Why This Station Is Tested
Domestic abuse and intimate partner violence (IPV) affect 1 in 4 women and 1 in 6 men in their lifetime. It is estimated that 30% of domestic abuse begins in pregnancy. The OSCE tests your ability to create a safe environment for disclosure, ask direct questions sensitively, assess risk, and navigate the safeguarding and multi-agency referral pathway — without putting the patient at greater risk by disclosure to the wrong person.
Definitions
Domestic abuse (UK government definition, Domestic Abuse Act 2021): behaviour by one person towards another personally connected person that is abusive — including physical, sexual, financial, emotional, or coercive/controlling behaviour. Covers all genders and sexualities. Includes ex-partners and family members.
Intimate partner violence (IPV): a subset of domestic abuse involving a current or former intimate partner.
Coercive control: a pattern of acts designed to make the victim subordinate or dependent — monitoring, isolation, financial control, threats. A criminal offence in the UK since 2015 (Serious Crime Act).
Creating the Conditions for Safe Disclosure
Before asking about abuse, ensure the patient is seen alone. If a partner insists on being present:
- "It is our routine practice to see all patients alone for part of the consultation — can I ask you [partner] to wait outside for a few moments?"
- Never ask about abuse in front of a possible perpetrator
Establish rapport and privacy. Document that the patient was seen alone.
⚠️ Red Flag
Never use a family member or friend as an interpreter for a patient you suspect may be experiencing domestic abuse — the interpreter may be the perpetrator, or may be controlled by the perpetrator.
Safe Enquiry — How to Ask
Safe enquiry is a routine, non-judgmental question that normalises asking. Two validated approaches:
Direct question (NICE-recommended approach for universal enquiry): "Because violence and abuse affect many people's health, I now ask all patients about this. Has anyone at home ever hurt or threatened you?"
Framing statement first: "I've noticed you have some injuries that concern me. Sometimes injuries like these happen when a partner or someone at home hurts people — is that what's happened to you?"
If the patient discloses: believe them, validate, thank them for telling you, and avoid asking why they have not left — this is judgemental. Recognise it takes great courage to disclose.
Assessing Risk — DASH Risk Identification Checklist
The DASH (Domestic Abuse, Stalking and Honour-based violence) risk identification tool is used by police and healthcare to stratify risk. In the OSCE, demonstrate awareness of high-risk features:
| High-risk indicator | Example |
|---|---|
| Threats to kill | "He said he would kill me if I left" |
| Use of weapons | Knife, firearm, strangulation |
| Strangulation/choking | Even once — highest predictor of future homicide |
| Escalating frequency or severity | "It's getting worse every week" |
| Controlling behaviour | Monitoring phone, financial control, isolation |
| Pregnancy | Abuse often begins or escalates in pregnancy |
| Presence of children | Safeguarding concern — child at risk |
| Perpetrator has access to weapons | Police firearms enquiry may be needed |
| Perpetrator breaching court orders | |
| Patient fears for their life | Always take this seriously |
Safeguarding Pathway
Children in the Household
If there are children present in an abusive household, this triggers a safeguarding concern — children witnessing domestic abuse are defined as suffering emotional abuse under UK legislation. You must consider:
- Making a referral to children's social care
- Contacting MASH (Multi-Agency Safeguarding Hub) in your local area
Adults at Risk
If the patient themselves lacks capacity or is vulnerable, adult safeguarding thresholds may be met — follow local policy.
MARAC — Multi-Agency Risk Assessment Conference
MARAC is a meeting of statutory and voluntary agencies (police, social care, housing, health, IDVA — Independent Domestic Violence Advisor) that shares information about high-risk cases to develop a co-ordinated safety plan. Refer to MARAC when:
- DASH risk assessment indicates high risk
- Professional judgement suggests high risk even without a high DASH score
- Three or more police attendances in 12 months to the same address
💡 Tip
In the OSCE, mention MARAC by name when discussing management of a high-risk case — this is a mark-scheme discriminator that distinguishes a merit from a pass.
Documentation
Document clearly, factually, and in the patient's own words (use quotation marks). Include:
- Body map for injuries (use a standard body map diagram)
- Time, date, and circumstances of injury as reported by patient
- Who was present during the consultation
- Risk assessment findings and referrals made
- What information was given to the patient (helpline numbers, IDVA contact)
Documentation may become evidence in criminal or civil proceedings. Never write anything that could compromise the patient's safety if the notes are accessed by the perpetrator.
Resources to Offer the Patient
- National Domestic Abuse Helpline (Refuge): 0808 2000 247 (free, 24/7)
- IDVA (Independent Domestic Violence Advisor): specialist advocate
- Safe Leave (safety plan for leaving): advise on what to take if they need to leave quickly (documents, medications, money, children's items)
- Safety planning: code word with a friend, informing school about the situation
Frequently Asked Questions
"How do I ask about intimate partner violence sensitively without alienating or endangering the patient?"
The key principles are: ensure privacy (patient alone, no partner or family member present), use a non-judgmental normalising framing ("I ask all my patients about this"), ask directly but compassionately ("Has anyone at home ever hurt or threatened you?"), believe and validate the disclosure without expressing shock, and avoid asking why the patient hasn't left — this is a common but harmful question that implies blame and ignores the complexity of leaving an abusive relationship (financial dependence, fear of escalated violence, children, immigration status, love for partner). If the patient denies abuse but you remain concerned (inconsistent explanation for injuries, fearful demeanour, partner reluctant to leave the room), document your concerns, offer resources, and arrange follow-up — repeated opportunities to disclose are valuable. Provide the National Domestic Abuse Helpline number (0808 2000 247) written on something discreet (e.g., inside a prescription, on a card that looks like a medical leaflet) so it cannot be found by the perpetrator.
"What is MARAC and when should a healthcare professional make a referral?"
MARAC (Multi-Agency Risk Assessment Conference) is a regular meeting of statutory and voluntary agencies — police, health, social care, housing, IDVA, and others — that share information about domestic abuse cases assessed as high risk and co-ordinate a safety plan around the victim. Referral thresholds: any case assessed as high risk on the DASH risk checklist (score ≥17, or individual high-risk markers such as strangulation, threats to kill, or pregnancy), cases where the professional uses their judgement to assess high risk even without a high DASH score, and cases with three or more police call-outs to the same address in the past 12 months. Healthcare professionals can make a direct MARAC referral through their local co-ordinator (usually via the police or safeguarding team). The patient does not need to consent to be referred to MARAC — information can be shared without consent where there is a risk to life, under the public interest test. In the OSCE, naming MARAC as part of a management plan for a high-risk domestic abuse case is a discriminating mark-scheme point.
"What is coercive control and why is it clinically important to recognise?"
Coercive control is a pattern of acts that make a victim subordinate and/or dependent by isolating them from sources of support, exploiting their resources and capacities for personal gain, depriving them of means needed for independence, resistance, and escape, and regulating their everyday behaviour. It became a specific criminal offence in England and Wales under the Serious Crime Act 2015 (and extended to ex-partners in the Domestic Abuse Act 2021). Clinically important signs of coercive control in the consultation: partner always insisting on being present, patient appearing fearful or deferring all answers to the partner, evidence of financial control (patient has no access to money or bank account), patient describing their movements being monitored, isolation from family and friends, patient needing to account for all time away from home, mobile phone monitored or controlled. Recognising coercive control is clinically important because it explains why victims do not leave (the perpetrator has systematically dismantled their independence and support networks) and because it is itself a form of abuse that causes significant psychological harm even in the absence of physical violence.
"What safeguarding concerns arise when children are present in a household affected by domestic abuse?"
Under the Children Act 1989 and 2004, and in alignment with Working Together to Safeguard Children (2018), children who witness domestic abuse are considered to be experiencing emotional abuse and are at risk of significant harm — this triggers safeguarding duties. Research shows that children in households with domestic abuse are at substantially increased risk of physical abuse themselves, developmental delays, mental health problems (anxiety, depression, PTSD), and academic difficulties. As a healthcare professional, if you identify or suspect that children are present in an abusive household, you must consider making a referral to children's social care (either directly or via the MASH — Multi-Agency Safeguarding Hub) even without parental consent if there is a risk to the child's welfare. You do not need proof — a reasonable suspicion is sufficient to make a referral. Document your reasoning clearly. In the OSCE, failing to identify safeguarding concerns about children in an IPV scenario is a common failure — always ask "Are there children in the home?" as a direct question.
"How do you document intimate partner violence concerns in the medical records safely?"
Documentation must be accurate, factual, and written with the awareness that medical records may be subpoenaed in criminal or civil proceedings or, critically, may be accessed by the perpetrator (e.g., if the perpetrator is a patient at the same practice, or if they accompany the patient and demand to see records). Key principles: record in the patient's own words where possible, using quotation marks ("patient states 'he punched me in the face'"); use a body map to record injury sites with dimensions, colour, and shape; record the history given, any inconsistencies with the injury pattern, and your clinical findings; document who was present during the consultation; record the risk assessment performed (DASH score or clinical assessment); document what information and resources were provided (helpline number given, IDVA contact); record referrals made (safeguarding, MARAC, social care). Code the entry appropriately in the notes system (many practices use a domestic abuse code for flagging). Avoid subjective language or speculation — write what was observed and reported, not your interpretation of the relationship dynamics.
"What should you do if a patient discloses domestic abuse but does not want you to take any action?"
Respecting patient autonomy is central to this situation — an adult patient with capacity has the right to refuse referral or intervention, even if you believe they are at risk. Your role is to ensure they have the information to make an informed choice, not to override their decision. Actions to take: believe and validate the disclosure, express your concern clearly without pressure, provide the National Domestic Abuse Helpline number (0808 2000 247) and information about IDVAs, safety plan with them (if they had to leave quickly, what would they take? Who could they call?), document the conversation fully, arrange follow-up and leave the door open for future disclosure. You may share information without consent where there is an immediate risk to life (GMC and Caldicott principles — public interest override) — this is a high threshold and should be discussed with your safeguarding lead. If there are children at risk, safeguarding duties for children may override the adult's refusal. The MARAC referral can still be made for high-risk cases even without consent, as the process is designed to protect life.
Related guides: Safeguarding OSCE Guide · Consent and Capacity OSCE · Psychiatric History OSCE · Overdose and Self-Harm History OSCE · Breaking Bad News OSCE