Domestic violence and abuse

Domestic violence (also called domestic abuse) includes physical, emotional and sexual abuse in couple relationships or between family members.

It can be defined as:
Any incident or pattern of incidents of controlling, coercive, threatening behaviour, violence or abuse between those aged 16 or over who are, or have been, intimate partners or family members regardless of gender or sexuality. 

The abuse can encompass, but is not limited to the following types:

• psychological (including coercive and controlling behaviour)
• physical 
• sexual 
• financial (including economic abuse, when an abuser restricts how a person acquires, uses and maintains money and economic resources, such as accommodation, food, clothing and transportation).
• emotional 
• coercive control: an act or a pattern of acts of assault, threats, humiliation and intimidation or other abuse that is used to harm, punish, or frighten their victim 
• so-called ‘honour’-based violence, forced marriage and Female Genital Mutilation (FGM).

Domestic violence can happen against anyone, and anybody can be an abuser. Domestic violence is experienced also by children living with adult family members. 

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UK guidance:

During the COVID-19 pandemic, domestic abuse charities and other organisations in the UK are reporting an increase in cases:

• General online domestic abuse searches have increased by 352.5%
• Support lines and web chat activity have increased by 53.9% and 70.4% respectively. 
• There has been a substantial rise in self-referrals to ChildLine and the NSPCC
• There has been an increase of up to 50% in Multi Agency Risk Assessment Conference (MARAC) domestic abuse referrals.

The UK Government’s stay at home advice in response to the COVID-19 pandemic may create new challenges for people subjected to domestic abuse and for those who support them:

• Self-isolating while living with an abuser may increase the risk of harm.
• Survivors may be at home with their perpetrator and unable to escape from the abuse. 
• Perpetrators may have more free time and fewer barriers, with increased frequency or severity of abuse. 
• Professionals may be required to make adaptations to how they support survivors due to COVID-19 response measures. 
• This may alter the advice provided, for example, safety planning advice may need to be tailored to encompass self-isolation. 
• How support is provided may also have changed, e.g. by phone. 
• Specialist domestic abuse services are still best placed to work with survivors of domestic abuse and collaborate with them to create safety plans. 
• Most services are operating and accept referrals in the same way as before. 

The End Violence against Women coalition have produced guidance in the context of easing of COVID-19 restrictions in the UK (July 2020). Despite easing of restrictions at that time, they report ongoing concerns (which may change as restrictions increase):

• Increased demand since the beginning of lockdown for support (especially web-based support and information) from organisations, as well as reduced capacity to provide this.
• Women seeking support are experiencing escalating violence and abuse. Furthermore, they have more complex needs and are often taking longer to work with, because they are experiencing violence as well as wide-ranging COVID 19 related socio-economic impacts. There is also increased contact from women with suicidal thoughts. 
• Some people are at particular risk, including those from a BAME/minority ethnic background, migrant women, those with disabilities, those who need to isolate or shield, those with long term health conditions. Women are more likely to be caring for others who need to isolate and so experience the impact of ongoing restrictions disproportionately. 
• Abusive men may continue to use isolation requirements as an additional tool for abuse and control 
• Many critical public services (e.g. GP surgeries, police, housing day centres, accommodation services, physiotherapy, community health), ‘walk-in services’ and face-to-face services have changed the services they provide during the COVID-19 pandemic or have a depleted workforce. 
• Digital and IT exclusion, particularly for older and disabled women, young children and those in rural areas has exacerbated isolation during this period. 
• Essential safety measures such as testing for women and children who need to access a refuge or other safe accommodation, and clinical guidance on the use of PPE has been an issue in some areas.

World guidance:

WHO:

Violence against women during COVID-19:

• is highly prevalent. Before COVID-19, globally, 1 in 3 women worldwide have experienced physical and/or sexual violence by an intimate partner or sexual violence by any perpetrator in their lifetime and most of this is intimate partner violence. 
• remains a major global public health and women’s health threat, and tends to increase during every type of emergency, including epidemics such as the COVID-19 pandemic. Women who are displaced, women who are refugees, and/or women living in conflict-affected areas are particularly vulnerable. 
• is likely to be increasing. Data are scarce but reports from China, the UK, USA and other countries suggest an increase in domestic violence cases since the COVID-19 outbreak. 
• will have long-term impacts on the health of women and their children. The health impacts of violence, particularly intimate partner/domestic violence, on women and their children, are significant: injuries and serious physical, mental, sexual and reproductive health problems, including sexually transmitted infections, HIV, and unplanned pregnancies. 

The COVID-19 pandemic can exacerbate risks of violence for women in the following ways:

• Stress, disruption of social and protective networks, and decreased access to services. 
• Distancing measures and encouraging people to stay at home increase risk for women in an abusive relationship and their children in the following ways:
  • family members spend more time in close contact, with additional stress and potential economic or job losses
  • less contact with those family and friends who provide support and protection
  • increased care work during the pandemic and school closures further exacerbate this
  • disruption of livelihoods and ability to earn a living, including for women (many of whom are informal wage workers) decrease access to basic needs and services
  • increasing stress on families with the potential to exacerbate conflicts and violence
  • resources become scarcer, increasing the risk of economic abuse
  • perpetrators may use restrictions due to COVID-19 to exercise power and control to further reduce access to services, help and psychosocial support from both formal and informal networks
  • perpetrators may also restrict access to necessary items such as soap and hand sanitizer
  • perpetrators may exert control by spreading misinformation about the disease and stigmatize partners
• Access to vital sexual and reproductive health services will likely become more limited. 
• Other services, such as hotlines, crisis centres, shelters, legal aid, and protection services may also be scaled back.

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It is essential that health and social care staff remain aware of the indicators of domestic abuse during the COVID-19 pandemic, bearing in mind that: 

• Services may have altered their ways of working e.g. there may be decreased face to face contact and support may be taking place over the phone. 
• Self-isolation and other COVID-19 measures may result in perpetrators using a range of different tactics as part of their abuse. 

Professionals should continue to be aware of general indicators of domestic abuse (DA) which existed before COVID-19. 

In addition, they need to consider additional indicators of abuse in the context of COVID-19:

• Behavioural Indicators:
  • Individual giving short or one-word answers to questions 
  • Frequent calls or requests for professional contact by the individual 
  • Frequent missed appointments and check-ins
  • An individual refusing to comply with restriction measures and/or appearing to disregard their wellbeing
• Emotional Indicators:
  • Individual discussing a ‘tense’ or ‘uneasy’ home environment or feelings of fear 
  • Increased feelings of anxiety, depression and/or panic
• Indicators of Control: 
  • Partner/ex-partner/family member requesting access to health advice, information or prescriptions on behalf of another person
  • Partner/ex-partner/family member repeatedly answering the individual’ phone
  • Indicator that someone in the background of a call is dictating or controlling the conversation with the individual, for example, a sense that you are on speakerphone or hearing another voice in the background of the call 
  • An individual who does not pick up their phone or uses hushed tones
  • Individual discussing a strict routine that they must stick to 
  • Individual discussing that they are unable to take daily exercise, go grocery shopping or pick up medication 
  • Individual discussing that they are unable to have phone or social media contact with friends/family

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UK resources:

Standing Together,  AVA (Against Violence & Abuse) and IRISi have provided guidance on safe enquiry around domestic abuse during COVID-19:

Ask

• When speaking to survivors on the phone, find out their location, check that they are alone and safe to talk (initially using yes/no questions) and that you are not on loudspeaker. 
• If the patient is not alone, advise them to say that it was the wrong number and let them know that you will call them on a later date, tell them to call 999 if they are in immediate danger and hang up. Speak to your manager afterwards and discuss an immediate plan of action. 
• Be aware that situations change quickly and the risk is dynamic. If there is any immediate danger, advise calling 999. (If they are unable to do this, offer to do this instead.)
• The perpetrator may be in the house or due back. Ask the client to end the call if they come into the room.
• Confirm whether you speak the same language. If not, use a professional interpreter. Do not use family members or friends to translate. 
• If it is safe to talk to the patient, establish a code word or sentence which they can say to indicate that it’s no longer safe to talk and end the call. 
• Use closed questions (yes/no answers) initially so that they can share they are being harmed even if they cannot talk freely.
• If you are providing remote consultation, discuss with your client whether contact via phone, text, email or messaging apps is safe and feasible. Remember that some survivors may be self-isolating with perpetrators.
• Make sure that you have sufficient time for the conversation so that the client will not be rushed.
• Explain confidentiality and information sharing procedures and be clear about when you would need to share information and how you would do this. 
• Frame your enquiry by explaining the prevalence of domestic abuse before asking a more direct question e.g. “We routinely ask all women/all patients (clients) about domestic abuse because it is so common, affecting approximately 1 in 3 women. Has anyone close to you, including family members or sexual partners, ever made you feel afraid, controlled or isolated, or physically hurt you? Are there times when you have felt unsafe at home?”

Validate

• Validate their experience, state that you believe them and that the abuse is not their fault. 
• It is important to believe and respond to all disclosures of domestic abuse. Many people using health services, and particularly those with mental health conditions, may experience paranoid thoughts, delusions and hallucinations. Say: “Thank you for telling me that. It is not ok for somebody to treat you that way. I am going to do what I can to get you the support that you want.”

Assess 

• Assess both if the patient is in immediate danger of further harm and/or death and the on-going risk.

Gather the following information in all calls:

• How can you safely check in with them next? Are there times when the perpetrator is out of the house? Is there a time of day when they get out for exercise? 
• Establish who is in the property and any additional risks this may pose. 
• Is it safe to send text messages/emails? Do they have phone credit? 
• Find out what the person is frightened of and/or worried could or will happen. 
• Check that they have access to basic items e.g. prescriptions/medication. Discuss what they can do if the perpetrator prevents access to essential items. 
• Ask if the survivor has any concerns about their children or other people living in the household. If there are children in the home, make an immediate safeguarding referral.
• Check if they are safe to remain at home and feel safe to call 999 in an emergency. 
• Find out what they want to happen and want to do next. 
• Discuss whether they have planned contact with professionals, friends or family who can raise the alarm if they need emergency help.
• Discuss potential scenarios relevant to the current circumstances. Look at how they might manage risk in different situations.
• Let them know what essential shops will remain open and may become safe places to flee during an emergency. These places of safety may include food retailers, pharmacies, hardware stores, corner shops, petrol stations, shops in hospitals, post offices etc.

Action 

• If you are concerned for your patient’s immediate safety, call 999.
• Remind them that they should call the police or leave their home to access a place of safety (including their local A&E Department) if needed, regardless of COVID-19 isolation/restriction measures in place. 
• Emergency services can also be accessed using ‘Silent Solution’. When calling 999, if you do not respond to the operator, the call will be put through to Silent Solution, if you dial 55 you will be transferred to the police.
• Specialist domestic abuse services are continuing to operate, some with adapted measures for face to face support and others offering online and telephone support only. Survivors may assume that these services have closed, therefore sharing this information is crucial.
• Share plans with multi agency partners, if the survivor is happy for you to do so.
• Use resources to support safety planning during COVID-19 (e.g. https://safelives.org.uk/sites/default/files/resources/Safety%20planning%20guide,%20victims%20and%20survivors,%20COVID-19.pdf, https://www.womensaid.org.uk/the-survivors-handbook/making-a-safety-plan/).
• Follow safeguarding procedures in your organisation. All referrals, whether internal or external, should be followed up.
• Consider whether a MARAC (Multi Agency Risk Assessment Conference) referral and/or child safeguarding referral is needed (see below for further details). Discuss this with your designated Safeguarding Lead, colleagues or local safeguarding professionals if needed. 
• Document domestic abuse within patient/service-user records. Keep the victim informed of what information you are writing down and whom this information might or will be shared with.
• Familiarise yourself with up-to-date information on specialist support options and referral pathways for survivors so that you can safely and appropriately refer.
• Sexual Assault Referral Centres (SARCs) remain open and accessible to offer non-judgmental advice and support. Victims and survivors will be triaged to ensure safe management during the COVID-19 pandemic. Remote support will be available to support pathways to therapeutic interventions. Forensic examination services will be offered to those that want it, to support a criminal prosecution. If a patient presents with signs of sexual assault, it is important that the SARC is informed urgently. A directory of local services is available at: www.nhs.uk/service-search/other-services/Rape-and-sexual-assault-referralcentres/LocationSearch/364

Standing Together also have guidance for homeless settings in the context of COVID-19 and COVID-19 guidance for violence against women and girls.

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See General advice (section 2a) and Resources for GPs (section 2d) in addition to the guidance here.

Safe Lives have produced a Children’s Social Care guide to keeping families safe from domestic abuse throughout the COVID-19 emergency:

• Coordination and multi-agency working:
  • It is vital for managers and staff to continuously risk assess their actions.
  • It will be harder to talk to each family and its individual members separately. Identify ways in which you can creatively work together to jointly support families. 
  • Find out how local domestic abuse services have adapted their support.
  • Work closely with local police to understand their strategy for managing arrests and contact with perpetrators who present with symptoms of COVID-19 or who are in self isolation due to symptoms.
  • Decisions about how to continue working with families regarding domestic abuse should be made on a case by case basis.
  • Seek input from specialists; many of them will be able to offer guidance for professionals even if they aren’t supporting the family themselves. 
  • Use your Multi Agency Risk Assessment Conference (MARAC, likely to be operating virtually), Multi-Agency Safeguarding Hub (MASH) daily triage discussions, specialist services etc to make multi agency decisions and identify how you can work together, using all resources available to support families. 
  • Operation Encompass remains operational with a Teachers’ Helpline available to schools nationally during the COVID-19 period for free confidential guidance to teachers following an Operation Encompass call (police have attended a domestic abuse incident at the child’s home). 
  • Use the SafeLives Multi-agency Values and Principles to help organisations work more effectively together, engage individuals and families and improve their experience of working with services.
  • If you have concerns, consider how you can gain access by discreet contact for example: school online, GP practice, a medical appointment, friends, creating safe passwords so victims can ask for help if someone is listening. Ask the victim what works best for them and how to end a call quickly should they need to abruptly leave.
• Risk assessment and risk management: 
  • Practitioners should ask clear questions (when safe to do so) which enable all family members to share information that highlights changes in risk and to share any concerns. 
  • Take all concerns seriously and think about how this affects risk and safety. 
  • Focussing on physical violence alone is not an accurate way to assess whether there is domestic abuse taking place in the family home. Coercive controlling behaviour is important. Pay attention to the fear, control and the impact of the abuse.
  • In your role to safeguard children, take the time to review each case and the risk posed to all who could be impacted, including those beyond the immediate family.
  • Factors to consider include:
    • Increased time at home 
    • Less opportunity to leave 
    • Dependence on the perpetrator as their carer 
    • Increased time in close proximity
    • Lack of external observation
    • Increased emotional and financial stress 
    • Increased isolation 
    • Reduced family and social support 
    • Risk from multiple perpetrators of abuse 
    • Increased risk of debilitating illness 
    • Changes to substance use, increased or decreased access 
    • Changes to/pressure on mental health
• Safety Planning:
  • Safety planning needs to be creative, flexible and focus on the basics, such as establishing opportunities for safe communication between vulnerable families, involving specialist domestic abuse services and referring to MARAC (Multi Agency Risk Assessment Conference) as relevant. 
  • Increasing the involvement of key agencies will keep these families in sight and provide opportunities for support and intervention. 
  • Share information with schools through the appropriate channels. 
  • Encourage school staff to proactively seek opportunities to interact with families. 
  • School staff should be curious and pay attention to any behavioural changes or differences in how children present and ensure they talk to children/parents about this, following their usual safeguarding protocols if they have concerns.
  • Use resources to support safety planning during COVID-19 (e.g. https://safelives.org.uk/sites/default/files/resources/Safety%20planning%20guide,%20victims%20and%20survivors,%20COVID-19.pdf, https://www.womensaid.org.uk/the-survivors-handbook/making-a-safety-plan/). Also consider digital safeguarding (see section 2g for further details).
• Children and Young People:
  • Older children and young people are at risk of abuse within their own relationships, as well as being victims and experiencing harm from domestic abuse in their homes. 
  • Social work practitioners and domestic abuse services should work together to review risk and safety plans, discuss contingency plans for children and families and how they will cope during the COVID-19 crisis. 
  • Give clear messages about the help available: ‘The instruction to stay at home does not apply to you if you need to leave your home to escape domestic abuse. Refuges and local services are still open, and the police will still attend an address and use all the usual powers to intervene and protect.’
  • The SafeLives Risk Identification Checklist for use with young people will help you identify risks. This may be wider than domestic abuse and include child sexual exploitation and abuse, ‘honour’-based violence and abuse, gang violence and county lines. 
  • Identify the children and young people on your caseloads where child sexual abuse is a known or potential risk. Work with the police and support services, such as domestic abuse services, to create targeted plans of support for victims and ‘disrupt’ plans for perpetrators.
  • The UK government also has a pre-COVID-19 guideline for health professionals supporting adults, young people over 16, and dependent children who are experiencing domestic abuse.
• Forced marriage, ‘honour’-based violence and abuse (HBV) and female genital mutilation (FGM) 
  • These forms of abuse are at higher risk of occurrence due to decreased visibility of children during lockdown. 
  • Once restrictions lift, the lag between increased movement/travel and schools reopening could create a gap in which children may be taken overseas before such acts can be prevented. 
  • Karma Nirvana have guidance and information for those who may be at risk of or has had a forced marriage. An emergency Forced Marriage Protection Order (FMPO) can be applied for with the support of the Local Authority and/or police.
• Child Contact
  • Child contact arrangements or disputes present a particularly risky environment for victims of domestic abuse and their children. (See here for further advice).
  • The UK Government’s guidance states that children can continue to travel between their separated parents, but this does not mean that they must. Consider relevant factors e.g. health issues or medical vulnerability in family members, handover increasing risk to a parent, presence of other risk factors which co-occur with domestic abuse such as alcohol/substance misuse. 
  • Victims and survivors of domestic abuse may find it particularly difficult to decide about child contact.
  • Practitioners can lessen this burden by talking to parents about the issues, helping them to weigh up the options and make a decision based on safety. 
• People who are perpetrating abuse 
  • Concern about the virus also presents a tool for those perpetrating abuse to further isolate victims and distance them from support. 
  • People experiencing domestic abuse have reduced autonomy and live with a high, credible threat of harm from the perpetrator. They may be prevented from giving, or feel too frightened to give, access to their home to Social Workers and others. 
  • Consider this, and record observations in case notes, to build a picture of the control and risk that a victim of domestic abuse is enduring. 
  • Lockdown for victims of forced marriages and ‘honour’-based abuse means increased family and community surveillance, and reduced interactions with school. These factors reduce opportunities for victims to report abuse.
  • Perpetrators of abuse should be targeted and visible within the plans and strategies created to keep families safe. 
  • There will be changes in services for perpetrators of abuse e.g. behavioural change groups. Most services have stopped face to face work, and some are able to offer virtual sessions instead. (see https://www.respect.uk.net/pages/15-covid-19 and section 2c for further details). Remember that children and young people may be living in households with multiple perpetrators.
  • Child- or adolescent-to-parent violence is not legally defined but is increasingly recognised as a form of abuse. It often involves coercive control and the adult being in fear of the young person. Quarantining and isolation are impacting this group of families.

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Safe Lives and Respect have both produced guidance for practitioners working with those who harm or are perpetrators of domestic abuse:

• Safety comes first. In the current context of increased risk, the safety and well-being of survivors and children remains the focus of any intervention aimed at domestic abuse perpetrators.
  • Any work delivered remotely should be focused on safety planning, stress and de-escalation techniques in the short to medium term, rather than long term attitudinal and behavioural change. 
  • Services should prioritise the provision of support for victims and seek their views about any proposed changes to interventions with perpetrators. Where this is not possible, or their concerns cannot be allayed, services will need to consider whether the work can safely proceed.
• Consider support for your client from family and friends.
  • Ask them to consider: calling someone they trust, talking to them about their experiences and concerns, discussing their behaviour change work, asking for support with set exercises to help challenge thought process 
  • SafeLives have a number of these set exercises from the Core Engagement Programme which can be adapted for use by frontline professionals and people who live alone or with another trusted person.
• Remember that self-care for your client is even more important.
  • As much as possible stick to usual routines, maintaining basic self-care like eating, showering, sleeping and exercising.
  • Take breaks from work if working from home (e.g. going for a walk, reading a magazine etc.)
• General safety planning: if this is not already in place, complete this over the phone with your client (someone who harms) as soon as possible, by asking the following questions:
  1. If there is already a personalised action/safety plan, provide help to update this, using other professionals if needed.
  2. What is the usual pattern of abuse? Think about ‘triggers’ and physical/emotional/behavioural signs that you are struggling. Think about times when things are calmer, how did it feel? 
  3. What are your main concerns and worries? 
  4. Who is in the family home? Who is going out to work and who is staying at home?  Will your family income be affected? How could this affect things? 
  5. Are you or anyone in the house using drugs and/or alcohol? How could your use change and what could this mean for your behaviour? 
  6. Do you know how you and your family might respond to self-isolation? This might increase sexual violence/ coercive control/ physical abuse and so work with the client to create an action plan/safety net strategy for this 
  7. Do you know what your options are if you want to leave? Plan the options in advance. 
  8. Discuss the timeout strategy and how this will be impacted by the lockdown. This is a structured way to interrupt an argument or negative emotions that are escalating before things become violent or abusive. It has five key steps:
     • Recognise your own warning signs that you are becoming stressed, controlling, aggressive, or angry. 
     • Referee yourself by blowing the whistle on what is happening using a word or phrase.
     • Remove yourself from the situation as much as you are able (it is important that the people around you do not follow). Think about where you will go for your timeout: walk in the garden/down the road/separate rooms? Discuss this with your partner so they know the plan and can give you space. Where would you go in an emergency? Remember some shops/restaurants/pubs may be shut.
     • Relax and Reflect e.g. breathing exercises, stretching, reading, listening to music, playing a game on your phone for 10-15 minutes, then reflect on the issue you had: 1) What is it I want to happen? 2) What could I do instead to get my views across? 3) Is it worth the consequences of scaring my partner and children into doing what I want? 
     • Return: resolve the issue by discussing it again or release it by letting it go? If the issue is more significant and you need to talk it out, try to follow these basic ABC’s of communication: • Accept and listen to the other person’s point of view. • Be clear and direct about the problem. • Come to a compromise if you can that respects each person’s wishes.
  9. Depending on risk levels, consider de-prioritising behaviour change work if full contact is not possible and ensure agencies who are involved with the family are aware. Consider alternative exercises to complete at home. 
  10. Review safety and support plans. Regular communication with multi-agencies will be essential and professionals’ meetings may need to be completed remotely.
  11. Support for Support Workers is key, and supervision will play a fundamental role in managing risk, stress and avoiding burnout. Respect advise: Daily or weekly team meetings for positive lines of communication and delivery of key messages, PPE for face to face contact with clients.
  12. If you or someone you know is in immediate danger, call 999 and ask for the police. 

The European Network for the Work with Perpetrators of Domestic Violence have provided guidelines to ensure responsible perpetrator work during COVID-19: 

At the current time, services should focus on short to medium term interventions designed to: 

• Reduce the risk of violence and abuse taking place 
• Decrease perpetrators’ stress and emotional arousal
• Increase perpetrators’ coping mechanisms 
• Mitigate additional risk factors in families forced into lock-down 
• Indirectly mitigate the effects of violence on family members 
• As much as is possible and safe, coordinate with victim support services and listen to victim’s voices and continue to make efforts to gather feedback from victims

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Please refer to general advice in section 2a.

IRISi (a social enterprise established to promote and improve the healthcare response to domestic violence and abuse) have guidance for GPs and GP Teams, including on how to enquire about domestic abuse over the phone or in video calls: 

• Children who are on Child Protection Plans, Looked After Children, children classed as a Child in Need and their families/carers may not have their usual support systems and therefore be at heightened risk.
• Families will be under increased amounts of stress from new financial pressures, household isolation, school closures and lack of normal outlets for stress and frustration. 
• Adults who are vulnerable and isolated may be at increased risk of financial exploitation by some pretending to help under the guise of ‘COVID kindness’.
• Children, young people and vulnerable adults who are already at risk of abuse or neglect may be more at risk as their normal support mechanisms are not in place and frontline professionals have less capacity to support and safeguard.
• Most patients will speak with reception or triage staff before the clinician, so it is important that all staff in telephone or video contact with patients have an understanding of the effect of domestic abuse on their patient population and the current risks during the COVID-19 pandemic. 
• Clinicians should check whether a patient’s medical record includes a Safeguarding/DVA (domestic violence and abuse) code before conducting a telephone or video consultation.

Follow Ask, Validate/Respond, Risk Assess, Action (Refer and Record) as outlined in section 2a, with particular note of the following:

• Consider whether a safeguarding referral is needed (children and/or vulnerable adults at risk) and follow your usual practice safeguarding procedures.
• Discuss with your Practice Safeguarding Lead, colleagues or your local safeguarding professionals if you need further advice and guidance.
• Consider whether you, or one of your colleagues, can call the patient again, to offer support and agree what time frame is realistic and appropriate.
• If your practice is an IRIS Domestic Abuse Aware Practice, please continue to refer patients to your IRIS Advocate Educator.
• If your practice is not an IRIS Domestic Abuse Aware Practice or the patient doesn’t want a direct referral, make sure you are aware of and can share contact details for local and national domestic abuse services and online support (see section 3a).
• Document all enquiries, disclosures and referrals on the patient’s record.
• Code any disclosure under the Read code 14XD (history of domestic abuse).
• Hide the consultation from online access.
• Ensure you code any disclosure on the medical records of any children or vulnerable adults in the household (see https://www.rcgp.org.uk/clinical-and-research/resources/toolkits/-/media/Files/CIRC/Toolkits-2017/Safeguarding-adults-at-risk-Toolkit/Guidance-on-recording-of-domestic-violence-June-2017.ashx for more detail).
• Document any concerns that you have, even if the patient does not disclose domestic abuse.

Suggestions for Resources to consider putting on the GP practice homepage for patients:

• National Domestic Violence Helpline: https://www.nationaldahelpline.org.uk/
• NSPCC helpline: https://www.nspcc.org.uk/keeping-children-safe/our-services/nspcc-helpline/
• Childline: https://www.childline.org.uk/
• MIND: Mental Health Support with specific advice on ‘Coronavirus and your wellbeing’. www.mind.org.uk
• YoungMinds:  https://youngminds.org.uk
• ICON: Babies cry: You can cope. http://iconcope.org/
• SafeLives: http://safelives.org.uk/
• IRISi interventions: http://irisi.org/iris/find-your-local-iris-site/

IRISi have also produced guidance on domestic abuse in the context of end of life care in the COVID-19 pandemic.

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The Royal College of Nursing has relevant resources at: https://www.rcn.org.uk/clinical-topics/domestic-violence-and-abuse/covid-19-and-domestic-abuse

The Institute of Health Visiting has guidance on remote consultations.

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Please refer to general advice in section 2a.

AVA (Against Violence and Abuse) have provided guidance for mental health professionals:

• Domestic abuse disproportionately affects women, and domestic abuse (DA) is considered a form of violence against women and girls (VAWG). 
• Across those accessing mental health services there is a high prevalence of people who are or have experienced domestic abuse. Mental health services have a key opportunity to identify abuse, and ensure survivors are safe and that they have appropriate support.
• The COVID-19 pandemic presents additional risks to survivors. Rates of domestic homicide have more than doubled since the COVID-19 lockdown.
• The pandemic presents additional challenges and barriers for survivors. Circumstances are likely to be extremely triggering and routes for accessing support and seeking safety are limited.
• Professionals need to adapt to how they enquire about and respond to DA and should be aware of the services and referral pathways available to survivors.

Signs of domestic abuse in the context of mental health difficulties:
Individuals can present in a variety of ways. Clinicians should be aware that mental health problems themselves are an indicator of potential risk of domestic abuse and there are also particular signals which may be present in the context of COVID-19 (see Section 1c).

All mental health patients should therefore be asked about domestic violence and abuse by clinicians who have been trained to ask about domestic abuse and when it is safe to do so. (Guidance and a toolkit for safe identification and response are freely available to download at https://www.kcl.ac.uk/psychology-systems-sciences/research/lara-vp-download-form. This guidance was developed pre-COVID-19, in collaboration with safeguarding leads, third sector specialists, the Department of Health and Social care, and other experts specifically for mental health professionals.)

In addition for people with mental health problems specific signals and/or signs may indicate abuse. These include, but are not limited to:

• An individual particularly triggered by the circumstances. This may result in overwhelming fear of contagion, increased self-harm, substance use relapse, suicidal ideation, escalation of mental distress.
• An individual not picking up prescriptions, not taking medication and/or not attending to their mental/physical health needs.
• An individual refusing to comply with restriction measures and/or appearing to disregard their wellbeing.

Impact of domestic abuse and COVID-19 on mental health: 

• Domestic abuse is extremely traumatic and likely to heavily impact survivors’ mental health.
• In the context of COVID-19, the mental health impact is increased: survivors are at increased risk of domestic abuse, survivors are experiencing increased trauma, and may find social isolation triggering, perpetrators monopolise circumstances to further control and coerce.
• Other factors are important, for example, survivors from BME (BAME) backgrounds are further impacted by barriers to accessing services and/or a lack of funding for BME specialist VAWG support. 

Clinicians should follow general guidance on safe enquiry, safety planning and safe referrals as outlined in section 2a.

The Social Care Institute for Excellence in association with the Alzheimer’s society have produced guidance on safeguarding adults with dementia during the COVID-19 crisis:

During the COVID-19 pandemic, people with dementia may be more vulnerable to abuse or neglect, as a result of:

• increased social isolation
• stress on carers and caring relationships
• overstretched and stressed care staff, with reduced support services such as lunch clubs or day care
• an increase in criminal behaviour including scams
• an increase in domestic abuse
• a range of new contacts, such as volunteers and people delivering food and medicines

Staff need to be extra vigilant and detect any early signs of abuse. People with dementia, staff, carers and family may not report abuse for a number of reasons, such as:

• fear of repercussions
• not realising that what is happening is abusive
• fear of being seen as a troublemaker

(See https://www.scie.org.uk/safeguarding/adults/introduction/types-and-indicators-of-abuse for advice on the types and indicators for abuse) 

If you are concerned that someone with dementia is being abused or neglected, it is important that you:

• Act on any concerns, suspicions or doubts and share these with your direct manager or supervisor and safeguarding lead, in line with organisational and local multi-agency procedures.
• Call 999 in an emergency, where there is actual or immediate risk of abuse.
• Ensure the immediate safety of those concerned – but not at the risk of your own safety.
• Provide first aid if needed, asking for help if necessary.
• Listen and clarify what the concern is and what has happened. Do not rush the person, probe or question.
• Provide reassurance and comfort.
• Do not panic or show shock or disbelief, be judgemental or jump to conclusions.
• Assure the person that the matter will be taken seriously.
• Ask the person what they want done.
• Explain what you will need to do and who you may need to inform.
• Do not promise confidentiality. Explain how and why the information might need to be shared.
• Try to gain consent to share information as necessary.
• Respect privacy as far as possible.
• Consider the person’s mental capacity to consent and seek assistance if you are uncertain.
• Arrange support for the person. 
• Contact the local authority children’s services if a child is or may be at risk.
• Make an accurate record of what has occurred (or what has been disclosed/alleged) and what action has been taken.
• Be careful not to contaminate or disturb any evidence. Do not interview witnesses, but do record any information volunteered by them. Do not approach the alleged abuser, unless they also have care and support needs and are in your care or they are a member of your staff.

[link3]
[link13]
[link14]

AVA have produced a digital safeguarding resource pack which includes a section on how technology can be used to abuse and control and how to advise patients about this when developing safety plans with them:

• Review what information exists about the victim online (this can also be useful for practitioners to do for themselves)
• Ensure all devices have updated antispyware software installed and turned on
• Keep all privacy settings on social media accounts up to date
• Turn off all GPS and location sharing settings
• Regularly change e-mail and passwords
• Avoid sharing photos that may identify your location or any personal information
• Request to be notified before anyone can check you in or tag you on facebook
• Make sure wireless hubs and routers have security options turned on
• Routinely ask about experiences of digital abuse during risk assessments
• Collect and save any evidence from social media sites (prior to asking for it to be removed)
• Keep recordings of calls and voicemails
• Document and report incidents

[link13]

The WHO have outlined actions that can help mitigate the impacts of violence against women (VAW) and children during this pandemic:

• Health systems:
  • All stakeholders involved in the COVID-19 response should be aware of and raise awareness of the potential impacts that physical distancing, stay at home and other measures to address the COVID-19 pandemic are likely to have on women who are subjected to violence and their children.
  • Health workers may themselves be at risk of violence in their homes or in the workplace, and this may be exacerbated when health systems are under stress. Health managers or facility administrators should have plans to address the safety of their health workers. Front-line providers dealing with COVID-19 might experience stigmatisation, isolation and social ostracisation. Providing psychosocial support, non-performance-based incentives, additional transport allowance, child-care support should be planned.
• Governments and policy makers must include essential services to address VAW in preparedness and response plans for COVID-19, resource them, and identify ways to make them accessible in the context of social distancing measures.
• Health facilities should identify information about services available locally (e.g. hotlines, shelters, rape crisis centres, counselling) for survivors, including opening hours, contact details and whether these can be offered remotely, and establish referral linkages. 
• Health providers need to be aware of the risks and health consequences of VAW. They can help women who disclose by offering first-line support and relevant medical treatment. First line support includes: listening empathetically and without judgment, inquiring about needs and concerns, validating survivors’ experiences and feelings, enhancing safety, and connecting survivors to support.
• Humanitarian response organizations need to include services for women subjected to violence and their children in their COVID-19 response plans and gather data on reported cases of VAW. 
• Community members should be made aware of the increased risk of VAW and the need to keep in touch and support women subjected to violence, and to have information about where help for survivors is available. It is important to ensure that it is safe to connect with women when the abuser is present in the home.
• Women who are experiencing violence may find it helpful to reach out to supportive family and friends, seek support from a hotline, or seek out local services for survivors. They may also find it useful to have a safety plan in case the violence escalates. This includes having a neighbour, friend or relative or shelter identified to go to in the event they need to leave the house immediately for safety

[link1]
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UK advice for employers on supporting their employees at home:

• For victims of domestic abuse (DA), working from home at this time may be particularly difficult and they may require support from their employer. 
• Remind staff that if you or someone else is in immediate danger call 999 and ask for the police.
• The Government’s shielding measures are necessary but likely to increase rates and severity of DA. 
• Raise awareness of domestic abuse, the support available and how it can be accessed securely. Domestic abuse thrives in secrecy. Aim to create an environment where it feels safe to talk. 
• Increase visibility of your domestic abuse policy so employees are aware of the support provided by their employer can provide. Examples of policies can be found here.
• Communicate to staff (e.g. via the staff intranet, on regular employee communications) that you are concerned for their welfare and if they disclose abuse they will be helped to access support if it is safe to do so. 
• Many staff experiencing DA will have used their work environment as a safe space to access specialist support and will now need an alternative (see section 3a for details).
• Ensure that line managers have sufficient structured contact with all their team members, including those on sickness leave or furlough. 
• Line managers may be in the best possible position to check in with someone who is isolated and may be at risk. Offer them support and basic training, so that they feel confident talking to their teams about domestic abuse and know what support is available. 
• If staff are concerned about their own behaviour, provide information and signpost to support (e.g. Respect helpline). 
• Check that all employees who are working from home have everything they may need to work effectively. 
• Think about the wider role of your organisation and be creative with resources to support staff practically (e.g. some larger employers are showing flexibility about pay and contract arrangements or making their legal team available for support with disputes around child contact). 

Advice for line managers and supervisors: 

• Stay in contact and have regular 1-2-1s and support and supervision sessions with staff. 
• Help support staff wellbeing by sensitively asking how they feel about changes to their working environment and whether there is any extra support needed.
• Ask staff to think about their own existing support systems, friends, family or neighbours and how these could be strengthened during this time. Consider helping them develop their own bespoke support plan. 
• Victims and survivors may want to discuss and review any existing support plans they have agreed with you, in light of their new working/living arrangements. Communicate with human resources, safeguarding leads and the senior leadership team to discuss individual cases and sign off any specific support. 
• Signs of domestic abuse will no longer be as obvious when staff work from home, so aim to have sufficient time during video calls to check in with people. 
• There could be visible injuries or other signs such as broken objects or damage to the home, but domestic abuse is much more than physical abuse. Other things to look out for might include:
  • Changes in behaviour, acting in a way that is unusual or out of character  
  • Withdrawing from previous sources of support e.g. team chat threads or catch-ups 
  • Wariness or anxiety about their partner or family member coming into the room whilst you are speaking with them 
  • Reluctance to talk about their home situation or avoiding answering questions about it 
  • Signs of tension, audible conflict in the home, shouting at children or others 

The HARM network, University of Central Lancashire suggest the following strategies:

• Board level buy-in: senior managers take the lead in demonstrating that they recognise all forms of domestic abuse as a workplace problem
• Appoint a workplace champion: as a main point of contact, with allocated time and resources.
• Poster campaigns: delivered digitally, to help access internal and external agencies (including those for ethnic minority groups).
• Anonymous ways of communicating concerns
• Responding to ‘red flags’
• Provide reputable and accessible e-learning

Pre-COVID sources of guidance for employers include:

• https://safelives.org.uk/sites/default/files/resources/DV%20Employer’s%20guidance%20FINAL%20Update%203%20-%20SafeLives%20rebranded.pdf
• https://www.bitc.org.uk/toolkit/domestic-abuse-toolkit/
• https://www.nhsemployers.org/case-studies-and-resources/2017/11/domestic-violence-and-abuse-supporting-nhs-staff

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• National Domestic Abuse Helpline, run by Refuge www.nationaldahelpline.org.uk, and advice during COVID-19: https://www.thehotline.org/2020/03/13/staying-safe-during-covid-19/
• Scotland: 24-hour Domestic Abuse and Forced Marriage Helpline: 0800 027 1234
• Northern Ireland: 24-hour Domestic & Sexual Violence Helpline: 0808 802 1414
• Wales: 24-hour Life Fear Free Helpline 0808 80 10 800.
• Gov.uk advice: https://www.gov.uk/guidance/domestic-abuse-how-to-get-help
• Galop: National LGBT+ Domestic Abuse Helpline: http://www.galop.org.uk/
• Men’s Advice Line: https://mensadviceline.org.uk/
• Women’s Aid: https://www.womensaid.org.uk/, live chat via https://chat.womensaid.org.uk, Making a safety plan, https://www.womensaid.org.uk/the-survivors-handbook/making-a-safety-plan/, https://www.womensaid.org.uk/covid-19-coronavirus-safety-and-support-resources/, Reports relevant to COVID-19 and domestic abuse: The Domestic Abuse Report 2020: The Hidden Housing Crisis, Nowhere to Turn 2020: Findings from the fourth year of the No Woman Turned Away project, Impact of COVID-19 on domestic abuse services
• Rape crisis: https://rapecrisis.org.uk/ and specific COVID-19 advice: https://rapecrisis.org.uk/get-help/coronavirus
• The Survivors’ Forum: https://survivorsforum.womensaid.org.uk/
• Elder Abuse Helpline: https://www.elderabuse.org.uk/
• NSPCC Helpline: https://www.nspcc.org.uk/keeping-children-safe/our-services/nspcc-helpline/
• NCDV https://www.ncdv.org.uk/ and Advice Now’s resources at www.advicenow.org.uk for those requiring support for injunctions or Legal advice
• Respect helpline (for anyone worried about their own behaviour): https://respectphoneline.org.uk/
• Suzy Lamplugh Trust (national stalking helpline): https://www.suzylamplugh.org/
• Forced Marriage Unit: https://www.gov.uk/guidance/forced-marriage
• Victim Support National 24 hour Support line: 0808 1689 111 
• Guidance on economic abuse during COVID-19 https://survivingeconomicabuse.org/resources/
• https://rightsofwomen.org.uk/get-information/family-law/coronavirus-and-child-contact-arrangements/
• Children and young people can access support through: https://thehideout.org.uk/, https://youngminds.org.uk/, https://www.childline.org.uk/
• Barnardo’s Coronavirus Advice Hub https://www.barnardos.org.uk/coronavirus-advice-hub
• NHS advice on the signs for domestic abuse and domestic violence and where to go for help: https://www.nhs.uk/live-well/healthy-body/getting-help-for-domestic-violence/
• NHS help page for those who have been raped or sexually assaulted: https://www.nhs.uk/live-well/sexual-health/help-after-rape-and-sexual-assault/
• The NSPCC Helpline for parents, families and professionals: email: help@nspcc.org.uk
• https://www.imkaan.org.uk/: resources for addressing violence in BME and migrant women in the context of Covid-19
• Karma Nirvana https://karmanirvana.org.uk/ for professionals to jointly risk assess and provide guidance to protect victims, and support victims whose support will be enhanced by call handlers with knowledge of the issues impacted by honour systems. 
• Operation Encompass Teachers’ Helpline provides school staff with immediate and confidential support to meet the needs of their vulnerable children. 8.00am – 11.00am Monday to Friday: 0845 646 0890
• UK government advice: https://www.gov.uk/government/publications/coronavirus-covid-19-support-for-victims-of-sexual-violence-and-abuse/coronavirus-covid-19-support-for-victims-of-sexual-violence-and-abuse, https://www.gov.uk/government/publications/coronavirus-covid-19-guidance-on-vulnerable-children-and-young-people/coronavirus-covid-19-guidance-on-vulnerable-children-and-young-people, https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/874568/COVID-19_-_guidance_on_isolation_for_domestic_abuse_safe-accommodation_settings.pdf?mc_cid=05385d6a47&mc_eid=b517e0c603, Scotland: https://www.gov.scot/publications/coronavirus-covid-19-guidance-on-domestic-abuse/pages/overview/
• Royal College of Psychiatrists’ advice: https://www.rcpsych.ac.uk/mental-health/parents-and-young-people/information-for-parents-and-carers/domestic-violence-and-abuse-effects-on-children
• Violence, Abuse and Mental Health Network: https://www.vamhn.co.uk/covid-19-resources.html, and http://www.sddirect.org.uk/media/1881/vawg-helpdesk-284-covid-19-and-vawg.pdf
• The Children’s Commissioner for England: https://www.childrenscommissioner.gov.uk/publication/children-domestic-abuse-and-coronavirus/
• Online safety: advise victims to delete browser history or use ‘private browsing’ as a way to hide searches. The following resources provide information on online safety: https://www.womensaid.org.uk/cover-your-tracks-online/, https://www.techsafety.org/resources-survivors, https://safelives.org.uk/sites/default/files/resources/Staying%20safe%20online%20guide.pdf

• https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/stress-coping/abuse.html
• https://www.massgeneral.org/news/coronavirus/domestic-violence-during-COVID-19

• https://www.canada.ca/en/department-national-defence/campaigns/covid-19/domestic-violence.html

• https://www.health.nsw.gov.au/infectious/covid-19/pages/violence-abuse-neglect.aspx

• https://www.unicef.org/press-releases/covid-19-children-heightened-risk-abuse-neglect-exploitation-and-violence-amidst
• https://www.who.int/emergencies/diseases/novel-coronavirus-2019/question-and-answers-hub/q-a-detail/violence-against-women-during-covid-19
• https://chayn.co/