Information

Supporting adults who present having experienced rape or sexual assault - draft clinical pathway: consultation analysis

An analysis of the responses to the consultation on the draft clinical pathway for healthcare professionals working to support adults who present having experienced rape or sexual assault.


Section 2: Healthcare and forensic medical examination

Consultation comment Project group response
135 The Pathway doesn’t take into account the role that other health professionals have in supporting those who have been raped or sexually assaulted. Not everyone will want to go to a specialised location for examination. Some patients many wish to access their GP, or an A+E department, for contraception or treatment of injuries. There is no guidance for staff who support patients in these roles. It would benefit the whole country if GPs/A+E staff also had training and guidance to ensure the best care was given to everyone who presents after being raped or sexually assaulted. Presently there appears to be conflicted opinions within GP practices about the part they play in providing healthcare, e.g. the belief that they shouldn't examine a patients injuries, the patient should only be seen at sexual health clinic The Clinical Pathways Subgroup acknowledges that not everyone will attend specialist services. The Clinical Pathways Subgroup have developed guidance for staff in other services (such as primary care and A&E), who may be the first point of disclosure for someone who has experienced rape or sexual assault, to ensure that those professionals can provide a trauma informed response and signposting as appropriate to the relevant services. This was included in the package of resources launched in November 2020.
136 Guidance issued about preserving forensic evidence (7.3 P36/37) is only possible when an immediate appointment is given, stressing the importance of patients having options to access appropriate and immediate services Noted - this is addressed in the Healthcare Improvement Scotland Standards for Healthcare and Forensic Medical Services for People who have Experienced Rape, Sexual Assault or Child Sexual Abuse: Children, Young People and Adults . Feedback will be shared with NHS Board Nominated Leads for further discussion.
137 We note the inclusion of a reference to trans-men who may need to consider emergency contraception (in section 7.1.1), and recommend that this be widened to ‘trans and non binary people who may need to consider emergency contraception’. This could be required regardless of whether someone consents to an exam or not. Wording has been amended in the revised pathway.
138 We note as a positive the inclusion of a ‘transgender’ and ‘other’ option in the confidential ‘personal details’ and ‘individual details’ sections. Noted.
139 There should be measures in place to prevent a clinician for refusing to carry out an examination in the event of the patient finding the questioning process distressing or frustrating. Distress doesn't equate to lack of consent when it comes to someone's health and safety being in jeopardy. The Clinical Pathways Subgroup agrees that consent is a dynamic process. Sexual offences examiners have undertaken the NES “Essentials in Sexual Offence Forensic Medical Examination and Clinical Management (Adults & Adolescents)” training and are sensitive to the needs of victims when they consent to an examination.
140 All of this is based on someone making the initial disclosure. Whilst the document talks about what trauma informed practice is it would be useful to include some very brief guidance about enabling and dealing with disclosure.
It might also be helpful to include some research on the role and benefits of advocacy support through the criminal justice process. As well as the full document
above there is a summary document here https://www.sccjr.ac.uk/wp-content/uploads/2018/01/RCS-NAP-Evaluation-Summary-Report_2018.pdf
The Pathway now includes guidance on dealing with the initial disclosure.
The Clinical Pathways Subgroup has added a reference to the Rape Crisis National Advocacy Project evaluation report, although the pathway has been developed to recognise wider ongoing work on advocacy. Implementation of the pathway in each NHS board area will depend on local circumstances.
141 We have no issues with the guidance so far as it goes, but suggest there could be greater detail in 7.2 in relation to Adult Support and Protection, giving information on when to make a referral and linking to appropriate guidance.
Each health and social care partnership will have developed multi-agency ASP procedures as a guide for professionals. Police Scotland also have a Public Protection hub and health and social care professionals will work in partnership with the Police on sexual abuse cases.
The Adult Support and Protection Code of Practice 2014 gives clear guidance on ensuring full participation by the adult in an investigation, as laid out in section 2 of the Act. There is less on when to intervene in cases of sexual assault, but this document should be referenced.
At 7.2.3, the reference to support for people with learning difficulties should be broadened – we suggest it should say ‘Local pathways should be in place for use of interpreters including British Sign Language interpreters, for support for people with learning disabilities or other communication needs (e.g. Speech and language therapists), and for general support and advocacy for anyone with a learning disability or mental illness.'
Again, the Adult Support and Protection Code of Practice Chapter 5 gives clear direction on this highlighting the use of advocacy services, clear communication aids and the use of reasonable adjustments to ensure barriers to the process are eliminated. http://www.rcslt.org/asp_toolkit/adult_protection_communication_support_toolkit/welcome
odi.dwp.gov.uk/inclusive-communications/alternative-formats.php
The above links have been produced by The Royal Society of Speech and Language Therapists and the Office of Disability to combat such barriers and aid professionals.
This section of the Pathway has been updated following engagement with key stakeholders to include reference to the relevant legislation and use of appropriate terminology.
142 It is more focussed on the procedures to follow than the patient. The Clinical Pathways Subgroup agrees that the pathway should be centred on the person. It is key that clinicians working in the field of sexual offences examinations are experienced, and work in a way that is person-centred and trauma-informed - this is underpinned in the processes outlined in the pathway.
143 Psychiatric assessment not included The Clinical Pathways Subgroup agreed that psychiatric assessment is not appropriate for every case and, therefore, this has not been included in the pathway.
144 Recent horror stories about IUD's --guidance does not reflect this Noted - There is very strong evidence for IUDs as a safe effective method of emergency contraception https://www.fsrh.org/standards-and-guidance/current-clinical-guidance/emergency-contraception/.
145 Again much of this depends on the manner and approach of the personnel so trauma informed training is vital. Workers need to recognise the power they hold as health professionals and to ensure the patients feel able to make choices and have as much control as possible. As noted above the gender of the examiner is the key piece of negative feedback around current provision. The “Essentials In Sexual Offence Forensic Medical Examination And Clinical Management (Adults & Adolescents)” course delivered by NHS Education Scotland, is a requirement for all general forensic physicians and sexual offences examiners who are providing these services within Scotland. It has a strong emphasis on trauma informed principles and the importance of trauma informed practice at each stage of the victim’s journey. This training is also available to nurses involved in the provision of care to victims of sexual crime.
Wider workforce training is out of scope of the clinical pathway. The terms of reference of the Workforce and Training Subgroup note that the group aims to ‘identify and support the training needs of sexual assault examiners’. The training needs of the wider health and social care workforce will be the responsibility of individual Health Boards and will be informed by the ‘Transforming Psychological Trauma: A Skills and Knowledge Framework for The Scottish Workforce’ strategy.
An initiative to develop the role of nurse sexual offences examiner in Scotland, to deliver on gender balance in the workforce, has been approved and work to progress is currently underway.
146 Although again it hinges not on the policy/protocol but on staff training & supervision The “Essentials In Sexual Offence Forensic Medical Examination And Clinical Management (Adults & Adolescents)” course delivered by NHS Education Scotland, is a requirement for all general forensic physicians and sexual offences examiners who are providing these services within Scotland. It has a strong emphasis on trauma informed principles and the importance of trauma informed practice at each stage of the victim’s journey. This training is also available to nurses involved in the provision of care to victims of sexual crime.
Wider workforce training is out of scope of the clinical pathway. The terms of reference of the Workforce and Training Subgroup note that the group aims to ‘identify and support the training needs of sexual assault examiners’. The training needs of the wider health and social care workforce will be the responsibility of individual Health Boards and will be informed by the ‘Transforming Psychological Trauma: A Skills and Knowledge Framework for The Scottish Workforce’ strategy.
147 It would be of benefit if there was Early Evidence Kits (7.3.7 P37) available within a range of services that may be the first point of contact for patient. For example GP surgeries, and voluntary support services. This would preserve more evidence and reduce impact of not having immediate access to an examination when patient chooses not to engage with police immediately Each NHS Board Nominated Lead will work with their multi-agency groups to determine how best design and develop person-centred services within their local areas.
148 We welcome the allocation of ‘gender appropriate’ Sexual offences Liaison Officer, and noted that it would be for the trans person who had experienced the rape or sexual assault to confirm what was a ‘gender appropriate’ person for them.
We welcome the addition of trans specific resources and support.
Noted.
149 In general we agree that it is person-centred, but would comment as follows in relation to 7.4.2:
We agree that issues of sexual orientation or identity are relevant, but not sure they should be classed as ‘Vulnerabilities’.
Mental illness should be added to the list of ‘Vulnerabilities’
Evidence presented in the Pathway suggests that some sexual orientations and identities may increase the risk of being subject to sexual violence and in some circumstances people may be less likely to seek support from families and peers. There are higher incidences of some potentially harmful coping behaviours including drug and alcohol use that may make people more vulnerable. As a result, the Clinical Pathways Subgroup decided not to amend the wording.
150 No the advice given by the European Parliament is simply one sentence within a 214 page long document (Overview of the worldwide best practices for rape prevention and for assisting women victims of rape) stating a colposcopy should be used, but no information is given in overview or The Pathway about when they should be used, what the recording will be used for, whether a patient is REQUIRED to have a colposcopy used. This guidance is given based on a single study. The Clinical Pathways Subgroup decided that it is important that people receiving care are offered the choice of colposcopy and are informed of the purposes. Clinicians working in the service should have training in colposcopy.
151 More importantly studies show very mixed results over the effectiveness of colposcopy use. One study found 87% of women who have been raped have injuries that show up on a colposcopy, another study found it was only 16%. Additionally, studies show nothing to distinguish a lot of these injuries in a woman who has been raped and a women who has had consensual intercourse. Again there is hugely mixed findings in studies that seek to look at injuries in those engaging in consensual sex. The Clinical Pathways Subgroup decided that it is important that people receiving care are offered the choice of colposcopy and are informed of the purposes. Clinicians working in the service should have training in colposcopy.
152 There is no consideration of the implication for the women who have been raped and no injuries are present. There is no consideration of how admissible this evidence is, and what it proves in light of the fact that women who have not been assaulted can present with the same injuries. (Using Colposcopy in the Rape Exam: Health Care, Forensic, and Criminal Justice Issues - Marilyn Sawyer Sommers; Bonnie S. Fisher; Heather M. Karjane, (2005)) The presence / absence of injuries is not the primary consideration of determination of rape and sexual assault. Colposcopy by trained examiners is only one of the methods used to gather evidence. The Clinical Pathways Subgroup decided that it is important that people receiving care are offered the choice of colposcopy and are informed of the purposes. Clinicians working in the service should have training in colposcopy. The reference will be passed on to NHS Education for Scotland for consideration of inclusion in its training manual for forensic medical examiners.
153 Much of this depends on the manner and approach of the personnel so trauma informed training is vital. Workers need to recognise the power they hold as health professionals and to ensure the patients feel able to make choices and have as much control as possible. As noted above the gender of the examiner is the key piece of negative feedback around current provision. The “Essentials In Sexual Offence Forensic Medical Examination And Clinical Management (Adults & Adolescents)” course delivered by NHS Education Scotland, is a requirement for all general forensic physicians and sexual offences examiners who are providing these services within Scotland. It has a strong emphasis on trauma informed principles and the importance of trauma informed practice at each stage of the victim’s journey. This training is also available to nurses involved in the provision of care to victims of sexual crime.
Being able to offer a choice of the sex of examiner involved in an individual's care is a key priority for the Taskforce and an important aspect of the HIS Standards for Healthcare and Forensic Medical Services for People who have Experienced Rape, Sexual Assault or Child Sexual Abuse: Children, Young People and Adults. Taskforce funding has been provided to NHS Education for Scotland to train more doctors in sexual offence examinations, with a view to increasing the number of, particularly female, doctors who are available to undertake this work. Funding will also be available in 2020/21 to train more doctors and nurses involved in the delivery of this service.
An initiative to develop the role of nurse sexual offences examiner in Scotland, to deliver on gender balance in the workforce, has been approved and work to progress is currently underway.
154 Some of the qualitative feedback comments around the forensic examination and how distressing it was relates to the manner, warmth and compassion of the examiner, aside from the gender and the other logistical considerations. The “Essentials In Sexual Offence Forensic Medical Examination And Clinical Management (Adults & Adolescents)” course delivered by NHS Education Scotland, is a requirement for all general forensic physicians and sexual offences examiners who are providing these services within Scotland. It has a strong emphasis on trauma informed principles and the importance of trauma informed practice at each stage of the victim’s journey. This training is also available to nurses involved in the provision of care to victims of sexual crime.
Being able to offer a choice of the sex of examiner involved in an individual's care is a key priority for the Taskforce and an important aspect of the HIS Standards for Healthcare and Forensic Medical Services for People who have Experienced Rape, Sexual Assault or Child Sexual Abuse: Children, Young People and Adults. Taskforce funding has been provided to NHS Education for Scotland to train more doctors in sexual offence examinations, with a view to increasing the number of, particularly female, doctors who are available to undertake this work. Funding will also be available in 2020/21 to train more doctors and nurses involved in the delivery of this service.
An initiative to develop the role of nurse sexual offences examiner in Scotland, to deliver on gender balance in the workforce, has been approved and work to progress is currently underway.
155 Again, we have no issues with the content as it stands, but it would be helpful to consider adding some cross-referencing to Adult Support and Protection procedures where appropriate. Section 9 of the Adult Support and Protection (Scotland) Act 2007 is clear on the requirement for medical examinations and the Code of Practice has given as an example:
Where there is an allegation or disclosure of sexual abuse and the type of assault may have left physical evidence.
Section 9 (2) of the 2007 Act states that the person to be examined must be informed of their right to be refused to be examined.
The Code of Practice Chapter 9 gives further guidance on how to proceed if consent is refused. This is also relevant to section 8.3 of the Pathway.
Both the issue of communication with adults and disabilities and obtaining consent in relation to incapacity, may require training / awareness raising for professionals in this area.
This section of the pathway has been updated following engagement with key stakeholders to include reference to the relevant legislation and use of appropriate terminology.
156 The healthcare response was well set out and demonstrated a person centred response. Noted.
157 The healthcare component looks comprehensive and covers key areas for intervention however, the pathway would also benefit from including a requirement for staff to be aware of inequalities sensitive practice and also adverse childhood experiences in addition to trauma informed practice. Workforce planning is out of scope of the national clinical pathway. Being able to offer a choice of the sex of examiner involved in an individual's care is a key priority for the Taskforce and an important aspect of the HIS Standards for Healthcare and Forensic Medical Services for People who have Experienced Rape, Sexual Assault or Child Sexual Abuse: Children, Young People and Adults.
Taskforce funding has been provided to NHS Education for Scotland to train more doctors to carry out forensic medical examinations, with a view to increasing the number of females who are available to undertake this work. Funding will also be available in 2020/21 to train more doctors and nurses involved in the delivery of this service. This training will include the impact of Adverse Childhood Experiences and inequality”.
158 Consider Reference to reasonable adjustments / accessible information Noted. The Pathway has been updated following engagement with key stakeholders to include reference to the relevant legislation and use of appropriate terminology.
159 Again this depends on the professionals interacting with the survivor. People accessing the pathway need to have choices about their decisions, they must not feel pressured into reporting. The professional will require to undertake training to ensure their approach is trauma informed. The accredited “Essentials In Sexual Offence Forensic Medical Examination And Clinical Management (Adults & Adolescents)” course delivered by NHS Education Scotland, is a requirement for all general forensic physicians and sexual offences examiners who are providing these services within Scotland. It has a strong emphasis on trauma informed principles and the importance of trauma informed practice at each stage of the victim’s journey. The course focuses on a trauma-informed approach to clinical management, forensic examination, evidence collection, documentation and preparation for presentation of evidence in a Scottish Court. This training is also available to nurses involved in the provision of care to victims of sexual crime.
The Advanced Forensic Practice postgraduate course, accredited by the Faculty of Forensic & Legal Medicine and certified by the United Kingdom Association of Forensic Nurses Advanced Standards in Education and Training within forensic practice, currently being developed at Queen Margaret University will provide nurses and doctors with the opportunity to further develop their skills. Continued professional development for doctors can be accessed through NHS for Education Scotland.
The terms of reference of the Workforce and Training Subgroup note that the group aims to ‘identify and support the training needs of sexual assault examiners’. The training needs of the wider health and social care workforce will be the responsibility of individual Health Boards and informed by the ‘Transforming Psychological Trauma: A Skills and Knowledge Framework for The Scottish Workforce’ strategy.
The agreed national model is underpinned by published Healthcare Improvement Scotland Standards which are clear about the need to deliver an improved gender balance within the clinical professionals who provide these services. An initiative to develop the role of nurse sexual offences examiner in Scotland, to deliver on gender balance in the workforce, has been approved and work to progress is currently underway.
160 We have ticked yes but would reiterate our comments from the previous section that this will rely upon the training and resources to be implemented. (Trauma-informed responses, access to the preferred gender of examiner etc.) Noted.
161 Recommending abortion is not person centred healthcare at all it’s not even medicine it’s just down right child murder how can recommending to a woman that she discriminate against an unborn child by killing it for the criminal background of another at all resemble any form of civilised pathway to medicine hear Scottish Government? I am against encouraging others to take any life even animal life I am against capital punishment full stop but if we brought it back for rape at least that would make more sense than terminating the life of an innocent unborn for the criminal actions of a guilty rapist.

I can’t think of anything less person centred than killing a person actually and that is exactly what part of this pathway proposes to do in regards a child in a womb of an already injured person. We are supposed to be creating pathways to counter the exploration of women hear not encouraging it and that’s exactly what this pathway does exploit the vulnerable who have already been exploited in order to recommend the murdering of an infant.

Shame on the Scottish Government!
The Scottish Government believes all women in Scotland should have access to clinically safe and legal abortion services, within the limits that are currently set down in law, should they require it. It is our view that abortion care should be part of standard healthcare provisions, free from stigma. All persons should be supported and free to reach their own decision on whether or not to have an abortion.
162 As seen consistently throughout the examination process, the patient is asked many questions in order to determine the outcome suitable to their needs. As it is a distressing and lengthy process, efforts should be made across the examination process to reduce the time it takes and the number of questions asked. Alternative ways of determining what emergency contraception is appropriate should be explored. For example using a poster detailing the time frames that certain contraception is applicable, with existing knowledge that most women have regarding contraception, could facilitate the patient determining appropriate contraception - reducing the number of questions a patient is asked. Of course patients should have the option of being given more assistance to make this choice if they feel they need it. Using a method like this would be in line with the person centered trauma informed approach, by offering choice and control to the patient, while taking practical action to reduce known distress caused by extensive questioning The national form has been revised to minimise duplication of questions. The Faculty of Sexual and Reproductive Healthcare guidance on emergency contraception contains a decision algorithm which is referenced in the pathway.
163 If the patient is pregnant as a result of rape, any conversation regarding potential evidence in the event of a termination (7.1.7 P27) should only be had if the patient explicitly states they wish to have a termination in order to prevent pressure or perceived pressure to have a termination, or any potential judgement by clinicians A person's right to choose is paramount. The options available to a person and the implication for evidence will be discussed in full and the person will be supported to make the decision that is right for them.
164 In my experience a baseline STI check is always done despite it being unlikely to be of any forensic relevance. This causes real difficulty understanding the purposes of the extensive questioning done by clinicians, if they are not using the information to determine specific needs (7.1.3.1 P28). Either treat everyone the same and don’t ask so many questions or adjust treatment appropriately based on the patients’ answers. Clinical history-taking is important to the healthcare of people who have experience of rape and sexual assault. Enquiry to sexual health, and other health needs, of individuals should be undertaken by clinicians to ensure a comprehensive and person centred assessment.
165 Although again it hinges not on the policy/protocol but on staff training & supervision The “Essentials In Sexual Offence Forensic Medical Examination And Clinical Management (Adults & Adolescents) “course delivered by NHS Education Scotland, is a requirement for all general forensic physicians and sexual offences examiners who are providing these services within Scotland. It has a strong emphasis on trauma informed principles and the importance of trauma informed practice at each stage of the victim’s journey. This training is also available to nurses involved in the provision of care to victims of sexual crime.
Wider workforce training is out of scope of the clinical pathway. The terms of reference of the Workforce and Training Subgroup note that the group aims to ‘identify and support the training needs of sexual assault examiners’. The training needs of the wider health and social care workforce will be the responsibility of individual Health Boards and will be informed by the Transforming Psychological Trauma: A Skills and Knowledge Framework for The Scottish Workforce’ strategy.
Workforce planning is out of scope of the national clinical pathway. Being able to offer a choice of the sex of examiner involved in an individual's care is a key priority for the Taskforce and an important aspect of the HIS Standards for Healthcare and Forensic Medical Services for People who have Experienced Rape, Sexual Assault or Child Sexual Abuse: Children, Young People and Adults.
Taskforce funding has been provided to NHS Education for Scotland to train more doctors to carry out forensic medical examinations, with a view to increasing the number of females who are available to undertake this work. Funding will also be available in 2020/21 to train more doctors and nurses involved in the delivery of this service.
An initiative to develop the role of nurse sexual offences examiner in Scotland, to deliver on the gender balance in the workforce, has been approved and work to progress is currently underway.
166 The healthcare response was well set out and demonstrated a person centred response. Noted.
167 By recommending abortion it is doing the exact opposite it is further harming rape victims not reducing harm. Let’s take the side of the victims in these issues for once Scottish Government - let’s not add to the psychological pain there already suffering by telling them murdering the secondary innocent victim to the crime, the unborn child is the answer.

Instead, let’s tell them that it’s not their fault they were raped nor the fault of the child for being conceived by rape and that the state will take care of her and the resulting child even if she wishes not to raise the human being herself - that there are plenty of LGBTI couples out there for example who are more than willing to adopt that could take very good care of the little one then once we have told them that Scotland […] we can then use that saved money from the terminated abortions that would otherwise go into the pockets of big U.S pharmaceutical fat cats who leach off human suffering under the guise of being benevolent hear in Scotland into real beneficial ventures such as good policing, preventive measures to stop rape in the first place and good procurator fiscal training to imprison the sorts that have ruined victims in the first place.

What about that?
The Scottish Government believes all women in Scotland should have access to clinically safe and legal abortion services, within the limits that are currently set down in law, should they require it. It is our view that abortion care should be part of standard healthcare provisions, free from stigma. All persons should be supported and free to reach their own decision on whether or not to have an abortion.
168 It would be helpful to have clarification for those physicians who are conscientious objectors and how alternative means need to be put in place. Conscientious objection to abortion care is outside the scope of the pathway. For those clinicians who have a conscientious objection to other aspects of health care (for e.g. emergency contraception) the employing NHS Board needs to put local processes in place to ensure there is no detriment to the person seeking care. The following sources provide further clarification: General Medical Council Guidance - https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/personal-beliefs-and-medical-practice/personal-beliefs-and-medical-practice.
Faculty of Sexual and Reproductive Healthcare principles - https://www.fsrh.org/documents/guidance-for-those-undertaking-or-recertifying-fsrh/.
169 Ensure alternative advice is clear regarding alternative options for conscientious objectors and those who don’t insert coils.
Ensure that this is available across Scotland. The on Call Gynae will quite simply NOT BE HAPPY if called to insert a coil at 3am.
Ensure clear guidance for routes of referral onwards
Conscientious objection to abortion care is outside the scope of the pathway. For those clinicians who have a conscientious objection to other aspects of health care (for e.g. emergency contraception) the employing NHS Board needs to put local processes in place to ensure there is no detriment to the person seeking care. The following sources provide further clarification: General Medical Council Guidance - https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/personal-beliefs-and-medical-practice/personal-beliefs-and-medical-practice.
Faculty of Sexual and Reproductive Healthcare principles - https://www.fsrh.org/documents/guidance-for-those-undertaking-or-recertifying-fsrh/.
170 Also includes good links to relevant documents. Noted.
171 The assessment gives medical professionals far too much power to identify someone as a vulnerable adult. Vulnerable adults in Scotland have few rights such as housing or employment in Scotland today. Emergency contraception can result in castration social and political exclusion etc. Noted.
172 The advice around the choice of oral emergency contraception is agreed. UPA is now considered 1st line as superior efficacy to LNG. It is acknowledged that there are some subtleties around not being able quick-start ongoing contraception after UPA for subsequent pregnancy risk due to the risk of interactions. It is however judged that in the case of sexual assault, preventing pregnancy from this episode is the clear priority. Noted.
173 Additional comment: In relation to the fitting of copper IUDs there would be a requirement to ensure that all FMEs were trained to fit these coils or have the ability to refer the patient for one to be fitted within 5 days of the incident. NHS Board Nominated Leads will decide what is most appropriate for their area and which relevant referral pathways should be in place. They will lead discussion within their multi-agency groups to determine how best to progress these issues within their local area.
174 Oral emergency contraception is less invasive. Noted.
175 I disagree with abortion on many premises Scottish Government one of those premises and perhaps one of the most overriding ones is the anti-democratic nature of the practice hear in Scotland. I may disagree with abortion but we only need to look to the western world to the Emerald Isle for an example of a nation state ran by a gay man that currently has more right democratically speaking to promote and use it than this country ever will for at least the Republic of Ireland had a referendum on the issue. Gay Catholics are lovers of democracy that’s why but this nation that will soon be ejected from the EU community knows no such rule by majority and when it comes to progressive Eire looks like an autocratic backwater - the lack of a direct referendum on this matter should therefore be enough for this government not to implement it, promote it or indulge it in this or any other action.

Sources to consider: Direct Democracy and the will of the common people.

Another reason is that its murder - if any form of contraception entails terminating a fertilised egg no matter how that egg is fertilised then it’s homicide and yes it’s as simple as that.

Reference: Western thought.

A third reason is that it causes more psychological damage to the woman who terminates the child than having the child and passing that child over to an lgbti adopting family would ever have for example . Many rape victims are regardless of the opinion of others plagued for the rest of their lives with added avoidable guilt and grief by the sheer fact that they have been pushed into aborting a child conceived out of rape by the medical profession and the stigmatisation they know society would throw at them for keeping the child. Many women who have chosen to keep the child conceived of rape have not just not regretted it but to quote one Irish woman whom kept her child treasured it regarded it as something beautiful out of something terrible yet this pathway while yes understands the true meaning of choice by allowing the victim to keep the child as well as terminate it instead of enforcing an obligatory termination makes no mention or propagation of such experiences or choices of survivors what so ever in fact such survivors who do choose to keep the child are becoming increasingly vilified and even the targets of violent attacks by pro-abortion advocates. Despite pro-life rape survivors on the increase. While there has been known to be co-ordinated attacks upon pro-life activists hear in Scotland by anti-democratic thugs it must be said however much to Scotland’s credit in fact that it is not known at least to the author of the response that a victim of rape whom has chosen to keep the child has ever been targeted by pro-choice advocates in anyway something to their credit as well and a situation that were it to change should be and would be of great concern to Scotland. There is however in a society increasingly being told by its government to accept abortion a great concern that those women in the future whom have been raped yet consider keeping their child will eventually face increasing pressure to abort.

There is also the added issue that conscientious objectors either by religion or adherence to the Hippocratic Oath could and most likely will be penalised if the refuse to recommend abortificant contraception to rape victims they come into contact with as the guidance might direct, something that may very well violate the human rights of the objector.

Sources:

https://www.irishtimes.com/life-and-style/people/a-baby-from-rape-is-something-beautiful-from-something-terrible-1.3269157

https://www.christianheadliNational Education Scotland.com/blog/rape-victim-s-decision-to-choose-life-makes-her-the-target-of-abortion-activists.html

and common sense.
The Scottish Government believes all women in Scotland should have access to clinically safe and legal abortion services, within the limits that are currently set down in law, should they require it. It is our view that abortion care should be part of standard healthcare provisions, free from stigma. All persons should be supported and free to reach their own decision on whether or not to have an abortion.
Staff with conscientious objection to performing or aiding abortion are not required to deliver these services and would not be penalised for their views. Clinicians who choose to opt out of providing particular procedures because of their personal beliefs and values, must make sure that arrangements are made for another suitably qualified colleague to advise, treat or refer the person.
176 Products of conception may be a particularly sensitive subject. A patient may not take in, or remember all of the information. It may be helpful to provide the patient with a hand out detailing considerations for a later date. Mention of products of conception has been removed from the pathway.
The Clinical Pathways Subgroup agree with this comment, although consider the detail of the support information given is out of scope of a clinical pathway. Work is ongoing to review and update current guidance materials available for people who have experienced rape and sexual assault. This feedback will be taken on board when further work is carried out on future guidance.
The Clinical Pathways Subgroup have developed an information leaflet to provide additional information on a forensic medical examination, which can be given to people who disclose rape and sexual assault and who choose to have a forensic medical examination.
177 Pregnancy testing should also be included in the ‘key points’ box on p25 Wording included 'assessment of the possibility of existing pregnancy should be undertaken'.
178 It includes comprehensive and appropriate links. Noted.
179 It is helpful you have noted self-taken swabs as an option. Collaborative approaches to overcoming barriers to forensic and health care procedures are highly valued by survivors. Noted.
180 “Page 28 re STI testing is contentious. On one hand we are being asked to do STI testing where it may be forensically significant, on the other we are being asked to screen all requests for the results and not disclose unless there is relevance to the crime on trial”. Not sure we are ever in a position to know enough information about the ""crime on trial"" to make that decision. This point is covered in the NHS Education for Scotland training for forensic medical examiners. Potential forensic relevance of testing for sexually transmitted infections depends on individual circumstances, for e.g. people without previous sexual experience at a particular anatomical site.
181 All of the guidance around vaccination would perhaps be best dealt with at a follow up appointment as it is a lot for a victim to deal with along with the forensic examination and potential emergency contraceptive processes. This is a matter of clinical judgement. Initiating vaccination early may confer partial immunity and increase uptake of subsequent doses. However, in some circumstances, this or other clinical interventions may be deferred.
182 Guidance regarding the Hepatitis B vaccination isn’t clear. It reads everyone should have a test but no guidance as to whether to vaccinate all (which is what has been done until now) or to do a risk assessment based on knowledge of assailant (which may be more appropriate). The timeline then says all should get a vaccination. The Clinical Pathways Subgroup recommends that all adults who present having experienced rape or sexual assault should have vaccination, as outlined in the timeline. Testing is to identify those who may have had previous exposure and require additional interventions.
183 Following on from comments 2 and 5, women have fed back the negative impact of having to make follow up appointments in order to address some of the sexual health risks. Having a pathway which was collaborative and identified a point of contact who would coordinate this would be beneficial to individuals and prevent further trauma. The previous Chief Medical Officer asked NHS Board Chief Executives to ensure there is a single point of contact to provide support with the coordination of ongoing care and support for victims.
184 Please note that there is a significant disparity of psychological support provision across Scotland. What is offered in the West and at Archway is NOT going to be offered in the North and Island Boards. Recognition of this is essential. All NHS Boards have local improvement plans in place. Within these plans, NHS Boards are required to consider access to services including Sexual Health Services and mental health treatment and care.
185 It includes comprehensive and appropriate links. Noted.
186 No one for victim to talk to other than medical professionals.

The trauma theory identifies victim as a brain damaged person who will never recover.

The assessment just destroys any future the victim might have.
The Pathway outlines that referral to other agencies would be done after agreement with the person who has experienced rape or sexual assault. Trauma-informed practice aims to offer choice to increase the possibility of recovery.
187 https://www.ucl.ac.uk/news/2014/sep/40-women-severe-mental-illness...

There must be adequate support provided timeously to victims with a recognition that support must be linked into a range of services such as mental health, women's aid etc. and not just simply focus on the sexual assault but perhaps this may be part of a broader range of issues such as domestic abuse.
The Pathway outlines that referral to other agencies would be done after agreement with the person who has experienced rape or sexual assault.
188 Calling it a 'risk assessment' is a bit limiting; why not a broader psycho-social assessment? Narrow focus might not encourage identification of subtler effects of the abuse, e.g. avoidance of certain situations/places etc. The Clinical Pathways Subgroup agrees that a broader assessment of a person is important. The terms ‘risk assessment’ and ‘psychosocial assessment’ are both used in the pathway.
189 It is positive that the key points highlight that the survivor should not be expected to coordinate multiple follow up appointments. Another key piece of feedback we have had through the monthly Police Direct Referral feedback protocol is where the forensic appointment has not considered the sexual health or pregnancy concerns and that they were signposted to others to address this. Having coordinated and proactive follow up services given the trauma is vital. Noted.
190 The importance of proactive follow up could be further emphasised - some survivors will be so overwhelmed that any requirement for them to proactively chase up appointments will be too difficult. This of course needs to be balanced with an emphasis on survivors being in charge/in control of what happens to them Noted.
191 Although the Pathway acknowledged the limitation of the use of DASH RIC questionnaire to cases that involved an element of domestic abuse, respondents sought greater guidance on the psychosocial risk assessment and judged that the pathway would benefit from a consistent tool to assess psychosocial risks. The Clinical Pathways Subgroup welcome any suggestions of a nationally accepted, validated tool to ensure consistency in assessment. In the absence of a clearly identified tool, the Clinical Pathways Subgroup recommend a series of standardised questions about personal circumstances which may form part of psychosocial risk assessment along with the risk identification checklist. There is training in psychosocial risk assessment as part of the NHS Education for Scotland training available to sexual offences examiners.
192 It is important that a survivor has choice, professionals need to have an awareness and understanding of the different ways a person may present after experiencing sexual violence. The follow up appointments will be more effective if survivors have someone to coordinate this on their behalf, survivors on the whole will find this too much after what they have experienced. Coordination of ongoing care after forensic medical examinations is a recognised priority within NHS Board Local Improvement Plans. Many local areas have already appointed or are seeking to recruit nurse coordinators to provide support and manage treatment and care needs at the time the person is ready for this.
193 Positive to see that local protocols should be referred to in order to avoid duplication. In relation to homeless accommodation it is vital that this is appropriate accommodation. It would be positive to see noted in the guidance excluding some accommodation. This may include busy mixed-sex environments. We would like to see further guidance regarding appropriate emergency accommodation. This is outside the scope of the pathway and for local determination. Local authorities have a duty to ensure that emergency accommodation is appropriate.
194 I am actually mostly in agreement with this however … stupidity aborts all chance of supporting this fully as there stupidity did in causing me to not support the nations independence bid as much as I would have liked to. There is a danger of vilifying the victim of sexual abuse hear by commencing an assessment that would entail examining if they are a so called risk to others most survivors are not risks to others at all its others that are a risk to them including their society and government, that is why they end up victims in the first place for the Scottish Government to even consider victims as risks to society is outrageous, ludicrous and absolutely laughable. So no. Only in Scotland could a victim of a brutal rape be considered on the same level as there attacker in regards threats to the public. Victims often engage in taking alcohol, drugs or engaging in outbursts of verbal aggression due to suffering intense emotional and psychological pain as a consequence of the heinous crime of rape leading to them being in turn prosecuted or institutionalised therein being very vulnerable to judgement by society and the state which in turn no surprise leaves such victims being disbelieved, blamed, stigmatised and criminalised for the Scottish Government to then add to that judgemental attitude already prevalent in society by recommending a risk to others assessment is counter-productive and an absolute disgrace. An utter disgrace...

It should be noted however that I am for the suicide risk assessment as for the domestic abuse risk assessment I think once a partner of anybody presents as being raped its went way over and above a domestic abuse risk don’t you think Scottish government?
Ridiculous.
The risk assessments mentioned are tools that aim to identify someone’s need for additional support. Identifying risks to others, for example children in the household, is an important step to offering survivors and those close to them appropriate support.
195 As per my answer in section 1 - locally provided, but medical examination should be provided by an expert. Noted.
196 A further pathway document would be useful for child protections issues, particularly if the individual who has been assaulted is the main carer of a child. The Pathway document refers to the National Child Protection Guidance which should be used, along with local child protection procedures.
197 As a result of the assault an individual may experience difficulties in caring for a child and may need extra support. This should be framed as supportive, rather than punitive. Noted. Referral to social work services if required is a part of the Pathway.
198 Consider moving to the beginning of section before the medical interventions Noted.
199 Psychiatric services in Scotland are just set up to identify people as sick. They are not set up to treat evil rapists or vulnerable rape victims. Noted.
200 I am very concerned that if products of conception are seized for DNA analysis this will include an inseminate egg or a foetus. Such should not be done again, this is due to the fact there has been no direct referendum on the issue of abortion and second due to the fact that it may create a culture of death were victims are encouraged to have an abortion to build a successful prosecution case for COPFS. Mention of products of conception has been removed from the pathway
201 "There is a small typo on p28 (require to remove the “than”) – Wording amended.
202 In circumstances where a positive screening sample is likely to be of forensic significance (where minimal chance that the person could have acquired infection from anyone other the assailant can be evidenced, usually in child cases or people without than previous sexual activity), baseline samples should be taken at time of examination and again 14 days post incident The Clinical Pathways Subgroup agrees with this comment. This is included in 7.1.2.1 on p39 of the consultation version of the document. It is also covered in the NHS Education for Scotland training for forensic medical examiners.
203 I think that it should be clear in the pathway that it is vital that survivors receive support during any physical examinations. Survivors need the choice to have a trauma worker present or not in the examination. Someone they have met and know can make a huge difference before going through a physical examination following a rape or sexual assault. I had the support of my SOLO who accompanied me to my appointments. My SOLO took me to drug testing in the Police HQ and she made sure a trauma worker could attend any medical appointments I had to attend due to the result of being raped. Police Scotland reiterated that the important role of the sexual offences liaison officer will not be changed by the introduction of this pathway. The examination and samples obtained must be undertaken in a forensic environment to ensure quality of evidence if the case would go to court. Consequently, best practice dictates that a minimum number of individuals should be present to protect this; i.e. two health professionals carrying out the examination. There are no issues with support being available before and after the forensic examination and at any other physical examination at the request of the person.
204 However I would suggest that further detail in terms of follow up would be helpful as the immediate impact of the assault may not cause immediate concern re: psychosocial risk which could have a delayed onset. Section 9 page 59 refers to follow up care. The Clinical Pathways Subgroup recognise that symptoms following an assault may not appear until a later date. The Subgroup have worked with Rape Crisis Scotland to develop an information leaflet. The leaflet provides information on what a person can expect in relation to a forensic medical examination and where to access support services should these be required.
205 The emphasis on health & care of survivor over forensic evidence is welcome although it can always be further strengthened Noted.
206 Some clinicians reported surprise that in section 7.4.2 under the general history, that sexual orientation was described as a vulnerability This wording has been removed from the Clinical Pathway, the Clinical Pathways Group are aware of evidence to support this and have included this in the Equality Impact Assessment as having a potential positive impact for LGBT groups.
207 Additional clarity re A&E / GP roles in responding to immediate injury would be beneficial. We have worked with women who have left A&E before treatment and who’s GPs felt unable to proceed with any medical intervention before forensics were taken. This risks people not receiving immediate care and has also left women feeling they had no other choice but to proceed with a forensic medical examination. It may be beneficial for some additional guidance to be made available to those within these settings as well as key partners so that external workers are clear about any limitations which may exist. The Clinical Pathways Subgroup agrees with this comment. The trauma informed training needs of the wider health and social care workforce will be informed by the ‘Transforming Psychological Trauma: A Skills and Knowledge Framework for The Scottish Workforce’ strategy.
The Clinical Pathways Subgroup have developed guidance for staff in other services (such as primary care and A&E), who may be the first point of disclosure for someone who has experienced rape or sexual assault, to ensure that those professionals can provide a trauma informed response and signposting as appropriate to the relevant services. This was included in the package of resources launched in November 2020.
208 I am very concerned that if products of conception are seized for DNA analysis this will include an inseminate egg or a human embryo. Such should not be done, again this is due to the fact there has been no direct referendum on the issue of abortion and second due to the fact that it may create a culture of death were victims are encouraged to have an abortion to build a successful prosecution case for COPFS.

I am in favour of ceasing products such as an embryo if the child has died other than by abortifacient means.
Mention of products of conception has been removed from the pathway.
209 The further guidance on “no police involvement” would be helpful. As would guidance for GPs/A&E and sexual health services in case patients present at other health service. Subsequent to the consultation process for the adult clinical pathway, the Forensic Medical Services (Victims of Sexual Offences) (Scotland) Bill was introduced to the Scottish Parliament and is nearing its final legislative stage – Stage 3 - in the Scottish Parliament. The Bill proposes a clear statutory duty for health boards to provide trauma-informed forensic medical services for victims and will provide for consistent access to self-referral so that a victim can access healthcare and request a forensic medical examination without first making a report to the police. The Bill will ensure that victims are informed about what will happen to any evidence taken from them and the circumstances under which it will be shared with the police.
A self-referral Subgroup of the CMO Taskforce was established in December 2019 and set up two Task and Finish Groups to develop key products. The Access to Services Task and Finish Group is looking at how people will contact self-referral services, as well as options for a national awareness raising campaign ahead of Bill commencement. A representative from the Scottish Police Authority (SPA) forensic services and NHS Tayside co-chair the National Protocol and Retention Task and Finish Group tasked with developing a robust protocol for health boards on how to maintain the “chain of evidence” in a way that meets the requirements of the Scottish criminal justice system.
The Clinical Pathways Subgroup have developed guidance for staff in other services (such as primary care and A&E), who may be the first point of disclosure for someone who has experienced rape or sexual assault, to ensure that those professionals can provide a trauma informed response and signposting as appropriate to the relevant services. This was included in the package of resources launched in November 2020.
210 Only that the importance for having options in the forensic suite for clean clothes into which to change following the examination All NHS Boards are tasked with making provision for clothing changes within their forensic suites. This is in line with HIS Standards for Healthcare and Forensic Medical Services for People who have Experienced Rape, Sexual Assault or Child Sexual Abuse: Children, Young People and Adults (included in Standard 3 practical evidence of achievement).
211 The section on preserving forensic evidence (section 7.3) could be strengthened by including advice on minimising loss of forensic evidence in non-forensic healthcare settings where first disclosure could be expected (e.g. accident and emergency departments). The Clinical Pathways Subgroup have developed guidance for staff in other services (such as primary care and A&E), who may be the first point of disclosure for someone who has experienced rape or sexual assault, to ensure that those professionals can provide a trauma informed response and signposting as appropriate to the relevant services. This was included in the package of resources launched in November 2020.
212 Will this be further updated if arrangements for self-referral are confirmed via other taskforce activity and how this may require change to the pathway? Subsequent to the consultation process for the adult clinical pathway, the Forensic Medical Services (Victims of Sexual Offences) (Scotland) Bill was introduced to the Scottish Parliament and is nearing its final legislative stage – Stage 3 - in the Scottish Parliament. The Bill proposes a clear statutory duty for health boards to provide trauma-informed forensic medical services for victims and will provide for consistent access to self-referral so that a victim can access healthcare and request a forensic medical examination without first making a report to the police. The Bill will ensure that victims are informed about what will happen to any evidence taken from them and the circumstances under which it will be shared with the police.
A Self-referral Subgroup of the CMO Taskforce was established in December 2019 and set up two Task and Finish Groups to develop key products. The Access to Services Task and Finish Group is looking at how people will contact self-referral services, as well as options for a national awareness raising campaign ahead of Bill commencement. A representative from the Scottish Police Authority (SPA) forensic services and NHS Tayside co-chair the National Protocol and Retention Task and Finish Group tasked with developing a robust protocol for health boards on how to maintain the “chain of evidence” in a way that meets the requirements of the Scottish criminal justice system.
213 Chaperones clearly need to be nurses trained specifically to corroborate swabs and injuries. Clarity is required around whether it is just genital injuries that need corroborated or all injuries noted on head to toe examination. The Crown Office and Procurator Fiscal Service confirmed that forensic medical examinations should be conducted by a clinician and witnessed by a second person who can give evidence of what occurred and what was observed during that examination, in particular, the taking of all samples and the presence of all injuries. That person should, ideally, be a healthcare professional with training in forensic medical examination and evidence gathering techniques.
214 It would be beneficial to have more details on storage of forensics (time length) for material captured from self-referrals. Subsequent to the consultation process for the adult clinical pathway, the Forensic Medical Services (Victims of Sexual Offences) (Scotland) Bill was introduced to the Scottish Parliament and is nearing its final legislative stage – Stage 3 - in the Scottish Parliament. The Bill proposes a clear statutory duty for health boards to provide trauma-informed forensic medical services for victims and will provide for consistent access to self-referral so that a victim can access healthcare and request a forensic medical examination without first making a report to the police. The Bill will ensure that victims are informed about what will happen to any evidence taken from them and the circumstances under which it will be shared with the police.
A Self-referral Subgroup of the CMO Taskforce was established in December 2019 and set up two Task and Finish Groups to develop key products. A representative from the Scottish Police Authority (SPA) forensic services and NHS Tayside co-chair the National Protocol and Retention Task and Finish Group tasked with developing a robust protocol for health boards on how to maintain the “chain of evidence” in a way that meets the requirements of the Scottish criminal justice system. This is appropriate because the protocol will need to be kept under constant review and updated to reflect any changes to other related national guidance issued by the Faculty of Forensic Legal Medicine or the Scottish Police Authority for example. The detailed protocol will set out detailed and robust requirements for the retention of forensic evidence, including what is stored, where and how. Processes will be put in place to ensure that the corroboration and secure retention of any evidence obtained will be admissible in any future criminal proceeding.
Further details about the storage period will be added to the pathway when more information is available.
215 As previously stated, the Final Standards Document - December 2017 lays out in detail the required standards for the gathering and preservation of forensic evidence and its provisions, along with the pathway guidance, should lead to a comprehensive, person centred, service. Noted.
216 Yes, if any evidence suggesting guilt is shared by COPFS or any other state authority with the defence suddenly is deemed missing or is damaged by the defence or if any evidence suggesting innocence shared by the defence with COPFS or any other state authority is deemed suddenly missing or is damaged by COPFS then the
courts should be required by law to take it extremely serious - as a contempt of court if committed by the defence or an automatic reason for acquittal if committed by the prosecution.
The Clinical Pathways Subgroup agreed that national judicial processes and case outcomes are out of scope of a clinical pathway.
217 Information is provided on different options and consent if gained at every point. Noted.
218 Again as with 1.1. It has the potential to be person centred but depends really on the delivery by the personnel involved. The narrative makes clear what a trauma informed approach should look like, and that survivors should be given meaningful choice about who they engage with, e.g. whether they report to the Police, and whether they can access a female examiner, but the manner and approach of the people at key points within the pathway determine whether this is meaningfully done and that people don’t feel under pressure to report or engage. The “Essentials In Sexual Offence Forensic Medical Examination And Clinical Management (Adults & Adolescents)” course delivered by NHS Education Scotland, is a requirement for all general forensic physicians and sexual offences examiners who are providing these services within Scotland. It has a strong emphasis on trauma informed principles and the importance of trauma informed practice at each stage of the victim’s journey. This training is also available to nurses involved in the provision of care to victims of sexual crime.
Being able to offer a choice of the sex of examiner involved in an individual's care is a key priority for the Taskforce and an important aspect of the HIS Standards for Healthcare and Forensic Medical Services for People who have Experienced Rape, Sexual Assault or Child Sexual Abuse: Children, Young People and Adults. Taskforce funding has been provided to NHS Education for Scotland to train more doctors in sexual offence examinations, with a view to increasing the number of, particularly female, doctors who are available to undertake this work. Funding will also be available in 2020/21 to train more doctors and nurses involved in the delivery of this service.
An initiative to develop the role of nurse sexual offences examiner in Scotland, to deliver on gender balance in the workforce, has been approved and work to progress is currently underway.
219 The forensic examination process described in the pathway was judged to be person centred and evidenced an understanding of trauma informed practice. Noted.
220 It incorporates all required elements of forensic examination as required to facilitate the process of justice. This experience will never be pleasant but done in a sensitive and efficient manner, it will provide the victim with an element that cannot be offered anywhere else. Noted.
221 Again as previously mentioned it depends on the professionals interacting with survivors, they need the appropriate training to ensure the service they are offering is trauma informed. Real choice, free from pressure to report, and a range of services they could access is key. The accredited “Essentials In Sexual Offence Forensic Medical Examination And Clinical Management (Adults & Adolescents) “course delivered by NHS Education Scotland, is a requirement for all general forensic physicians and sexual offences examiners who are providing these services within Scotland. It has a strong emphasis on trauma informed principles and the importance of trauma informed practice at each stage of the victim’s journey. This training is also available to nurses involved in the provision of care to victims of sexual crime.
Being able to offer a choice of the sex of examiner involved in an individual's care is a key priority for the Taskforce and an important aspect of the HIS Standards for Healthcare and Forensic Medical Services for People who have Experienced Rape, Sexual Assault or Child Sexual Abuse: Children, Young People and Adults.
Taskforce funding has been provided to NHS Education for Scotland to train more doctors in sexual offence examinations, with a view to increasing the number of (particularly female) doctors who are available to undertake this work. Funding will also be available in 2020/21 to train more doctors and nurses involved in the delivery of this service. An initiative to develop the role of nurse sexual offences examiner in Scotland, to deliver on the gender balance in the workforce, has been approved and work to progress is currently underway.
222 If the evidence collection entails the facilitation of an undemocratically verified dispense of abortifacients then no, it’s not. In that sense, the preservation of evidence
procedure seems to be more obsessed by its overriding drive of punishing the innocent for being conceived through no fault of its own than actually catching and punishing the offender.

Such is not victim centred. I'm sorry.
Second, I am concerned about the rather careless attitude displayed in regards the prospect of cross contamination of evidence such contamination can cause a
Prosecution case to fail or an innocent person to be imprisoned and if the aim is justice and not just to fill conviction quotas such an attitude should be avoided not
When possible but […]. A disrespect to all persons involved and in no way person centred. Such negligence may also leave the medical services liable by either party. Negligence on this issue, is absolutely unacceptable.
A person's choice of whether to proceed to termination or not is paramount, and it is within the principles of the pathway to encourage choice as much as possible. Whether products of conception can be, or are, used as evidence will dependent on the circumstances of that particular case
HIS Standards for Healthcare and Forensic Medical Services for People who have Experienced Rape, Sexual Assault or Child Sexual Abuse: Children, Young People and Adults Standard 3 outlines that each NHS Board should ensure that the facilities and equipment for forensic examinations are appropriate, safe and effectively managed.
223 The discussion on the patient being in control of what is being done and the samples being taken is very helpful. Noted.
224 Not enough emphasis on flexible responses, choice, and training of staff The Clinical Pathways Subgroup agreed that flexible response and choice are integral to the pathway. Training of staff is out of the scope of the pathways document, but skilled training can be provided through the relevant Queen Margaret University postgraduate course in advanced forensic practice and, for continuing professional development for medical practitioners, via NHS Education for Scotland.
225 This section should also reflect techniques that staff can use when examining a woman that can reduce the likelihood of triggers – NES 1 in 4 resources would be useful to reflect here. The accredited “Essentials In Sexual Offence Forensic Medical Examination And Clinical Management (Adults & Adolescents)” course delivered by NHS Education Scotland, is a requirement for all general forensic physicians and sexual offences examiners who are providing these services within Scotland. It has a strong emphasis on trauma informed principles and the importance of trauma informed practice at each stage of the victim’s journey. This training is also available to nurses involved in the provision of care to victims of sexual crime.
226 The longer a rape victim is left in the same clothes and cannot wash the longer the nightmare continues. This process needs to be done instantly. I was not able to shower for nearly 8 hours after I was raped and I will never forget the feeling of being repulsed by my own skin. The Taskforce aims to prevent people from having these experiences of services. Adults should have access to a forensic examination within the 3 hour timeline stipulated by the HIS indicators. NHS Boards are required to provide washing facilities and spare clothes immediately after the forensic examination as part of local improvement plans.
227 Again as with 1.2 The narrative makes this clear but delivery depends very much on the training, understanding and experience of the personnel involved. The accredited “Essentials In Sexual Offence Forensic Medical Examination And Clinical Management (Adults & Adolescents)” course delivered by NHS Education Scotland, is a requirement for all general forensic physicians and sexual offences examiners who are providing these services within Scotland. It has a strong emphasis on trauma informed principles and the importance of trauma informed practice at each stage of the victim’s journey. This training is also available to nurses involved in the provision of care to victims of sexual crime.
228 It also depends on whether the services and logistics are in place to ensure that there are female examiners available for everyone, that people do not have lengthy waits where they are unable to wash, and that their access needs are considered. All NHS Boards are required to have local improvement plans in place to meet the HIS Standards for Healthcare and Forensic Medical Services for People who have Experienced Rape, Sexual Assault or Child Sexual Abuse: Children, Young People and Adults in their area.
229 Again the importance of the option of having forensics done without a report to police at this stage needs to be further highlighted. Subsequent to the consultation process for the adult clinical pathway, the Forensic Medical Services (Victims of Sexual Offences) (Scotland) Bill was introduced to the Scottish Parliament and is nearing its final legislative stage – Stage 3 - in the Scottish Parliament. The Bill proposes a clear statutory duty for health boards to provide trauma-informed forensic medical services for victims and will provide for consistent access to self-referral so that a victim can access healthcare and request a forensic medical examination without first making a report to the police. The Bill will ensure that victims are informed about what will happen to any evidence taken from them and the circumstances under which it will be shared with the police.
A Self-referral Subgroup of the CMO Taskforce was established in December 2019 and set up two Task and Finish Groups to develop key products. A representative from the Scottish Police Authority (SPA) forensic services and NHS Tayside co-chair the National Protocol and Retention Task and Finish Group tasked with developing a robust protocol for health boards on how to maintain the “chain of evidence” in a way that meets the requirements of the Scottish criminal justice system.
230 Although the guidance on the examination process demonstrates a clear understanding of trauma it also details actions that need to be carried out in order to collect evidence and ensure the chain of evidence is not broken, the approach examiners take when carrying out these actions is important to reduce the risk of causing further trauma. Noted.
231 The process clearly demonstrates that following completion of the forensic evidence collection that individuals should have control of their follow up care; however it may be helpful for the individual to be guided through what after care services are available by a designated care coordinator and/or Rape Crisis/ independent advocacy worker. The Clinical Pathways Subgroup has added a reference to the Rape Crisis National Advocacy Project evaluation report, although the pathway has been developed to recognise wider ongoing work on advocacy. Implementation of the pathway in each NHS board area will depend on local circumstances.
232 Explaining in detail the invasive procedure and why certain procedures need to be carried out in the collection of evidence is key. Survivors having the choice of the gender of the forensic examiner and the option to have support during this process. The procedure to be carried out timely, without delays. Noted.
233 There are a significant number of questions to be asked during this process. Some of the questions may be asked by more than 1 of the multi-agency workers. Comments from women who have been through the process have noted that being asked the same questions again feels unnecessary and intrusive. Having clarity (perhaps through local protocols) about what information is gathered and by whom, or some formalised process of agreeing information to be shared with other professionals, e.g. Police, advocacy, trauma support worker may prevent further trauma to the individual. The Clinical Pathways Subgroup agree with the principles of this comment. The national form has been revised to reduce duplication and support appropriate sharing of information between professionals.
234 Having a consistent approach can only but support the legal process in the larger setting. Noted.
235 As in previous replies, remote GPs in my area believe that the most appropriate service is a regional model with local practitioners providing first contact and support, but with the legal critical forensic examination being provided by an expert FME, not local GPs. The local view was that no amount of local training could empower local generalists to safely and expertly provide such examination when performed so infrequently, nor to enable their evidence to withstand legal scrutiny. Local training only confirmed that view for those who attended.
Providing gender appropriate examiner is also very challenging in some areas.
The Taskforce recognises that small and island Boards will require a level of support from larger Boards within their region. There are collaborative models and support networks established already which provide forensic medical examination services for survivors and support to clinicians who are involved in providing treatment and care. The Clinical Pathways Subgroup agree that clinical expertise is essential to the delivery of the pathway at local level. The subgroup decided, however, that this was out of scope of the clinical pathway and relates to national service design.
The agreed national model is underpinned by published Healthcare Improvement Scotland Standards which are clear about the need to deliver an improved gender balance within the clinical professionals who provide these services. An initiative to develop the role of nurse sexual offences examiner in Scotland, to deliver on gender balance in the workforce, has been approved and work to progress is currently underway.
236 Yes and No.

• No information is included on fingernail samples or the kit used. This would be a helpful addition in the top-to-toe examination section.
• It would be helpful to include guidance on clothing bought in by the patient, but not worn at the time of examination (for example clothing brought in, in a bag).
• An early evidence kits and chain of custody flow chart may be useful.
Detail on fingernail samples is available in the FFLMRecommendations for the Collection of Forensic Specimens from Complainants and Suspectsdocument which is linked in the pathway. The handling of clothing under these circumstances would require a discussions between the sexual offences examiner and the sexual offences liaison officer on a case by case basis.
237 Enabling anonymous storing of forensic samples across the country will significantly increase options for survivors who have not yet had the time to fully consider whether they want to/are in a position to formally report. The Forensic Medical Services (Victims of Sexual Offences) (Scotland) Bill enables access to self-referral services. Further guidance will be added to the pathway once arrangements for self-referral can be implemented across the country.
A Self-referral Subgroup of the CMO Taskforce was established in December 2019 and set up two Task and Finish Groups to develop key products. A representative from the Scottish Police Authority (SPA) forensic services and NHS Tayside co-chair the National Protocol and Retention Task and Finish Group tasked with developing a robust protocol for health boards on how to maintain the “chain of evidence” in a way that meets the requirements of the Scottish criminal justice system. This is appropriate because the protocol will need to be kept under constant review and updated to reflect any changes to other related national guidance issued by the Faculty of Forensic Legal Medicine or the Scottish Police Authority for example. The detailed protocol will set out detailed and robust requirements for the retention of forensic evidence, including what is stored, where and how. Processes will be put in place to ensure that the corroboration and secure retention of any evidence obtained will be admissible in any future criminal proceeding.
238 Having systems in place to store forensic evidence while survivors have the opportunity to decide if they feel able to report will increase options for survivors. Subsequent to the consultation process for the adult clinical pathway, the Forensic Medical Services (Victims of Sexual Offences) (Scotland) Bill was introduced to the Scottish Parliament and is nearing its final legislative stage – Stage 3 - in the Scottish Parliament. The Bill proposes a clear statutory duty for health boards to provide trauma-informed forensic medical services for victims and will provide for consistent access to self-referral so that a victim can access healthcare and request a forensic medical examination without first making a report to the police. The Bill will ensure that victims are informed about what will happen to any evidence taken from them and the circumstances under which it will be shared with the police.
A Self-referral Subgroup of the CMO Taskforce was established in December 2019 and set up two Task and Finish Groups to develop key products. A representative from the Scottish Police Authority (SPA) forensic services and NHS Tayside co-chair the National Protocol and Retention Task and Finish Group tasked with developing a robust protocol for health boards on how to maintain the “chain of evidence” in a way that meets the requirements of the Scottish criminal justice system. The detailed protocol will set out detailed and robust requirements for the retention of forensic evidence, including what is stored, where and how.
Processes will be put in place to ensure that the corroboration and secure retention of any evidence obtained will be admissible in any future criminal proceeding.
239 Minus the abortion the forensics behind this are actually quite good. Noted.
240 For areas when the provision of another trained medical member for examination is highly unlikely and the colposcopy images should be considered for corroboration.
Nurses cannot provide any corroboration for injuries and can only corroborate that swabs were taken, by which doctor, which complainer and when and where.
The Crown Office and Procurator Fiscal Service has confirmed that colposcope images cannot, in isolation, provide the necessary corroboration. Accordingly, there must be a second person present in the examination room who can give evidence of what occurred and what was observed during that examination, in particular, the taking of all samples and the presence of all injuries. That person should, ideally, be a healthcare professional with training in forensic medical examination and evidence gathering techniques.
Colposcope images may be useful to the criminal justice process for other reasons but it should be noted that this may require the images to be disclosed to the solicitor representing the accused and, on very rare occasions, to be shown in court.
241 Clarity needed from Scottish Government is needed regarding the use of colposcopy for corroboration
We cannot recruit in the North and therefore use of Colposcope images is invaluable.
The Crown Office and Procurator Fiscal Service has confirmed that colposcope images cannot, in isolation, provide the necessary corroboration. Accordingly, there must be a second person present in the examination room who can give evidence of what occurred and what was observed during that examination and, in particular, the taking of all samples and the presence of all injuries. That person should, ideally, be a healthcare professional with training in forensic medical examination and evidence gathering techniques.
Colposcope images may be useful to the criminal justice process for other reasons but it should be noted that this may require the images to be disclosed to the solicitor representing the accused and, on very rare occasions, to be shown in court.
242 We agree that the document Overview of the Worldwide best Practices for rape Prevention and for assisting women victims of rape 2013 does include the sentence described at section 4.6.2. However there is no context around this statement.
The Lovett paper 2004 suggests that developments in skills of SOEs would include the use of colposcopy.
However there is no guidance via the FFLM as to the necessity of a colposcopic examination for all adult examinations.

The Statement that appears to have been taken directly from the National Guidance on the delivery of police custody healthcare & forensic medical services is not actually as stated:

It does NOT say that “colposcopes should be used where consent has been provided” or that “video colposcopy provides the best quality of forensic evidence in relation to intimate examinations” and we would be keen to see evidence that this is the case. As colposcopy is technical skill that takes years to learn, is open to technical failures, images may be obscured by the examiner particularly where they are less experienced and therefore may not provide any forensic evidence let alone best quality forensic evidence.

We agree that “where taken digital recording of genital examinations would enable the crown to obtain where necessary the opinion of a medical expert” (“not present at the examination” is also not within the above National Guidance) and that it affords defence medical experts an opportunity to view the recording.

In our experience this opportunity is rarely taken and it would be concerning if this was a routine as it would also further afford an opportunity to for the defence challenge/discredit the medical examiner should the recording be of a suboptimal standard/technical failure/ not show the injury quite as the SOE has described.
It needs to be recognised that the images recorded may for minor injuries not appear with the same clarity as to the naked eye.

The statement superior magnification and lighting provided by colposcopes increasing the rate of injury detection is also controversial and we would be interested to know how many practicing forensic physicians in UK use the colposcope in this way in this setting.

Again the issue of injury in sexual assault if minor is unlikely to be helpful in discrimination of consensual sexual activity from that of non-consensual activity.

If the images are unable to provide corroboration in themselves again why this would be recommended for all examinations?

Corroboration is provided by experienced nurses observing the location of the swabs obtained and this provides the possibility of forensic evidence being relevant to the case.

In England where no corroboration is required in Law…there are no such recommendations regarding the routine use of Colposcopy that we can find.

SOEs in our unit are encouraged to use colposcopy after an injury has been seen with the naked eye and during training to facilitate best practice in genital examination,
And it is only embedded with in a protocol where the complainers under 16 yrs. old, or under 18 where they are LAAC.

We feel this section of the guidance should be revised.
This section was subject to considerable discussion prior to the consultation as current practice varies from region to region. The Clinical Pathways Subgroup, however, maintains that the recommendation for colposcopy use in the pathway is sufficient. . Colposcopy was recommended by Her Majesty's Inspectorate of Constabulary in Scotland inspectorate report and CMO taskforce quality improvement group; it is included in the HIS Standards for Healthcare and Forensic Medical Services for People who have Experienced Rape, Sexual Assault or Child Sexual Abuse: Children, Young People and Adults. The pathway includes reference to examination 'ideally' with colposcopy. It is recommended that all Boards aspire to use of colposcopy as standard, and training of staff in its use. Colposcopy equipment and facilities for secure image storage are being commissioned in all Boards. It is not used for corroboration, but to add to the clinical examination by providing magnification and as a valuable tool for peer review and for, as well as potentially, although rarely, being used by a second expert witness and / or being made available to the defence.
243 Page 43 - Colposcopic images cannot in themselves provide corroboration of the findings of forensic medical examinations”. This needs clarified. Nothing can in itself provide corroboration.

Rape issue is about consent not genital injury. Minute genital injuries or even marked genital injury make little difference to verdicts.
Noted.
244 I agree with the use of colposcopy as recommended by the European Parliament yes; but I do not agree with its use the way it’s being proposed to be used by the Scottish Government […]. Current evidence gathered by the responder in regards matters of data and gender intimacy in Scotland between a five year sample period 2014-2019 shows that DPA procedures are often deliberately ignored and breached when the state and medical profession feels it has a vendetta on assumed petty criminals or complaints even by the ICO itself meaning there is no guarantee of privacy to the victim as a lot of victims are often involved in complaint processes or petty crime due to their life circumstances there in due to rape in fact a s22 breach of the Gender Recognition Act 2004 or an action that would amount to the same effect as a breach maybe possible with this in regards transgender persons due to the UKs (including Scotland's) flaunting of DPA regulations when other EU states (that will be in the EU after march unlike Scotland may I add) have not surprisingly had very little issues with EU Privacy regulations and matters such as sex and gender. I am worried as well that if consent is refused then the Crown will threaten to drop the case therefore coercing the victim into agreement in order to promote use and therefore future production of the device for business or business partners.

Saying all of the above in principle yes I am for it but it must always be with the written consent of the person, not in breach s22 of the Gender Recognition Act 2004 (or an action that would amount to the effect of a breach) and never be favoured over or in place of collaboration of other more concrete evidence.
Noted.
245 “The primary purpose of the healthcare and forensic medical examination for rape and sexual assault is to support the health and wellbeing of individuals and identify the health care needs of the patient (European Parliament 2013). The secondary purpose is to collect evidence that would support investigation and prosecution of crime.”
It is proposed that this section be amended to reflect the fact that healthcare and forensic medical examinations have two equally important purposes.
The Clinical Pathways Subgroup take the position that the primary purpose of the healthcare and forensic medical examination for rape and sexual assault is to support the health and wellbeing of individuals and identify the health care needs of the patient(European Parliament 2013). The secondary purpose is to collect evidence that would support investigation and prosecution of crime.
246 “In certain cases it may be appropriate to prioritise emergency medical care despite the possibility of some compromise of forensic evidence.” It is proposed that this wording be amended to “In exceptional cases…” to reflect that this is not the normal procedure. Noted - wording has been amended in the revised pathway.
247 “Where forensic medical examination is planned, every effort should be made to preserve forensic evidence and avoid contamination. There may however be situations where immediate clinical needs override this, in which case Forensic Physicians should be informed that this has occurred, and this should be recorded.”
It is proposed that this wording be amended to “There may, however, be exceptional situations…” again to reflect that this is not the normal procedure.
Noted - wording has been amended in the revised pathway.
248 “Colposcopic images cannot in themselves provide corroboration of the findings of forensic medical examinations.”
It is proposed that this line be deleted. It is not necessary in light of information provided later regarding corroboration and could cause confusion about the value using colposcopes for other purposes.
Noted - wording has been amended in the revised pathway.

Contact

Email: CMOtaskforce.secretariat@gov.scot

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