Domestic Violence: Wrist Injury

Clinical Scenario

Jade Thompson, 31, a hairdresser, presents with a painful swollen right wrist after 'falling down the stairs' last night. She is wearing long sleeves despite warm weather and appears anxious, avoiding eye contact. The injury pattern is inconsistent with a fall — the bruising suggests a grabbing mechanism. When explored sensitively, she discloses that her partner grabbed and twisted her wrist during an argument. This has been escalating over 6 months. She has a 4-year-old daughter who was in the house during the incident. She is not ready to leave and does not want the police involved.

What This Case Tests

Recognising injury patterns inconsistent with the stated mechanism; creating a safe environment for domestic violence disclosure; conducting a DASH risk assessment; understanding safeguarding duties regarding the child witness; safety planning for a patient who is not ready to leave; documenting injuries accurately for potential future use

Common Mistakes Trainees Make

The three most common mistakes are: accepting the 'fell down stairs' explanation at face value and managing the wrist injury without exploring further — the inconsistent mechanism and body language are clear indicators; pressuring the patient to leave the relationship or contact the police, which removes her autonomy and may increase danger — leaving is the most dangerous time in an abusive relationship; and forgetting the safeguarding duty for the 4-year-old daughter who witnessed the violence — children who witness domestic abuse are suffering significant harm and this requires a safeguarding referral.

The Consultation Challenge

Jade has come about her wrist. She has not come to discuss domestic violence. You need to create the conditions for disclosure without forcing it.

Start with the injury. Examine it thoroughly — this builds trust and demonstrates you are taking her seriously as a patient. While examining, note the bruising pattern aloud in a factual way: 'The bruising here looks like it wraps around the wrist, which is a bit unusual for a fall. Can you talk me through exactly what happened?'

If she maintains the fall story initially, don't push. Create space: 'I see injuries like this quite regularly, and sometimes there's more going on at home than people feel comfortable sharing straight away. If that's ever the case for you, this is a safe place to talk, and everything is confidential within certain limits.'

When she discloses, respond with calm validation: 'Thank you for telling me, Jade. What's happening to you is not OK, and it is not your fault. I want to make sure you and your daughter are safe.'

Conduct a brief risk assessment: Is the violence escalating in frequency or severity? Has he ever strangled or choked her? Has he threatened to kill her or himself? Does he have access to weapons? Has he been violent to the children? Is she afraid of him right now? These questions map to the DASH (Domestic Abuse, Stalking, and Honour-Based Violence) risk assessment tool.

Address the child: 'I need to be honest with you — because your daughter was in the house during the violence, I have a duty to make a safeguarding referral to children's services. This isn't about judging you as a mum — it's about making sure support is available for both of you. Children's services can actually help families in this situation.'

Respect her decision not to leave. Safety planning is more productive: does she have a safe place to go in an emergency? Can she keep a bag packed? Does she have access to money? Can she store important documents elsewhere? Give her the National Domestic Abuse Helpline number and local refuge contacts.

Document everything meticulously: photograph the injuries with consent, record her exact words, note the mechanism inconsistency, and code appropriately using the domestic violence clinical code.

Time check: Minutes 1-3 on examining the wrist and creating space for disclosure. Minutes 3-6 on responding to disclosure and risk assessment. Minutes 6-9 on safety planning and the child safeguarding discussion. Final 3 minutes on documentation, support services, and follow-up.

How Examiners Mark This Case

Data Gathering and Diagnosis: Examiners assess whether you recognise the inconsistency between the stated mechanism and the injury pattern, create an opportunity for disclosure, and conduct a structured risk assessment covering escalation, strangulation, threats to kill, and impact on the child. They look for identification of the child safeguarding concern and assessment of Jade's immediate safety.

Clinical Management and Medical Complexity: Examiners evaluate whether you manage the wrist injury appropriately (X-ray if fracture suspected), explain the safeguarding referral for the child clearly and compassionately, provide practical safety planning, and offer support services (National Domestic Abuse Helpline, local refuge, IDVA referral). Documenting injuries with photographs and accurate descriptions demonstrates medicolegal awareness. Knowing that MARAC referral is indicated for high-risk cases shows system knowledge.

Relating to Others: This domain carries the most weight. Examiners look for non-judgemental, empathetic communication throughout — from the gentle challenge of the fall explanation through to respecting her decision not to leave. Explaining the child safeguarding referral as supportive rather than punitive is crucial. The patient should leave feeling supported and empowered, with a clear plan, not shamed or pressured.

Example Opening

Strong opening: "Hello Jade, I can see you've hurt your wrist. Let me have a look at that first — can you tell me what happened?"

Creating space for disclosure: "I see injuries like this regularly in my work, and I've learned that sometimes there's more going on behind the scenes than people feel ready to share. If anything like that applies to you, I want you to know that this is a safe and confidential space."

Avoid: "Is your partner hitting you?" — too direct and confrontational at this stage. It forces a yes/no answer before trust is established and may provoke denial and withdrawal.

How This Appears in the SCA

Domestic violence cases test your ability to recognise non-accidental injury patterns, create conditions for disclosure, conduct a risk assessment, and balance patient autonomy with safeguarding duties. Examiners value candidates who respect the patient's decision-making while ensuring safety for both the patient and the child.

Key Statistic

On average, a victim of domestic abuse experiences 50 incidents before seeking help. Two women a week are killed by a current or former partner in England and Wales, and risk of homicide is highest in the period immediately after leaving.

Relevant Guidelines

• NICE QS116: Domestic violence and abuse
• NICE PH50: Domestic violence and abuse — multi-agency response
• DASH risk assessment tool
• MARAC (Multi-Agency Risk Assessment Conference) referral criteria
• Children Act 1989 and 2004 safeguarding duties.

Frequently Asked Questions

What injury patterns suggest domestic violence rather than accidental injury?

Key indicators include: bruising that wraps around limbs (suggesting grabbing), injuries at different stages of healing (suggesting repeated incidents), injuries to areas typically covered by clothing (torso, upper arms, thighs), defensive injuries on forearms and hands, facial injuries with inconsistent explanations, and any injury where the stated mechanism does not match the pattern. Strangulation marks on the neck are a critical red flag — non-fatal strangulation is one of the strongest predictors of future homicide in domestic abuse.

What is the DASH risk assessment and when should I use it?

The DASH (Domestic Abuse, Stalking, and Honour-Based Violence) risk assessment is a standardised tool used to identify high-risk victims. Key questions cover: escalation of frequency or severity, strangulation or choking, threats to kill, use of weapons, jealous or controlling behaviour, stalking, substance misuse by the perpetrator, and separation (recent or planned). A score of 14 or above, or professional judgement that the risk is high, triggers referral to MARAC. In the SCA, you don't need to score formally, but asking these key questions demonstrates knowledge of structured risk assessment.

How do I handle the safeguarding referral for the child?

Be transparent: 'Because your daughter was present during the violence, I have a responsibility to let children's services know. This isn't about questioning your parenting — you're protecting her by being here today. Children's services can actually provide support for both of you, including housing advice and family support workers.' Frame it as supportive, not punitive. The referral is to the local authority children's social care team and should be made the same day. Document the child's name, age, school, and the circumstances of exposure.

What should I do if the patient doesn't want to leave?

Respect the decision. Leaving is the most dangerous time — homicide risk peaks around separation. Instead, focus on safety planning: identify a safe place she can go in an emergency (friend, family, refuge), keep a packed bag with essentials, store copies of important documents outside the home, establish a code word with a trusted person, save the National Domestic Abuse Helpline number (0808 2000 247) under a disguised contact name. Offer an IDVA (Independent Domestic Violence Advocate) referral — they specialise in safety planning and can work with her at her own pace.

How should I document a domestic violence consultation?

Document thoroughly: record the patient's exact words in quotation marks, describe the injuries precisely (size, shape, colour, location, stage of healing), note the inconsistency between stated mechanism and injury pattern, photograph injuries with written consent, code the consultation using the domestic violence clinical code, and record all actions taken (referrals, safety plan, resources given). This documentation may be requested for future legal proceedings including family court. Store it securely and consider adding a clinical alert to the record for future attendances.