Publication - Consultation analysis

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

Published: 10 Dec 2020

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.

162 page PDF

1.9 MB

162 page PDF

1.9 MB

Contents
Supporting adults who present having experienced rape or sexual assault - draft clinical pathway: consultation analysis
Section 5: The national form

162 page PDF

1.9 MB

Section 5: The national form

Consultation comment Project group response
347 Consistent recording of information and a consistent approach to the examination. Results in a streamlined approach with trauma informed practice throughout. Noted.
348 The national form should provide a natural flow and progression from the pathway. IT DOES NOT! The form is disjointed, it is nonsensical. It does not follow the natural rhythm we as healthcare providers are trained into. It needs to be in a logical forma: CONSENT, Present complaint, History of presenting complaint, Examination, management, Follow on plans....
This form runs the risk of important information being missed.
It is far too long!!! We do not need the spaces for the production bag numbers...this is for the cops, not the healthcare provider.
I do not support this form and would recommend that it is reviewed in its entirety.
Wording amended - the national form has been updated to improve flow for healthcare providers. Production bag numbers have also been removed from the form, following discussions between health, the SPA, Police Scotland and COPFS.
349 There is also no guidance given on how clinician should avoid straying into the role of investigator in the absence of police involvement. Of course much of the information is required to deliver the best evidence. However there should be flexibility in the amount of details a patient should be required to give in order to respect their decision not to report, as the questioning process replicates the process of reporting and associated difficulties and barriers e.g. struggling to talk about incident, fear, shame. There is a danger of the questioning process with the clinician becoming a further barrier to reporting, e.g. if patient found it too difficult or had a bad experience with clinician. Noted - clinicians working in sexual offences examinations are trained to provide trauma and person informed care. Trauma-informed training is available for all NHS staff through NHS Education for Scotland.
350 The National Form is impersonal and doesn’t support person centred or trauma informed practice. For example including questions about someone's drug/alcohol and suicide/self-harm history can cause undue distress, and the insensitive nature of ticking yes/no boxes comes across as cold and uncaring, and also can cause the patient anxieties about being judged. The questions don't consider the impact of trauma The Clinical Pathways Subgroup decided that questions around drug / alcohol and suicide / self-harm history are clinically relevant and will inform a safety assessment by the examiner and potentially referral to other services. Staff are trained to ask questions in a trauma informed and person-centred way. Trauma informed training is available for all NHS staff through NHS Education for Scotland.
351 It is lengthy and involves page turning back and forward whilst carrying out forensic history and examination
I would prefer if consent was for 'history and examination' not just 'examination'

I don't like the use of terms 'cunnilingus' and' fellatio'
Wording amended - the national form has been updated to improve the flow for healthcare providers. These are legal terms that are used and staff are trained to understand and use them appropriately.
352 Too many often irrelevant questions. Questions should be person centred and not to tick boxes. Service users should be able to ask for clarification or purpose of a question without the exam being stopped. This has not been the experience The Clinical Pathways Subgroup expects clinicians to ask these types of questions in a person-centred way. Trauma-informed training is available for all NHS staff through NHS Education for Scotland.
353 The question that asks the clinician to record “perceived concerns that the individual hasn’t raised”. This is potentially damaging as it is demeaning to the patient (who may view these notes at some stage.) It is inviting the clinician to judge the patient, which contradicts the person centered approach, and raises the question of whether the forensic examiner is qualified to make a judgement This question has been removed from the revised version of the form.
354 In the ’vulnerabilities’ section, simple tick boxes regarding issues such as dementia seem insufficient. If these are reliant on examiner ‘observation’, it would be useful to say what research enables that to be accurate enough under these circumstances to proceed with a certain approach towards that individual. The Clinical Pathways Subgroup believes that existing medical conditions and issues may be identified from the history given by person or carer, rather than by simple observation, to support the clinician to adapt their approach to the consultation. Dementia diagnosis cannot be made by observation alone and requires a tailored approach
https://www.nhs.uk/conditions/dementia/diagnosis-tests.
355 Some omissions: Immediate personal needs of victim such as housing.
Family details e.g. children who might be affected.
Named person details and advocacy contact details.
These have been included in revised form.
356 In the section where it is deemed that safety is “not assured” there is only a question of referral to psychiatry services, and nothing relating to the safety of patient from perpetrator which seems confusing as the form relates to an incident of abuse not a psychiatric incident. A question has been included in the revised form on concerns about the person’s safety.
357 The follow up section of the form refers only to the health related issues i.e. STI testing, contradicting the stated aim of the Pathway to “initiate recovery” and the “provision of ongoing support The form has been revised to cover follow up support.
358 Questions should be person centred and not to tick boxes. Service users should be able to ask for clarification or purpose of a question without the exam being stopped. This has not been the experience of our service users One aim of the Pathway and the supporting national form is to improve the experience of service users. This involves shared decision-making and ensures informed consent at every stage of the pathway, including the examination.
359 Section 5 could become a block. Service users agreed that re-traumatizing a survivor during an exam can’t be completely avoided and if exams are stopped due to distress many exams will never happen, despite the choice of the survivor. Noted - the aim of conducting the examination in a trauma-informed way is to minimise re-traumatisation. Acknowledging and responding to distress must include assessment of capacity to consent to continuing a forensic examination, but the presence of distress would not in itself be seen as lack of capacity.
360 In discussion about the national proforma for use by doctors, we note the following:
• Documentation is too long
• Consent needs to be sought from the outset
• Order of the form does not flow with the order of the examination (some of which is set as is a requirement of evidence gathering)
Wording amended - the national form has been updated to improve flow for healthcare providers.
361 Please ask the local teams collective opinions. See the forms they are using currently and how they differ. Discuss with the SOLO and SIO in cases to see if they could add information...and most especially REMOVE pages. The form was reviewed by Police Scotland, the SPA and COPFS to ensure it was fit for purpose. It was also tested by clinicians in this field to ensure the questions included are relevant. There will be a facility to feedback on any issues with use of the Form after introduction and this feedback will inform future revisions.
362 The Forensic History part of the examination (7.4.2 P39) is lengthy and almost all questions relate to potentially distressing details of patients life and of the incident. It is not made clear to the patient what is done with this information (e.g. is it used in a lab to determine forensic results, is there a potential for the perpetrator/court to be made aware of any answers). Without information on how this information is used, a patient doesn’t have sufficient information to give consent to having this information gathered, stored and shared. They may not feel comfortable answering questions when it is not clear why they are being asked, and who the information will be shared with Work is ongoing to review current guidance materials available for people who have experienced rape and sexual assault, to understand the overlaps and gaps in the guidance. This feedback will be taken on board when further work is carried out on future guidance.
Before the forensic examination begins, it will be explained to the person who has experienced rape or sexual assault what will happen to the information that is captured on the form
363 Standardised information and guidance would help ensure things are not missed. Noted.
364 The number of questions that an individual is asked is not person centered. The number and depth of questions is not necessary. For instance, having to repeat information twice- once to the police and then again in depth to the doctor is distressing and repetitive The national form has been updated to prevent the person having to repeat the same details that have already been provided to the police.
365 raising awareness and targeting key service providers Noted.
366 It will assist in identifying rape victims as brain damaged individual s with no right to decent health care, housing and employment. Noted.
367 Consistent approach Noted.
368 Provide consistency across Scotland Noted.
369 It will ensure consistency across Scotland; prompt healthcare professionals to meet a wider range of healthcare needs and result in improved outcomes for survivors of sexual violence. Noted.
370 The form would not download, so I am afraid I cannot comment. Noted.
371 Provides a clear illustration of the key considerations and decisions that should follow. The design and wording of the form provides a clear emphasis on the ‘choices’ available to the victim. Noted.
372 Increased consistency and a reminder of practice essentials Noted.
373 Feedback amongst clinicians was variable and tended to demonstrate apprehension about the proposed draft. There was an acknowledgment that a national proforma would improve consistency and quality of service, but most expressed concerns that the length and repetitive nature of the national form would detract from the patient centred response.

The chronology of the form does not match typical forensic medical examination. For example a clinician from sexual health noted that “documenting height and weight in the middle of history taking and asking about dependent children in the middle of emergency contraception risk assessment” was counterintuitive and did not flow.
It is suggested that the following chronology supports the implementation of a seamless pathway;

1. Demographics
2. Forensic Examination Sexual Offences Form
3. Medical Assessment (excluding follow up, risk assessment and information sharing)
4. Forensic Examination SPA Forensic Support Form
5. Medical Assessment (information sharing, follow up and risk assessment).

It is further suggested that the PDSA methodology is applied to the development of the proforma to ensure its appropriateness, comprehensiveness, and ease of use.

Specific feedback also included;
if. Absence of section on presence of pubic hair in males (p.21). This section is however present in the female genital examination (p.20),

ii. Assaults that included cunnilingus did not differentiate between those perpetrated or coerced by the assailant – a differentiation that is made in assaults that include fellatio (p.31),

iii. Systems Examination (p.20) should be contained within the confidential medical assessment section. Its inclusion in this section does not support current or future police engagement.
Wording amended - the national form has been updated to improve flow for healthcare providers.
374 This should allow the easy sharing of information between agencies - however at the moment it seems too long. it should also facilitate the collection of a minimum data set Noted.
375 It enables the Government to monitor key data consistently.
It ensures all victims are consulted upon all aspects of care, dependent on their individual circumstances, rather than what an individual practitioner chooses.

For future requests for access to data in the medical record (by court, or others, including the patient themselves), there could be key areas that would be redacted automatically. Without a core form, this will be variable.
Noted.
376 A national form which details the follow up care and onward referrals would only be supportive if the services exist within local areas, it is crucial that services to support individuals in their recovery are consistent across the country. The configuration of local services is outside the scope of a national clinical pathway; the implementation of the pathway is for local determination. NHS Board Local Improvement Plans are in place to identify needs for additional capacity in through care services. Scottish Government has provided funding through the Taskforce and Mental Health funding to support improved access to services required in managing the ongoing treatment and care of victims.
377 I understand that the form is in two parts. The first, which details health related matters, and the second, which details the findings of the forensic examination. The plan appears to be that the Police will seize the second part of the form but the first part will remain with health.

This is likely to be unproblematic in many cases but will causes issues in some.

Archway employs a similar style of form and there have been requests from both prosecutors and defence for sight of the first part of the form. This has resulted in lengthy debate and processes in order to obtain the first part of the form.

In criminal investigations the police have a duty to “provide the prosecutor with details of all the information that may be relevant to the case for or against the accused that the agency is aware of that was obtained (whether by the agency or otherwise) in the course of investigating the matter.”

The information in the first part of the form could fall into this definition.

Provision of the information by the police to the prosecutor does not mean necessarily mean that the form itself requires to be provided to the prosecutor and it certainly does not mean that the form or its contents would necessarily be disclosed to the defence or used in evidence.

The prosecutor has a duty to review all relevant information submitted by the police and disclose only material information to the defence. In some cases that will require evidence from the first part of the form to be disclosed but in others it will not. The key is that the criminal justice agencies have the chance to review the information and decide if it is relevant and material.

There would be benefit in discussions before roll out of the national form between health, police and COPFS in order to decide how to deal with this issue.
Discussion has taken place between Police Scotland, the Scottish Police Authority, the Crown Office and Procurator Fiscal Service, health and Scottish Government and a decision has been reached on the inclusion of further questions in the Forensic Medical Examination section of the national form.
378 It would be better to record the clinical aspects on NaSH in electronic format. I think a national form is duplication and if too cumbersome, will not be filled in properly The Quality Improvement Subgroup of the CMO Taskforce is currently working to introduce a national Clinical IT system for Forensic Medical Services in Scotland and following implementation, the National Form will be accessed electronically.
379 A national form would ensure consistency and act as a check list for individuals often operating in highly stressful situations. As commented in Appendix C it is important that any national form is compatible with IT systems and future proofed as far as possible. Noted.
380 Download error received. Noted.
381 It is not clear how transgender statistics will be collated, as it is currently presented as MALE FEMALE TRANSGENDER - would it be a double tick i.e. FEMALE and TRANSGENDER to indicate transitioned to female, as just ticking TRANSGENDER doesn’t indicate one or the other. If we are trying to capture data to examine trends, needs, etc. this is insufficient. In terms of gender recognition consultation at the moment, we cannot ignore that gender is not sex, and this may lead to confusion in terms of accuracy for robust statistics for future service development in clinical pathways. This section of the form has been updated.

Contact

Email: CMOtaskforce.secretariat@gov.scot