Healthline - health and social care matters

Welcome to the Spring edition of Healthline. We hope that you will find the following articles interesting and useful.

Domestic abuse – assessing risk for professionals

This article looks at how professionals across health and social care can best assess risk to individuals and use established multi-agency processes to support victims.

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Vaccinations in a new light

This article looks at whether we will be seeing decision-making around vaccination for children in a new light.

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Practical issues when preparing for and attending a remote Inquest hearing

This article looks at practical issues that witnesses should be aware of when attending a remote inquest hearing.

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Domestic Abuse - assessing risk for professionals

The pandemic has brought fresh and serious concerns about the national prevalence of domestic abuse, including coercive control in what has been a prolonged period of lockdown. As lockdown eases and more cases of domestic abuse emerge this article looks at how professionals across health and social care can best assess risk to individuals and use established multi-agency processes to support victims.

The most common use of risk assessment is the DASH form. This is a nationwide tool created in 2009. The DASH form (domestic abuse, stalking, harassment and honour-based violence) checklist was created by Laura Richards, BSc, MSc, FRSA on behalf of the Association of Chief Police Officers and in partnership with Safe Lives, a national charity dedicated to ending domestic abuse. Its purpose is to capture information and to assess level of risk around incidents of domestic abuse, stalking, harassment and honour based violence. This form is mostly used by the police but in fact was designed to be used by all professionals across agencies who may have concerns about an individual. This is not the only risk assessment tool available but remains the most used.

The quality of the risk assessment is determined by the comprehensive collection of information attached to each question and on the summary page at the rear of the form. The risk management framework of the DASH is based on there being three levels of risk to the victim:

• Standard – current evidence does not indicate likelihood of causing serious harm
• Medium – There are identifiable indicators of risk of serious harm. The offender has the potential to cause serious harm but is unlikely to do so unless there is a change of circumstances, for example, failure to take medication, loss of accommodation, relationship breakdown, drug or alcohol misuse, separation.
• High – There are identifiable indicators of risk of serious harm. The potential event could happen at any time and the impact would be risk of serious harm (Home Office 2002 and Offender Assessment System 2006): “A risk which is life threatening and/or traumatic and from which recovery, whether physical or psychological, can be expected to be difficult or impossible”.

High risk DASH forms will be sent into the Multi‐Agency Risk Assessment Conference (MARAC) Administrator for processing; sharing information, referring to the independent domestic abuse advisory service, safety planning and arranging multi‐ agency meetings where necessary to discuss interventions. 

The DASH form can and should be completed by any professional who believes their service user is a victim of one of these forms of abuse. Therefore it should be used by health professionals eg, in Emergency Departments: ambulance staff; General Practitioners; midwives and any other professionals who may come into contact with victims such as social workers. 

It is best practice that a professional completes a DASH if someone is believed to be a victim of domestic abuse. There are two enhanced sections of the form which must be completed if there is a positive answer to the question “Is there any other person that has threatened you or that you are afraid of?” This enhanced section has a further ten questions and goes into much greater detail of the victim’s circumstances. The other enhanced section is with reference to stalking and honour‐based crimes.

This important capture of information and assessment of risk is vital for all agencies to support victims and help them keep safe. While the police will consider what action is required without other agencies and professionals supporting them in their public protection role and understanding domestic abuse and its serious consequences the professional response to help the victim will not be optimized. Health and social care professionals are also well placed to identify risk to others in the family eg children and other dependents. Children are much more of risk of significant harm in an environment where there is domestic abuse.

It should also not be forgotten that young people can also be subjected to domestic abuse in their own young relationships and Safe Lives developed a young person’s DASH form in 2013.

Responding to domestic abuse: a resource for health professionals was produced in 2017 and In June 2020 a new toolkit to help health professionals identify and respond to domestic abuse victims in England was launched. Glow was one of eight pathfinder pilot sites to work with health professionals from various sectors to develop their response to domestic abuse, with the findings directly informing the toolkit.

The pilot project was set up by several national organisations, including IRISi, Standing Together Against Domestic Abuse, AVA, Imkaan and Safe Lives, to help transform the way the sector, including the NHS, responds to victims and to help identify them sooner. The project found that around 85% of victims seek help 5 times from professionals before they get effective support.

In our safeguarding work we can help professionals better understand the features of domestic abuse and coercive control to improve their ability to respond to victims and work inter-agency more effectively. This may be through training, policy formulation to ensure the processes are in place, or support in individual cases.

 

For further information please contact Deborah Jeremiah.

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Vaccination for Children - a New Approach?

With the advent of the Covid 19 vaccination programme now becoming embedded into the health system in the UK for adults, it may be fair to ask whether we will be seeing decision-making around vaccination for children in a new light? Currently the Government has avoided the step of mandatory vaccination for all given the likely Human Rights challenges this would provoke.

The act of introducing a vaccine (vaccination) into the body to produce immunity (immunisation) to a specific disease is not new, of course. The flu vaccination programme has been running and developing  for many years along with long established vaccination programmes for children, the latter of which has caused a great deal of controversy in the past on safety grounds. For children who cannot make decisions themselves as they are too young and/or lack competency to do so, those with parental responsibility will make decisions for the child.

It is fair to say that past controversies on vaccination safety have not disappeared. The concerns around the measles, mumps and rubella vaccine (MMR) programme following an adverse research paper in The Lancet in 1998 was seismic for children’s vaccinations.  This research was later retracted and discredited but some would argue the damage to the faith in that vaccination programme for children was done. Even today, some parents choose not to submit their children for vaccinations against medical advice.

These decisions are even more complex when parents disagree. In M v H [2020] EWFC 93, there was parental dispute around vaccination of two young children (aged 4 and 6). Mr Justice MacDonald found that “whilst not compulsory, scientific evidence has established that it is generally in the best interests of otherwise healthy children to be vaccinated given that the current established medical view is that the routine vaccination of infants was in the best interests of those children and for the public good.” It was stated that when considering the broad range of welfare factors to be taken into account in an application such as this, it would be unlikely to conclude that immunisation with the vaccines recommended for children by Public Health England and set out in the routine immunisation schedule was not in the child’s best interest.  The only exceptions would be either a credible development in medical science, or new peer-reviewed research evidence which indicated significant concern for the efficacy and/or safety of one or more of those vaccines subject of the application; and/or a well-evidenced medical contraindication specific to the child or children who were the subject of the application.  Neither of these exceptions were demonstrated in this case.  The Judge also said that he did not accept that allowing the vaccinations amounted to an interference with the children’s Article 8 rights. The Judge went on to say “I am satisfied that the objective of vaccination, namely to protect the children from the consequences of the diseases vaccinated against and the population more widely from the spread of such diseases, is sufficiently important to justify the limitation of a fundamental right and is rationally connected to the objective”

This has implications as to how the Covid vaccination may be approached for children, but the Judge made clear in reaching this decision that he was making no comment on the efficacy of the Covid-19 vaccine, nor raising any doubts concerning it.  However, he went to add that it was very difficult to foresee a situation in which a vaccination against Covid-19 approved for use in children would not be endorsed by the Court as being in the child’s best interest, absent peer-reviewed research evidence indicating significant concern for the efficacy and/or the safety of one or more of the Covid-19 vaccines or a well-evidenced contraindication specific to the child. The Judge went on to say, that given a degree of uncertainty remains as to the precise position of children with respect to one or more of the Covid-19 vaccines consequent upon the dispute,  and having arisen at a point very early on in the Covid-19 vaccination programme, that he was satisfied it would be premature to determine the dispute that has arisen in this case  in reference to the Covid 19 vaccine.

With the advent of Covid 19 vaccine clinical trials for children and with the hope that this will be available for children in the future (dependent on the results of such trials), health professionals will need to be alive to the decision-making of parents around whether they permit their child to be vaccinated. This will need to be viewed against a backdrop of what is in the best interest of the child and the appropriate use of parental responsibility in reference to accessing health care for a child. One expects that this matter will come  before the Court at some point within a treatment case and certainly where parents disagree it is highly conceivable this issue will be aired in the future in the Family Court. The inference is that a Court would lean towards endorsing such a vaccination being given but as ever each case would need to be considered on its merits and specific facts.

 

For further information please contact Deborah Jeremiah.

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Practical issues when preparing for and attending a remote Inquest hearing

Remote hearings are currently being adopted by Coroners across England and Wales to conduct their inquest proceedings. Whilst we are seemingly on our way out of the current national lockdown, the Chief Coroner has yet to issue guidance to Coroners in respect of when this default position will be amended. It is difficult to predict when in-person hearings will be carried out on a widespread basis and in the volume achieved prior to the pandemic taking hold in March 2020.

Remote hearings are here to stay whether we like it or not, at least to some degree. At Bevan Brittan, our advocates have conducted numerous remote hearings in the last year for a range of organisations, including NHS and other health and social care clients, schools and individual medical practitioners. We have seen what works well for witnesses but we have also encountered practitioners and Court staff alike facing avoidable difficulties during a remote hearing. We hope that the below is of practical benefit to you in preparing for and attending a remote hearing.

Prior to the hearing

In any pre-inquest correspondence with witnesses or at a pre-inquest meeting, ensure that they have received the remote hearing link from the Court and that they check that their technology (i.e. their laptop and screen(s)) works. It is also useful for the witnesses to ensure that they have the right software for their device (e.g. MS Teams or Zoom) and that they know how to join the remote hearing on the day it is listed for.

Most Coroners like to ensure that they know where each witness is dialling into the hearing from. You may wish to check this with your witnesses and then confirm it to the Court in correspondence (if the Court requests this information in advance). It is also good practice to request that the witnesses confirm that they are due to provide live evidence from a quiet room where they will have privacy and will not be disturbed. If the witness requires someone else present in the room whilst they are giving live evidence, be sure to obtain that person’s details and inform the Court to ensure that the Coroner is aware of all the individuals who are dialled into the hearing.

In advance of the hearing, you may wish to provide each witness with the following checklist:

• Witnesses should attempt to have a plain/neutral background behind them, such as a blank wall – if this is possible. Translucent background applications on the software being used for the hearing can also be used and are effective. Witnesses should attempt to avoid having any distracting objects (ornaments or pictures) or bright colours in their background. They should be wary that the camera may show more of their room to others joining the remote hearing than they can see on the thumbnail on their computer screen;
• They should close the door to the room from which they are dialling into the hearing. This will hopefully prevent unwanted sights and sounds from interfering with the participation of the witness in the remote hearing;
• The light in the room should ideally be in front of the witness, so that their face is not shadowed. It is important that the witness informs those who they work with that they must not be interrupted during the course of the remote hearing;
• The device that the witness will be using needs to be fully charged to ensure they are not cut off during the remote hearing (most importantly not during their evidence);
• The witnesses should ensure that their mobile telephone and/or other devices are switched off or on silent. They should also remove anything around them which could distract them whilst they are in the remote hearing;
• They will need to have any relevant documentation ready before entering the remote hearing. The specifics will vary from case to case, however, for example, their witness statement and/or the Court bundle should ideally be available to the witness on a separate screen, if available, or in paper copy so these can be accessed easily during the hearing;
• Witnesses should not forget to dress appropriately for the remote hearing. For example, they should dress as if they were attending an in-person hearing. They should also be ready at least 15 minutes before the remote hearing is set to start or for the time specified in the correspondence from the Court.

Whilst the hearing is being conducted

When a witness’ video screen is on, they can of course be seen at all times. As such, witnesses should take care to ensure they are mindful of their behaviour and body language when their camera is switched on.

If a witness is not being spoken to directly by the Coroner or member of the Court staff, they should have their microphone on ‘mute’ to reduce interference or feedback or unwanted noise. Non-speaking witnesses (so when witnesses are not providing live evidence), should turn off video (to avoid distraction/to reduce the Court’s bandwidth) unless expressly directed not to do so by the Coroner.

Some witnesses have reported that remote hearings can be more draining than attending an in-person hearing. During their evidence, if a witness requires a break they should request this. As is the convention during in-person hearings, the Coroner will always question the witness first. The family, or their legal representatives, will be invited to ask questions following this and then questions from any legal representative for the witness will conclude the questioning. 

If it is envisaged that witnesses will be giving evidence from a room at their workplace (for example, a hospital or community team base), it is best practice for the witness to have informed the Court in advance. As noted above, if the witness requires someone else present in the room whilst they are giving live evidence, be sure to obtain that person’s details and inform the Court to ensure the Coroner is aware of all individuals who are dialled into the hearing.

At the end of the hearing, do ensure that all remote links are closed down before commencing any debrief with witnesses.

 

For further information please contact Toby de Mellow.

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