Are you disclosure ready?

Author: Daniel Hardiman-McCartney MCOptom, Clinical adviser 
Date: 5 November 2018

Recently I spoke to a College member who had examined a person with an ocular injury, who then subsequently disclosed she that was a victim of domestic abuse. The optometrist handled the situation well, and set about a course of action to protect and help her patient, however I wondered- how many of us would be prepared for such a disclosure and would know what to do? 

Domestic violence disclosures to optometrists seem to be relatively rare compared to that of other healthcare professionals; however, domestic abuse is not. It is considered a significant public health issue with 1.03 million incidents recorded by the police in 2016. With an estimated one in four women experiencing abuse in their lifetime, female victims attempt to leave an abusive relationship between five and seven times before successfully and permanently doing so. People experiencing domestic abuse want help but often feel that they cannot speak out. People may drop hints when seeing a health professional because they trust them to notice it and probe sensitively. This trust shows that health professionals, including optometrists, have the opportunity to play an important role in helping people to access help, protection and end a cycle of abuse. 

There are ethical considerations for healthcare professionals, primarily relating to the matter of confidentiality. Optometrists must consider confidentiality and balance it with their duty to make a disclosure. When there is a real risk of harm to others such as the person's children, it may appropriate to make a disclosure to the local safeguarding team, without the patient’s consent. Where only the patient is at risk of harm, confidentiality must be observed, and a disclosure made only once the patient is ready. You can read more about this in section C75 of our guidance. Giving the patient details of a support service is all you can do until they are ready to make a disclosure. It is important that this confidentiality is observed to ensure those subject to abuse know they can trust health professionals in order to continue to access health services and without proper support in place disclosing the abuse may lead to more harm. 

With an estimated one in four women experiencing abuse in their lifetime, female victims attempt to leave an abusive relationship between five and seven times before successfully and permanently doing so.

There are practical considerations too: who is the local safeguarding team lead, how do you access them and what should you write on the record card? It may have been years since last completing your safeguarding training, so such details may not be at the forefront of your mind. My advice to members is to plan. Ensure you have these details to hand and kept up-to-date, so when you need them they are readily available both in the consulting room and somewhere accessible to the rest of the practice team.  

The College advice is to follow the guidance published by the Optical Confederation and more general guidance for healthcare professionals from the Department of Health. It is also useful to keep details of a helpline to hand for those affected by abuse, such as the National Domestic Violence Helpline or Refuge both specifically for women affected. (There is also support available for men affected*) Finally, when presented with a disclosure, or if you have a concern, you can contact the College’s clinical advice line and discuss it with Dr Susan Blakeney FCOptom or myself. We cannot tell you what to do, but we can talk you through the process and important considerations. Finally ensure your practice has the current contact details of your local adult and child safeguarding teams readily at hand, to ensure you are disclosure ready.

If an adult discloses they are a victim of domestic abuse and consents to your informing the safeguarding team, you should: 

• Discuss the case with a senior colleague, whilst respecting the patient’s confidentiality. (C75)  If their children are at immediate risk of harm, you should contact the police and the local safeguarding team. 
   
• If appropriate, inform the local NHS safeguarding lead (adult or child) and supply them with a copy of your recorded observations. When reporting information, reports should be restricted to:
  • the nature of the suspicious behaviour or concern, such as the disclosure made
  • facts which support the concerns.
     
• Confirm telephone notifications in writing by fax, email or letter within 48 hours. You should receive confirmation of referral within one working day from the safeguarding team. If you have not heard back within three working days, contact again.
   
• Ensure that all observations, advice sought, received and actions taken are recorded and stored confidentially and separately from the patient’s optical record.

You should not break patient confidentiality where only the patient is at risk of harm; in such cases, it may be useful to pass helpline information to the patient, so they can talk to an expert if they choose to. This may, in turn, give the patient the confidence to decide to report the abuse, when they are ready.  

Useful links 

• College of Optometrists Clinical Advice Service or email clinical.adviser@college-optometrists.org
   
• OC guidance on Guidance on Safeguarding, Mental Capacity and the Prevent Strategy Protecting Children and Vulnerable Adults
   
• Responding to domestic abuse, a resource for health workers
   
• 24-hour National Domestic Violence Helpline Freephone 0808 2000 247

*This article specifically relates to domestic violence against women. However, abuse can also affect men, with one in five men thought to be affected. Domestic abuse occurs across society, regardless of age, gender, race, sexuality, disability, wealth and geography. Despite this, it is important to also acknowledge that it is predominately women who suffer as a result of it. That is why most government strategies over the last decade have specifically focused on violence against women and girls.   

Daniel Hardiman-McCartney FCOptom
Clinical Adviser, College of Optometrists

Daniel graduated from Anglia Ruskin University, where he won the Haag Strait prize for best dissertation. Before joining the College, he was Managing Director of an independent practice in Cambridge and a visiting clinician at Anglia Ruskin University. He has also worked as a senior glaucoma optometrist with Addenbrooke’s Hospital in Cambridge, with Newmedica across East Anglia and as a diabetic retinopathy screening optometrist. Daniel was a member of Cambridgeshire LOC from 2007 to 2015 and a member of the College of Optometrists’ Council from 2009 to 2014, representing its Eastern region.  

He is Clinical Adviser to the College of Optometrists for three days each week, dividing the remainder of his time between community practice, glaucoma shared care clinics and providing consultancy to Specsavers. Daniel is a passionate advocate of the profession of optometry, committed to supporting all members of the profession and ensuring patient care is always at the heart of optometry. He was awarded Fellowship by Portfolio in December 2018.

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