Persist with his line of enquiry and try to persuade Marlena to seek help?
Marlena Cieslak has come to Accident and Emergency with a suspected fractured arm, cracked ribs and bruising around her neck.
Marlena has seen the triage nurse. She told the nurse that her injuries are the result of a fall down the stairs in her flat. Because of the nature of her injuries, Dr Gallagher is concerned that Marlena may be a victim of domestic violence.
I feel like such a fool! I don't know what happened, I just tripped at the top of the stairs. I will try to be more careful in the future. Will it take much time to get better?
We'll see - there's no rush. The important thing is that you make a full recovery. Miss Cieslak, I hope you don't mind me asking but...you've come to A&E several times over the last few months. Is there a reason for that?
I'm just very clumsy I suppose. I keep falling.
But the bruising around your neck is a very unusual injury to sustain from a fall. It's far more likely to have been caused by pressure being applied, perhaps from someone's hands...? Is everything okay at home?
I don't know what you're suggesting but everything is just fine with my boyfriend. We are very happy together. Can you please just fix my arm and let me go home now?
Despite Marlena's reluctance to open up, Dr Gallagher persisted and asked a few more questions about her injuries when she suddenly began to cry. She told Dr Gallagher that her relationship with her boyfriend had broken down and he'd been acting violently towards her for several months now. She explained that she thought she may be suffering from depression and felt powerless and afraid, unable to tell anyone about the abuse. Dr Gallagher gave her advice about support services and encouraged her to contact them. He also offered to write to her GP, with her permission, to recommend a referral for counselling to address her depression.
50. All patients have the right to a confidential medical service. Challenging situations can however arise when confidentiality rights must be balanced against duties to protect and promote the health and welfare of patients who may be unable to protect themselves
52. As a rule, you should make decisions about how best to support and protect adult patients in partnership with them, and should focus on empowering patients to make decisions in their own interests. You must support and encourage patients to be involved, as far as they want and are able, in decisions about disclosing their personal information
53. There are various legal requirements to disclose information about adults who are known or considered to be at risk of, or to have suffered, abuse or neglect.18 You must disclose information if it is required by law.
a. satisfy yourself that the disclosure is required by law
b. only disclose information that is relevant to the request, and only in the way required by the law
c. tell patients about such disclosures whenever practicable, unless it would undermine the purpose of the disclosure to do so
55. You must disclose personal information about an adult who may be at risk of serious harm if it is required by law (see paragraph 53). Even if there is no legal requirement to do so, you must give information promptly to an appropriate responsible person or authority if you believe a patient who lacks capacity to consent is experiencing, or at risk of, neglect or physical, sexual or emotional abuse, or any other kind of serious harm, unless it is not of overall benefit to the patient to do so.
56. If you believe it is not of overall benefit to the patient to disclose their personal information (and it is not required by law), you should discuss the issues with an experienced colleague. If you decide not to disclose information, you must document in the patient’s records your discussions and the reasons for deciding not to disclose. You must be able to justify your decision.
57. As a principle, adults who have capacity are entitled to make decisions in their own interests, even if others consider those decisions to be irrational or unwise. You should usually ask for consent before disclosing personal information about a patient if disclosure is not required by law, and it is practicable to do so.
58. If an adult patient who has capacity to make the decision refuses to consent to information being disclosed that you consider necessary for their protection, you should explore their reasons for this. It may be appropriate to encourage the patient to consent to the disclosure and to warn them of the risks of refusing to consent.
59. You should, however, usually abide by the patient's refusal to consent to disclosure, even if their decision leaves them (but no one else) at risk of death or serious harm (see endnote 19). You should do your best to give the patient the information and support they need to make decisions in their own interests – for example, by arranging contact with agencies to support people who experience domestic violence. Adults who initially refuse offers of assistance may change their decision over time.
(Confidentiality: good practice in handling patient information (2017), paragraphs 50-59)
19. In very exceptional circumstances, disclosure without consent may be justified in the public interest to prevent a serious crime such as murder, manslaughter or serious assault even where no one other than the patient is at risk. This is only likely to be justifiable where there is clear evidence of an imminent risk of serious harm to the individual, and where there are no alternative (and less intrusive) methods of preventing that harm. This is an uncertain area of law and, if practicable, you should seek independent legal advice before making such a disclosure without consent.