CCE-CBD-222

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are the red flags in this consultation that raise suspicion of domestic violence?

• Prompt: What signs and symptoms indicate possible abuse?
• Prompt: How does the patient’s presentation fit with known domestic violence patterns?

Q2. How would you explore this issue sensitively with the patient?

• Prompt: What trauma-informed communication strategies would you use?
• Prompt: How do you ensure the patient feels safe and supported?

Q3. What are the key components of risk assessment and safety planning?

• Prompt: How would you determine the level of risk?
• Prompt: What are the immediate and long-term safety considerations?

Q4. What are your responsibilities regarding documentation and confidentiality in this case?

• Prompt: How should the consultation be documented in medical records?
• Prompt: Under what circumstances can confidentiality be breached?

Q5. What support services and referrals would you offer to this patient?

• Prompt: Which local and national domestic violence resources are available?
• Prompt: How can you provide ongoing support in primary care?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What are the red flags in this consultation that raise suspicion of domestic violence?

There are several red flags in this consultation that suggest domestic violence (DV):

Physical Signs

• Multiple presentations for injuries (e.g., bruises, sprains) with inconsistent explanations.
• Fading bruises on upper arms and back, suggestive of gripping injuries.
• Tenderness over ribs, potentially indicating recent blunt trauma.

Psychological and Behavioural Indicators

• Hypervigilance, anxiety, and avoiding eye contact.
• Flinching at sudden movements, which may indicate a history of physical abuse.
• Low mood and signs of psychological distress.

Social and Situational Risk Factors

• Partner frequently attends appointments, which may suggest coercive control.
• Limited social support—estranged from family and few friends.
• Lack of financial independence, a common feature of economic abuse.
• Fearful demeanour and reluctance to disclose information until directly asked.

These red flags are consistent with coercive control, psychological abuse, and physical violence, requiring a sensitive approach to further assessment and intervention.

---

Q2: How would you explore this issue sensitively with the patient?

Trauma-Informed Approach

• Ensure privacy: Speak to the patient alone, without the partner present.
• Build rapport: Express concern in a non-judgmental, supportive manner.
• Use open-ended questions:
  • “I’ve noticed some bruises and that you seem quite anxious. Can you tell me what’s been happening at home?”
  • “Do you feel safe in your relationship?”
• Validate emotions: Acknowledge distress and reassure confidentiality.
• Assess immediate safety:
  • “Are you afraid of your partner?”
  • “Do you have somewhere safe to go if needed?”
• Normalise disclosure: “Many people in difficult relationships experience similar situations. You’re not alone, and there are ways to help.”

---

Q3: What are the key components of risk assessment and safety planning?

Risk Assessment

• Assess severity of abuse: Frequency, escalation, threats to harm, presence of weapons.
• Children at risk? Mandatory reporting if child safety is a concern.
• Lethality risk: Recent escalation, threats to kill, choking history.

Safety Planning

• Emergency contacts: Ensure the patient knows who to call in crisis.
• Safe exit strategy: Identify a place to go if violence escalates.
• Important documents: Encourage safe storage of essential IDs and emergency money.
• Referral to local DV services: Provide details for 1800 RESPECT, women’s shelters, and legal aid.

---

Q4: What are your responsibilities regarding documentation and confidentiality in this case?

Documentation

• Objective, factual records of injuries, patient disclosures, and concerns.
• Direct quotes where possible to preserve accuracy.
• Photos (if permitted) for medical-legal purposes.

Confidentiality and Legal Considerations

• Maintain confidentiality, unless there is an imminent risk to life or child safety concerns.
• Mandatory reporting: If children are at risk, notify Child Protection Services.
• Consent for referrals: Patient consent is essential unless a duty of care overrides.

---

Q5: What support services and referrals would you offer to this patient?

Immediate Referrals

• Domestic violence crisis services: 1800 RESPECT (24/7 national DV helpline).
• Local women’s shelters: Provide safe accommodation options.
• Legal services: Support for intervention orders (AVOs).

Ongoing Support

• Mental health referral: Trauma-focused psychological support.
• Financial counselling: To regain financial independence.
• Primary care follow-up: Ensure ongoing medical and psychological care.

---

SUMMARY OF A COMPETENT ANSWER

• Identifies multiple red flags for domestic violence, including physical, psychological, and social indicators.
• Uses a trauma-informed, patient-centred approach to explore concerns sensitively.
• Conducts a thorough risk assessment, including assessing for lethality and child safety.
• Develops a tailored safety plan, including crisis contacts and escape planning.
• Documents accurately and appropriately, ensuring legal and ethical compliance.
• Provides timely referrals to domestic violence services, shelters, and legal support.

PITFALLS

• Not recognising red flags and missing an opportunity for intervention.
• Failing to ensure privacy, leading to risk of harm if the perpetrator overhears.
• Pressuring the patient to disclose or leave immediately, which may increase danger.
• Neglecting to assess for child safety, missing mandatory reporting obligations.
• Inadequate documentation, which may impact legal support for the patient.

REFERENCES

• RACGP White Book on Abuse and Violence: Working with Our Patients in General Practice
• 1800 RESPECT (National Sexual Assault, Domestic & Family Violence Counselling Service)
• Australian Government on Centrelink Crisis Payments for Domestic Violence

---

MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Engages patient with empathy and establishes a safe, supportive environment.
1.2 Uses trauma-informed communication techniques.

2. Clinical Information Gathering and Interpretation

2.1 Identifies red flags for domestic violence.
2.2 Assesses physical and psychological impact.

3. Diagnosis, Decision-Making and Reasoning

3.1 Recognises domestic violence and its impact on the patient’s health and safety.
3.2 Determines risk level and need for immediate intervention.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops a safety plan tailored to the patient’s situation.
4.2 Provides appropriate referrals to domestic violence support services.

5. Preventive and Population Health

5.1 Identifies community resources and support networks.

6. Professionalism

6.1 Demonstrates confidentiality and patient autonomy.

7. General Practice Systems and Regulatory Requirements

7.1 Documents the consultation accurately and sensitively in medical records.

9. Managing Uncertainty

9.1 Manages risk when the patient is ambivalent about seeking help.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises the mental and physical health consequences of domestic violence.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD