDVA (Independent Domestic Violence Advisors) service is associated with improved safety, including reduced domestic abuse escalation, severity, and recurrence [Keynejad, 2021].
    • The recommendation not to advise the person on what action to take is based on the fact that risks, including homicide, can escalate when the person tries (or is suspected of planning) to leave, and also increase after separation [Keynejad, 2021]. The SafeLives guidance also notes there is a higher risk of abuse around the time of separation, including increased risk to the person's physical safety, due to the perpetrator's perceived lack of control [SafeLives, 2019]. This approach is supported by the Department of Health guideline and the BMA report.
    • The information that a person's risk level can change quickly is based on the SafeLives publication [SafeLives, 2019] and expert opinion in a review article [Keynejad, 2021].
Advising on patient confidentiality and sharing information
  • These recommendations are based on the NICE public health guidance [NICE, 2014], the Home Office statutory guidance [Home Office, 2023], the SafeLives publication [RCGP/SafeLives/IRIS, 2014], the BMA report [BMA, 2014], and expert opinion in a review article [Keynejad, 2021].
    • The NICE guideline notes that information sharing without consent risks losing the person's trust and may endanger a person's safety.
    • The BMA report recommends that healthcare professionals emphasize that any discussion about domestic abuse will be confidential, as reassurance could affect whether or not a person chooses to disclose information. It also highlights the importance of the person being involved in all stages of the decision-making process and retaining as much control as possible over disclosures of information. They may feel threatened by the thought of others knowing about their situation, and may be concerned that disclosure may lead to further violence and abuse.
    • The BMA report notes, however, that there are limits to confidentiality in exceptional circumstances, such as risk of serious harm to a third party such as a child or vulnerable adult. The decision of a professional to disclose is based partly on balancing the risk and likelihood of harm if no disclosure is made, the risk and likelihood of harm if a third party disclosure is made, and the need to maintain the trust of the person.
Advising on sources of information and support
Arranging referral or liaising with local agencies and services
  • These recommendations are based on the NICE public health guidance [NICE, 2014], the Home Office statutory guidance [Home Office, 2023], the Department of Health guideline [DH, 2017], the BMA report [BMA, 2014], the SafeLives publications [RCGP/SafeLives/IRIS, 2014; SafeLives, 2019], and expert opinion in a review article [Keynejad, 2021].
    • The Department of Health guideline highlights the importance of multi-agency working for the person and also healthcare professionals involved in the person's care. The affected person will only be able to disclose the things they know about, however other services such as the police, probation, youth justice, substance misuse, mental health, and other health services may have additional information about the perpetrator.
Providing ongoing support and follow-up

How should I respond to a disclosure made by a perpetrator?

The approach to managing a person suspected of perpetrating domestic abuse depends on whether the person acknowledges their behaviour as a problem, seeks help for a related problem, or has been identified by others as a perpetrator.

  • Before seeking or enabling a disclosure from a person suspected of being a perpetrator of domestic abuse:
    • Consider your safety and that of the person being abused and any children.
    • Seek advice from, or refer the person to, a local specialist domestic abuse service, if needed.
  • Advise the person that any discussion is confidential, and that the information provided will be shared only with their consent, subject to practice policy on adult and child safeguarding.
    • If it is believed that withholding information puts a child or another adult at risk of significant harm, then disclosure may be justified in the public interest and/or in order to protect the vital interests of the third party.
    • If there is any uncertainty about ongoing management, discuss with colleagues or seek specialist advice. See the sections on Confidentiality and information sharing and Multi-agency working for more information.
  • Use motivational interviewing techniques when gathering information. 
    • Express empathy through reflective listening, using phrases such as 'Thank you for talking about this', 'These behaviours could be really affecting your partner/family', and 'Help is available'.
    • Identify any discrepancy between the person’s goals or values and their current behaviour, and explore it further.
    • Avoid argument and direct confrontation.
  • If the person presents with a related problem, such as alcohol or drug misuse, carer stress, or a mental health issue, but does not acknowledge their behaviour as a problem, consider asking the following questions:
    • 'How is this drinking/drug use/stress at work/mental health issue affecting how you are with your partner and family?'.
    • 'When you feel like that, what do you do/how do you behave?'.
    • 'Do you find yourself shouting or smashing things?'.
    • 'Do you ever feel violent towards a particular person?'.
    • 'It sounds like you want to make some changes for your benefit and for your partner and family. What choices do you have? What can you do about it? What help would you like to make these changes?'.
  • If the person admits that domestic abuse is an issue and they are not the victim, useful questions may include:
    • 'How does your behaviour make you feel?', 'How does your behaviour affect people close to you?', 'How do alcohol/drugs affect your behaviour?'.
    • 'What do you think will help you change your behaviour?'.
  • If the person responds openly to these questions, consider asking direct questions relating to risk factors for immediate risk of harm, such as:
    • 'Do you feel unhappy about your partner seeing friends or family? Do you ever try to stop them?'.
    • 'Have you assaulted your partner in front of the children?', 'Have you ever assaulted or threatened your partner with a knife or other weapon?'.
    • 'Did your behaviour change towards your partner during pregnancy?'.
  • If there is a significant risk to the person being abused (and any children), share information with other agencies and services appropriately, depending on clinical judgement.
  • Advise on sources of information and support, such as:
  • Offer to refer the person to a local specialist service supporting perpetrators of domestic abuse.
    • This may include a local perpetrator behaviour change programme to help challenge and support the person to make long-term changes to their behaviour.
      • Refer a young person aged 16–18 years through the local child safeguarding referral pathway if they are harming their partner, siblings, parents, or other adult family members. Be aware that children who harm others are likely to have considerable needs themselves.
    • Assess the person's physical, mental and/or emotional wellbeing and need for ongoing support, treatment, and/or referral.
  • Document any discussion with the person clearly, accurately, and safely in the primary care health record.
    • Explain the need to document the consultation. Explain that, as a duty of care, healthcare professionals have a responsibility to record a disclosure.
    • Ensure that the medical record can only be accessed by those directly involved in the person’s care, and ensure any documentation does not place victim(s) at risk.
      • Make use of the online visibility function in the electronic medical record, and consider use of a code or special mark to indicate cases of (or suspected) domestic abuse in the person's medical notes. Ensure that documentation of domestic abuse is hidden from accessible online records.

Basis for recommendation

These recommendations are based on the National Institute for Health and Care Excellence (NICE) public health guideline Domestic violence and abuse: multi-agency working [NICE, 2014], the Home Office publication Domestic abuse: statutory guidance [Home Office, 2023], the Department of Health guideline Responding to domestic abuse: A resource for health professionals [DH, 2017], the British Medical Association (BMA) report Domestic abuse [BMA, 2014], the SafeLives and IRIS publication Responding to domestic abuse: guidance for general practices [RCGP/SafeLives/IRIS, 2014], and expert opinion in a review article on identifying and responding to domestic abuse [Keynejad, 2021].

Ensuring personal and victim safety
  • This recommendation is largely based on the Department of Health guideline [DH, 2017]. It is also pragmatic, based on what CKS considers to be good clinical practice.
Advising on patient confidentiality and sharing information
Asking open and direct questions about perpetrating domestic abuse
  • These recommendations are largely based on the Department of Health guideline [DH, 2017], together with the expert opinion of a previous external reviewer of this CKS topic, and expert opinion in a review article [Keynejad, 2021]. They are also pragmatic, based on what CKS considers to be good clinical practice.
    • The Department of Health guideline notes that the response of a health professional to any disclosure of domestic abuse could be significant in encouraging personal responsibility and motivating a perpetrator to change.
Assessing for and managing significant risk of harm
  • These recommendations are based on the NICE public health guidance [NICE, 2014], the Home Office statutory guidance [Home Office, 2023], the Department of Health guideline [DH, 2017], the SafeLives publication [RCGP/SafeLives/IRIS, 2014], and expert opinion in a review article [Keynejad, 2021].
    • The Department of Health guideline highlights that a thorough risk assessment can guide safety planning, referrals to appropriate specialist support services, and aid any police investigation.
    • The Home Office statutory guidance highlights the importance of sharing information with other agencies if appropriate.
Advising on sources of information and support
Offering referral to a local specialist service
  • These recommendations are extrapolated from the NICE public health guidance [NICE, 2014], and are also based on the Home Office statutory guidance [Home Office, 2023] and the Department of Health guideline [DH, 2017]. They are also pragmatic, based on what CKS considers to be good clinical practice.
    • The NICE guideline recommends the provision of tailored interventions for perpetrators depending on a local needs assessment, with the primary aim of increasing the safety of the person being abused and any children. It states that risk assessments of perpetrators should be linked with safety planning and specialist support services for people experiencing domestic abuse.
    • The Department of Health guideline highlights that referral pathways for perpetrators of abuse should include specialist services as well as provision of support for related issues such as mental health and/or substance misuse. It notes there is a risk that a perpetrator may avoid taking responsibility for their abusive behaviour with increased risk of harming others if specialist support is not provided. This may be the remit of the criminal justice system or community-based programmes, usually run by third-sector organizations.
Ensuring clear and accurate documentation
  • These recommendations are based on the Home Office statutory guidance [Home Office, 2023], the Department of Health guideline [DH, 2017], the BMA report [BMA, 2014], the SafeLives publication [RCGP/SafeLives/IRIS, 2014], and expert opinion in a review article [Keynejad, 2021].
    • Healthcare professionals should record and share information about suspected and actual abuse accurately to better support victims of domestic abuse [Home Office, 2023].
    • The BMA report notes that the primary care health record may be required as evidence, for example during the prosecution of a perpetrator, if the victim was obtaining protection through an injunction or court order, in cases where the person is at risk of deportation due to immigration laws, for housing provision applications, and to assess the possible risks to children. In addition, the Department of Health guideline highlights the importance of keeping accurate records to enable continuity of care, and they may be used as evidence in legal proceedings, serious case reviews, child and adult safeguarding reviews, domestic homicide reviews, or other inquiries.
    • The expert opinion of a previous external reviewer of this CKS topic notes various challenges associated with recording domestic abuse information in the electronic medical record of people experiencing or perpetrating abuse (and any children). It is essential to avoid increasing the risk of harm to the person being abused (and any children), for example, due to an accidental discovery of disclosure by a perpetrator.

Supporting evidence

The recommendations in this CKS topic are largely based on the National Institute for Health and Care Excellence (NICE) public health guideline Domestic violence and abuse: multi-agency working [NICE, 2014], the Home Office publications Domestic abuse: statutory guidance [Home Office, 2023] and Domestic abuse: recognise the signs [Home Office, 2020], the Department of Health guideline Responding to domestic abuse: A resource for health professionals [DH, 2017], the British Medical Association (BMA) report Domestic abuse [BMA, 2014], various SafeLives publications, and expert opinion in review articles. The rationale for individual recommendations is outlined in the relevant basis for recommendation sections of the topic.

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search was conducted for guidelines and systematic reviews on primary care management of domestic violence and abuse.

Search dates

June 2018 - July 2023

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for EBSCO Medline.

  • (MH "Domestic Violence")
  • (MH "Elder Abuse")
  • (MH "Spouse Abuse")
  • (MH "Intimate Partner Violence+")
  • AB (domestic N2 (violence or abus*)) OR TI (domestic N2 (violence or abus*))
  • AB elder abuse OR TI elder abuse
  • AB intimate partner violence OR TI intimate partner violence
  • AB ((honor* or honour*) N2 violence) OR TI ((honor* or honour*) N2 violence)

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
  • Consistency with other providers of clinical knowledge for primary care.
  • Accuracy of implementation of national guidance (in particular NICE guidelines).
  • Usability.

Principles of the consultation process

  • The process is inclusive and any individual may participate.
  • To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
  • Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
  • External reviewers are not paid for commenting on the draft topics.
  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
  • All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

  • Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
  • Stakeholders identified from the following groups are invited to review draft topics:
    • Experts in the topic area.
    • Professional organizations and societies (for example, Royal Colleges).
    • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
    • Guideline development groups where the topic is an implementation of a guideline.
    • The British National Formulary team.
    • The editorial team that develop MeReC Publications.
  • Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

  • Topic selection
  • Scoping of topic
  • Selection of clinical scenarios
  • First draft internal review
  • Second draft internal review
  • External review
  • Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
  • Personal family interest
  • Personal non-financial interest
  • Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

References

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