What is MARAC?

Multi-agency risk assessment conference for very high risk domestic violence cases.  Only the top 5% of known domestic violence cases will be escalated to a MARAC, so if one is being held the victim is at high risk of serious harm/death and the perpetrator is high risk perpetrator. 

The aim of the MARAC notification is to share information and devise an action plan to improve victim safety. This is a regular meeting to share information on victims of domestic violence who are at highest risk of homicide/serious harm. The meeting is multi agency including police, NHS, education and social services and meets fortnightly. For any concerns with respect to victims of domestic violence contact the MARAC Coordinator on 01274 437339/435175. Concerns can also be discussed with Sue Thompson (designated nurse for safe guarding children) on 01274 256082.

What admin staff need to do

• MARAC notification recieved via secure NHS email
• The MARAC form needs to be scanned into the victims notes and the on-call GP notified that there is a MARAC to be reviewed. The form can be printed off from the email and put on the blue board.
• The doctor needs to look in the patients note and inform the safeguarding team of any relevant issues. This could be injuries sustained and seen in surgery or in A and E or things that increase the patients risk of DV eg mental health issues, drug and alcohol abuse, other reasons for vulnerability eg learning difficulties .
• The doctor needs to put an entry in the SG adult template and highlight that at risk of DV. The alleged perpetrator can be recorded as alleged in the node. (see below)
• Nothing should be put into the alleged perpetrators notes even if they are a patient at the surgery.
• The newer MARAC notifications come complete with an attached form to fill out which highlights all of these issues. This then needs returning to admin so that the form can be returned via the secure NHS mail.
• Entries in the victims notes should be marked as containing third party information and not for online access.

What Doctors need to do

The perpetrator should not be aware the MARAC is taking place as this may put the victim at risk.  For this reason the MARAC should not be mentioned in the New Journal or scanned into Communications & Letters.  Instead, do the following…

1. At risk of DV
2. Hx of DV
3. Notification received
4. Record contains 3^rd party into

• Right click on floppy disc > do not show online record > reason: safeguarding
• Should now be a cross on the internet icon on the tab journal entry (double check)

1. Safguarding Information > add entry > add: MARAC completed see mothers record
2. Tab Journal > Change filter to EVERYTHING
3. Go to tab journal for your new entry > set to not for online viewing > reason: safeguarding

A case was discussed at MARAC recently and the woman suffering from high risk domestic violence disclosed to a worker that her husband interprets for her during appointments at the GP practice.  Therefore, GPs and staff need to be aware that often perpetrators of domestic abuse will accompany partners to appointments, and if they are used as interpreters this means that the victim will not be seen alone and will not have an opportunity to disclose domestic abuse or be offered support.   If you have suspicions, find a way of getting to have a 1-1 consultation with the patient.

Do I need consent from the victim?

If possible, before reporting, obtain consent of the person experiencing the abuse. Consent is not necessary if…

1. they lack capacity,
2. there is a risk to life or limb,
3. there is a risk to others,
4. the abuse/neglect is caused by a person in a professional capacity,
5. the abuse is institutional or systemic abuse in a care setting,
6. the abuse has resulted in a grade 3 or 4 pressure ulcer.

IMCA – Independent Mental Capacity Advocate.  The IMCA service is for any person over the age of 16 years who lacks capacity. They may be consulted if there is no one else to consult with, in respect to serious medical treatment, a long-term care move, adult protection procedures or a care review. They offer support for the individual, represent them in discussions, provide information to help work out what is in the persons best interest, challenge decisions that appear not to be in their best interests but they do not make decisions for them.

IMCA contacts:

• Bradford Council Advocacy Page Website: https://www.bradford.gov.uk/adult-social-care/living-independently/advocacy/
• Learning Disability : CHOICES advocacy – Website: www.choices-advocacy.org.uk Email: hello@choices-advocacy.org.uk, Tel: 023 8078 3715  
• VoiceAbility Tel: 01274 888 017  Website: www.voiceability.org 
  
• VITAL (formerly BAMHAG) Tel: 01274 770 118 Website: www.vitalprojects.org.uk
• Bradnet : advocacy and one to one support for disabled people – Tel: 01274 665598 Website: https://inspiredneighbourhoods.co.uk/bradnet-2/
• Bradford and Airedale Citizens Advice Bureau –  Tel: 0808 2787828 Website: https://www.citizensadvice.org.uk/local/bradford-airedale/
• Information taken from General Practice Resource Pack Safeguarding Adults Bradford: Airedale, Wharfedale and Craven Bradford Districts, Bradford City CCGs.

You must treat women and children in refuges (who may not have proof of identity) in the same way as any other patient who does have proof of identity.     Do not deny access to health care and protection based on the inability to prove identity.   BMA guidance on Patient registration for GP practices states:  ‘There is no contractual duty to seek evidence of identity or Immigration status or proof of address. Therefore practices should not refuse registration on the grounds that a patient is unable to produce such evidence’.  Anyone who is in England is entitled to receive NHS primary medical services at a GP practice and  applications for registration for any patient in England must be considered in exactly the same way, regardless of country of residence.

If as a dr you are concerned about forced marriage or a patient presents with fears of a forced marriage it is vital that you act IMMEDIATELY (not something to think about as patient may disappear in interim if at high risk). Keep the patient in the surgery and phone the Bradford Safeguarding Unit (police) number on 01274 376116. It is also vital that you make no attempts to negotiate with the family involved as this will put your patient at increased risk.

It is a GMC requirement to report FGM. If a child is at risk of FGM this needs to be reported to the safeguarding unit so action can be taken to protect the child or if a child has undergone FGM this needs reporting. All cases of FGM noted in an adult need to be coded and potentially discussed if other members of the household are at risk.

If any doctor has concerns about the possibility of radicalisation/terrorism related concerns in a patient – discuss it with the Safeguarding Leads (numbers above). If the patient is a minor this can be reported to safeguarding. If this is concerning a consenting adult and there is risk to others the police need informing immediately. If there is no immediate concerns this can be discussed with the Safeguarding leads (numbers above).

If a staff member is suspected of being a possible perpetrator of child or adult abuse or domestic violence this is something that must not be ignored. Any concerns should be highlighted to the adult or children’s safeguarding leads and they should then seek advice from the CCG team.

• The Power of Attorney (POA) is a document that only comes into effect when the patient has lost capacity for specific decisions.
• A family member or relative will often seek POA when their loved one has lost their capacity so that they (the family member/relative) can then take over and make the best decisions on their loved one’s behalf.  
• As doctors we should always aim to treat patients in their best interests.   Hopefully, most of the time – family members will agree with what the doctor suggests.   
• However, if there is conflict regarding treatment between a dr and a family member who say they hold a POA for health…
  1. 1. 1. Firstly, the patient’s capacity needs to be assessed again in relation to the specific decision at the time.
        2. If the patient is found to lack capacity the POA then needs to be seen and also checked with the Office of the Public Guardian as these can be revoked so need to be current and accurate.
        3. Finally, if the conflict remains, please get in touch with Adult Safeguarding for further advice.   Never forget that as a doctor, you need to act in the best interests of the patient and sometimes that can be at variance with what the family wants.  

• GP lead: annual adult safeguarding update
• Other Drs: adult safe guarding training 3 yearly.
• Non-clinical staff: e-learning or presentation from GP lead using slides provided by the adult safeguarding lead.
• Other clinical staff: can attend 1 day courses provided by adult safeguarding team.

Employment decisions are not based on automated decision-making.