Authors: Adrian Boyle / Editor: Tadgh Moriarty / Codes: SLO10, TP10, XC4Published: 31/05/2024

Introduction

  • Victims of violence frequently present to emergency departments (ED), either as a consequence of their injury or with associated problems.1,2
  • There are several types of violence that we see in EDs e.g. child maltreatment, domestic abuse, elder abuse, sexual assault, and community violence. This module is largely concerned with an intervention that reduces community violence; the fights that largely occur in pubs and nightclubs among young men.
  • Most patients who present to healthcare professionals after violent injury are never recorded by the Police. This means even if the Police were successful at catching all perpetrators, there would still be a lot of victims requiring medical care.
  • People who live in deprived areas are much more likely to attend an emergency department after an assault.2
  • It is very possible to reduce levels of violence in communities. There is substantial unwarranted variation in levels of violence between different areas of the country and different countries.
  • Emergency department data about assaults can have a valuable role in improving local understanding of violence. It is not the only intervention that helps reduce community violence, benefits are also seen with advocacy services, alcohol control and varying policing strategies.3

Context

The Public Health Approach to Violence Prevention

The public health approach to violence prevention is a four-step approach that succinctly describes how violence can be reduced.

  1. Define and monitor the problem by collecting data on the who, what, when, where and how of violence.
  2. Identify risk and protective factors that influence the occurrence of violence.
  3. Develop and test prevention strategies that target the identified factors.
  4. Assure the widespread adoption of the effective strategies by disseminating and implementing them.

The legal responsibilities about reporting violence to the police

Usually there is no obligation for a clinician to report a violent injury to the Police and patients expect us to keep their personal information confidential, but there are some important exceptions. The guidelines around reporting violent injury to the Police are described by the GMC in Good Medical Practice. Firstly, patients should be encouraged to report assaults to the police. If the clinician suspects a victim is at risk of Female Genital Mutilation, then the law in England and Wales requires mandatory reporting. If a child presents after an assault, a notification should be made to child safeguarding services. Likewise, if the clinician believes that reporting an assault is in the ‘public interest’ then they should report. Essentially, ‘public interest’ means whether you believe other people could be harmed, so would be expected after gun, knife crime or gang violence. The General Medical Council offer advice on this Reporting gunshot and knife wounds – professional standards – GMC (gmc-uk.org). This blog goes into this in more detail, but this is a complicated area and worth discussing with a senior colleague. Revised gunshot and knife wounds guidance: my view from A&E – Improving medical education and practice across the UK (wordpress.com).

These short films here will talk you through the process.

Step 1

At patient registration, ED receptionists are instructed to ask three additional questions if a patient discloses that they have been assaulted. These are:

  1. When did the assault occur?
  2. Where did the assault occur?
  3. What weapon, if any, was used?

These shouldn’t be time consuming, and a patient may already have volunteered this information e.g. ‘I got punched outside the King’s Head on Market Street an hour ago’.

Step 2

Each month an anonymous list of all the assaults recorded is sent to the local community safety partnership. The data mustn’t identify individuals, but does identify locations, weapons, and times. An example is shown below:

Date and Time of assault Location of assault Weapon Used
31/12/2023   23:45 The King’s Head, Market Street None
31/12/2023   23:40 Zaboosh Nightclub Bottle
31/12/2023   22:00 Kebab van, Market Street Fist
31/12/2023  18:00 Behind the chemist on High Street Knife
31/12/2023  21:30 Zaboosh Nightclub Needle spiking

Feet and fists can be recorded as a weapon.

Every region of England and Wales has a Community Safety Partnership. They were established as part of the Crime and Disorder Act 1998. They compromise of representatives from the Police, Fire and Rescue, Local Authorities, the NHS and Probation Services.

Step 3

The Community Safety Partnership analyst combines this data with routine police data and produces a short report describing the local picture of violent injury and trends.

Step 4

The Community Safety Partnership can intervene to reduce violence hotspots, this can involve re-siting CCTV cameras, asking licensing authorities to review alcohol licenses within problem premises/areas or adjusting police patrols.

Where this has been implemented, there has been a 30% reduction in the number of patients attending the emergency department after an assault.7 Furthermore, this preventative work is extremely cost effective, with every pound spent on implementation saving £82.8 There are some caveats, however, including that this has never been shown to prevent murders. Likewise, this information is collected at reception and most people would be unlikely to disclose domestic abuse or sexual assault in an open area to a stranger. These are also important problems which require different interventions and approaches. This is specific form of violent injury surveillance that is effective in reducing community violence.

Confidentiality

Patients need to trust that their personal information they share with healthcare professionals is not shared irresponsibly and this is regulated through the General Medical Council and the Information Commissioner’s Office. Though this data is given to the community safety partnership, which includes the Police, it is not to assist in crime detection, but crime prevention. No patient identifiable data should leave the NHS Trust. The police also understand that they aren’t allowed to use this data from crime detection.

The Information Commissioner’s Office looked at whether this process was justified in 2010 and concluded.

‘‘…The Data Protection Act 1998 is not a barrier to the appropriate sharing of personal information. It should not be seen as preventing any Trust from sharing this anonymised information in a responsible manner.’ An Information Sharing Agreement is not normally required but can be implemented. There is a specimen Information Sharing Agreement on the RCEM website.

The Serious Violence Duty

In 2022, the Serious Violence Duty became law in England and Wales. This requires Local Authorities to work in partnership to prevent and reduce serious violence. This also places an obligation for the NHS to participate in violence reduction initiatives.

The effectiveness of this process depends on the quality of information collected. It is accepted that some patients do not provide good information about their assault, either because of their injury, intoxication or wariness of authority and their own conduct. The RCEM guideline suggests that 70% of usable information about the location of assault is a good benchmark. In most places this information is collected by receptionists, though it can also be successfully collected by other staff groups.

However, meaningful information about the location of assaults is critically important to allow the Community Safety Partnership to intervene. Consider the difference between the two entries below.

Date and Time of assault Location of assault Weapon Used
21/12/2023   23:05 Inside The King’s Head, Market Street None
21/12/2023   23:40 London Road Bottle

The first entry (23:05) provides more meaningful data than the second (23:40). London Road is not specific, and some roads may be long with several premises.

In general, meaningful location data should be considered as data which is sufficient for someone to identify the location. It takes time, effort, and positive feedback to encourage ED receptionists to collect this information. Explaining the value of this information and how it can be used is helpful to engage the receptionists. Furthermore, showing them the monthly returns can act as a further tool in positive feedback.

  1. WHO CC. Understanding the burden and costs of unintentional injuries and violence to European health systems. Jones S, Bell Z, Quigg Z, et al. 2024.
  2. Cusimano M, Marshall S, Rinner C, Jiang D, Chipman M. Patterns of urban violent injury: A spatio-temporal analysis. PLoS One [Internet]. 2010;5(1):e8669.
  3. Snider C, Lee J. Youth violence secondary prevention initiatives in emergency departments: a systematic review. CJEM. 2009 Mar;11(2):161-8.
  4. The Royal College of Emergency Medicine (RCEM) Best Practice Guideline. Guideline for Information Sharing to Reduce Community Violence Revised: September 2017. QEC_Guideline_Information_Sharing_to_Reduce_Community_Violence_Sept2017.pdf (rcem.ac.uk).
  5. Serious Violence Duty. Preventing and reducing serious violence Statutory guidance for responsible authorities. England and Wales, December 2022. Final_Serious_Violence_Duty_Statutory_Guidance_-December_2022.pdf.
  6. Bellis MA, Hughes K, Anderson Z, et al. Contribution of violence to health inequalities in England: demographics and trends in emergency hospital admissions for assault. Journal of Epidemiology & Community Health 2008;62:1064-1071.
  7. Boyle AA, Snelling K, et al. External validation of the Cardiff model of information sharing to reduce community violence: natural experiment. Emerg Med J. 2013 Dec;30(12):1020-3.
  8.  Florence C, Shepherd J, Brennan I, Simon T. Effectiveness of anonymised information sharing and use in health service, police, and local government partnership for preventing violence related injury: experimental study and time series analysis. BMJ. 2011 Jun 16;342:d3313.