Forensic Gynaecology (2011)

Forensic Gynaecology (2011) This ATSM is designed to create departmental and regional leaders who can structure a successful multi-professional service to manage the victims of domestic violence and sexual assault. Section 1 covers the law and the basic competencies for the initial contact, management, examination, evidence collection and subsequent follow up. Trainees who have previously completed the Society of Apothecaries of London Diploma in Forensic and Clinical Aspects of Sexual Assault (DFCASA) will have prior experience of acquiring these skills. For section 1 the DFCASA may be used to supplement current evidence of ongoing training. Completion of the Diploma of the Faculty of Sexual and Reproductive Healthcare (DFSRH) prior to the ATSM is recommended but not mandatory. Training to child protection level 3 is required. This may be undertaken either prior to or during the ATSM The ATSM must be undertaken under the supervision of an identified preceptor who must be in a position to directly supervise and assess competency. In order to ensure exposure to the required case mix the unit must be of a sufficient size to ensure completion of the training. Once trained, individuals should: be clinically competent and confident in all aspects of domestic violence and forensic services be competent to lead the provision of domestic violence and forensic services in a unit of region work well as part of a multidisciplinary team be clinically competent in understanding police processes and know how the Police Criminal Evidence Act [1984] might impact on the process of forensic medical examination be competent and confident to write a statement which is an accurate account based on contemporaneous evidence be able to define and identify different types of injury by undertaking full examination be able to undertake and use clinical audit be able to write protocols and evidence based guidelines This ATSM carries a work intensity score of 2.0. 1

Section 1: Basic clinical competencies To understand the law as it relates to domestic violence and forensic services To understand how best to manage the initial contact To develop the skills needed to take a detailed forensic history, perform an appropriate examination, offer perform and archive the necessary investigations and arrange comprehensive aftercare. Knowledge criteria Clinical competency Professional skills and attitudes The law Training support Evidence/ Assessment Detailed understanding of: -Offences as outlined in the Sexual Offences Act 2003 Understand the different legal systems and laws relevant to country of practice and have an awareness of the countries (and laws) that the key local demographic represent Understand the differing roles of professional and expert witness Successful liaison with the police Attendance at specialist domestic violence courts Attend a pre-trial conference within the Criminal Prosecution Service Attendance at a sexual assault Court case Attendance at a domestic violence Court case Knowledge of the legal system and its structure. Experience of presenting in Court Practice confidentiality and appropriate information sharing. Prepare a statement from clinical records Sexual offences Act 2003 (HMSO website) Consent guidance and sample consent form (Faculty of Forensic and Legal Medicine- FFLM) Forensic/sexual assault Course Domestic Violence guidance (Home Office) The Mental Capacity Act (2005) Level 3 Child Protection Certificate Evidence of successful liaison with the police Team observation form Reflective learning: identify and explore case studies Record of Court room attendances Legal report writing based on clinical records Understand the laws of consent, confidentiality, Caldicott principles, the capacity to consent to treatment by under 16s (Fraser guidelines). 0-18 years guidance for all doctors (2007) GMC The capacity to consent to examination including effects of age, intoxication, special educational needs, mental illness, 2

Knowledge criteria Clinical competency Professional skills and attitudes non-english speakers. Training support Evidence/ Assessment Management of victims Understand types of violence to women and their presentation in the clinical setting. Link particular behaviours and circumstances to sexual assault and domestic violence Understand: - the causes of aggression - how power control works - how victims keep themselves safe Sesual exploitation in adolescents and young adults Sexual trafficking For victims of torture, understand their specific needs and how this relates to their management. Be familiar with the impact of drugs or alcohol, their effects of intoxification and withdrawal. Understand the role of SARCs The examination Identify domestic violence presenting in the clinical setting Use critique Identify and manage or refer any urgent health needs that should take priority over management of the sexual assault, taking account of optimum preservation of evidence. Take a thorough history and obtain consent for: Full or limited examination Full or limited investigations Establish whether consent is given for the information to be shared with relevant services. Apropriate referrals to SARCs Understand the wider health implications of incidents including the impact of: - acute injuries - sexual and reproductive health - mental health - changes in needs according to the time interval between incident and disclosure -follow up for health needs For victims declining involvement of other services - explain limitations of this option if decides to involve criminal justice system - inform of lack of guarantee of complete confidentiality (reports, child protection) Assisting and advising victims of sexual assault in the family planning setting FACT (FSRH) Visit a refuge Demonstrate familiarity with Be able to competently BASHH guideline on Demonstrate familiarity with National and local polices. Case-based discussion or case reviews Team observation form 3

Knowledge criteria Clinical competency Professional skills and attitudes Identify and record injuries accurately Understand the necessity to report both normal and abnormal findings Recognition evidence of female genital mutilation. Recognise past or new mental health concerns Understand how forensic evidence is collected, labelled and stored. Documentation forensic examination kits and the need to: -protect any evidence available for forensic processing - identify suitable location for examination - undertake appropriate medical and forensic examination guided by account of type and timing of incident - obtain appropriate forensic specimens if storage available - ensure appropriate labeling of specimens to maintain chain of evidence - perform pregnancy test if indicated identify and manage different types of cases, specific to rural and urban situations. With agreement of victim and having addressed any immediate health needs: -refer to appropriate service for on-going management of case For victims declining involvement of other services -obtain consent to forensic and medical examination as appropriate: Training support management of adult victims of sexual assault. Proforma for post pubertal female/male forensic sexual assault examination (Faculty of Forensic and Legal Medicine- FFLM) Sampling guidelines for perianal area, anal canal and rectum (Faculty of Forensic and Legal Medicine- FFLM) Guidance on Paediatric forensics Examinations in relation to possible child sexual abuse. Evidence/ Assessment Log book of cases Case based discussions Mini-CEX Good practice in: -note writing -records of examination findings -photo documentation - report writing for immigration authorities Clearly document history and examination may be used as evidence - to facilitate subsequent writing of legal reports if required. Discuss findings with victim Provide written (or translated/interpretable) information as appropriate. Anonymous prevalence survey Log of cases Case based discussions Audit of local documentation standards Ability to: - ensure capacity to consent to examination. - arrange examination in appropriate clinical environment - involve any other Audit of protocols for evidence collection (including photo documentation) 4

Knowledge criteria Clinical competency Professional skills and attitudes appropriate agencies - counsel fully regarding examination - ensure patient understands they can halt the examination at any point Report writing and documentation Training support Evidence/ Assessment Evidence Be aware of: the different types of evidence, injury and effects of timing on the evidence. Understand the relevance of samples according to timing of incident, how evidence is preserved and the chain of evidence. Be aware of the facilities for management of forensic samples outside the criminal justice system Undertake sensitive examination and maximise gathering of appropriate evidence. Manage any evidence appropriately. Ensure appropriate storage of notes and evidence. Log of cases Case based discussions 5

Knowledge criteria Clinical competency Professional skills and attitudes Discharge protocols Manage any identified health needs. Understand safe discharge protocols of victims. Understand the role of the support agencies. Including: -Family planning (emergency IUCD, TOP) -Genitourinary medicine, -General Practice -Social services - Domestic violence team -Counselling -Paediatricians Explain management recommendations and prophylaxis. Including, as necessary Postcoital contraception STI prophylaxis Genital infection Hepatitis B HIV Ensure clear follow up arrangements made, including other support agencies Ensure patient understanding of findings, implications and future management options. Ensure care pathways to provide HIV post-exposure prophylaxis and counseling are in place. Encourage involvement of GP and write summary letter if patient is in agreement. Discuss need for ongoing support and follow up. Ability to explore the possible physical or emotional sequelae of incident. Training support Evidence/ Assessment Log of cases Case based discussions 6

Section 2: Provision of the service To understand the organization, staffing structure and equipment needs of a forensic service Knowledge criteria Clinical competency Professional skills and attitudes Staff roles, responsibilities and pathways Training support Evidence/ Assessment Have detailed knowledge of the roles and responsibilities of all involved in the provision of care Have knowledge of public health and a specific awareness of the cultural demographic specific to the area of practice. Understand the management of victims who decline additional support and service involvement Ensure care pathways are in place for appropriate care Ensure teams are aware of recommended and safe discharge protocols of victims. Ensure colleagues are aware of how to manage cases of domestic violence and sexual exploitation safely and appropriately. Ensure colleagues are aware that colleagues they work with may be victims of domestic violence Be able to competently identify and allocate teams to different types of cases, specific to rural and urban situations. Be able to competently identify and refer to appropriate services according to health and forensic needs of the victim Observation and discussion with senior colleagues Role play Video scenarios Trainers course Case-based discussion or case reviews Team observation form Reflective learning: identify and explore case studies Reflective learning: written report to critique practise Logbook Equipment needs, organisation and allocation Understand the place of evidence kits within the service (urine testing kits and mouthwash) and within relevant departments. Understand the role for photo Identify those criteria that make premises suitable for delivering clinical care. Ensure systems are in place to protect any evidence available for forensic processing and manage any evidence appropriately. Ensure team members know of the availability and appropriate use of evidence kits (urine testing kits and mouthwash) Demonstrate familiarity with local guidelines and polices. Audit of protocols for evidence storage and collection (including photo documentation). 7

Knowledge criteria Clinical competency Professional skills and attitudes documentation of evidence. Ensure appropriate storage of notes and evidence. Training support Evidence/ Assessment 8

Section 3: Leadership of the service Learning outcomes: To understand how services are commissioned To understand the strategic organisation / staffing structure / equipment needs of a forensic service To be expert in managing cases and allocating staff appropriately To be proficient in writing evidence-based guidelines and performing audit relevant to the forensic service To be able to analyse and report on the forensic workload and statistics To understand the process for implementing and managing change effectively Knowledge criteria Clinical competence Professional skills and attitudes Training support Evidence / Assessment Commissioning and strategic organisation of the service Have knowledge of the processes and procedures involved in commissioning a service at a local and national level. Understand the organisation of staffing structures, equipment needs, and the role of translation and interpretation services. Participate in the co-ordination of the clinical running of a domestic violence and sexual assault service including - how to manage case load - how to allocate staff appropriately to the management of clinical cases - the role of forums Co-ordinate appropriately and communicate effectively all plans and decisions to team members Demonstrate understanding of how the service relates to colleagues, the police, patients, families and support services. Observation and discussion with senior colleagues. National enquiries and reports Attendance at domestic violence and sexual assault forums, guidelines groups, audit meetings. Understand how the service relates to colleagues, the police, patients, families and support services. Evidence based guidelines audit and service delivery Understand the role of guidelines audit (including the analysis of Perform clinical audit relevant to practise: define standard based on evidence Understand how local data collection informs service Provide new or revised evidence based guideline 9

Knowledge criteria Clinical competence Professional skills and attitudes Training support Evidence / Assessment workload) and how this influences practice. Understand the principles underlying evidence-based guidelines and audit and how they relate to domestic violence and sexual assault services. prepare project & collate data re-audit and close audit loop formulate policy implement change based on audit results Develop and implement a relevant clinical guideline provision. Understand the process for implementing change at a local level. Completed audit cycle Maintain domestic violence and sexual assault workload / statistics define purpose and scope identify and classify evidence formulate recommendations identify auditable standards introduce into practice 10

Section 4: Communication, team working and leadership skills Learning outcomes: Demonstrate effective communication with colleagues Demonstrate good working relationships with colleagues Demonstrate the ability to work in clinical teams and have the necessary leadership skills Knowledge criteria Clinical competence Professional skills and attitudes Communication Training support Evidence / Assessment Understand the principles of joint decision making Knowledge of good practice recommendations for breaking bad news Be able to communicate effectively both verbally and in writing with colleagues. Ability to break bad news appropriately and support distress Ability to communicate effectively with colleagues Observation of and discussion with multiprofessional teams Team Observation Team working Understand the roles and responsibilities of team members. Understand the contribution of mentoring and supervision. Be aware of the factors that influence and inhibit team development and the ways of improving team working including objective setting and planning motivation and demotivation organization respect Ability to communicate effectively with: junior medical staff senior medical staff midwifery staff patients & relatives obstetric anaesthetists neonatologists Demonstrate good working relationships with colleagues. Recognise the factors that influence and inhibit team development. Observation of and discussion with multiprofessional teams Team observation Leadership - qualities and behaviours Ability to work effectively within a Be able to recognise and positively influence a Leadership course Training the trainers Log of experience and competence 11

- styles - implementing change / change management multiprofessional team Participate in leading a clinical team Deal with difficult colleagues dysfunctional team Respect other s skills, knowledge and opinions course Reflective learning 12

Section 5: Training / Assessment / skills and drills Learning outcomes: To understand different methods of training and learning Demonstrate the ability to assess competencies / set objectives / deal with difficult learners To understand and use different methods of assessment, and feed back effectively To utilise and deliver skills training, scenario training and fire drills appropriately Knowledge criteria Clinical competence Professional skills and attitudes Training & Assessment Training support Evidence / Assessment Understand how to assess basic competencies. Understand how to structure a staff interview to identify: concerns and priorities expectations understanding and acceptance Participate in the assessment of basic competencies for different members of staff. Set individuals objectives and assess against these objectives Be able to deal with difficult learners Demonstrate the ability to use different assessment tools and give effect feed back. Demonstrate familiarity with the different methods of training and learning. Observation of and discussion with senior medical / midwifery staff Training the Trainers course Log of experience and competence Team observation Mini-CEX Case based discussions Develop an understanding of level of skills. - how to set objectives - how to support and facilitate training - understand different methods of adult learning - how to deal with difficult learners - assessment of team performance - feedback techniques e.g. Pendleton s rules Be proficient in the use of the various assessment tools. Formally assess members of the team using different assessment tools: Mini-CEX, case based discussions. Know which assessment methods to use depending on the training session objectives. Identify team deficiencies and strengths. 13

Skills and drills Understand the differences between skills training, scenario training and fire drills. Know when to use these methods, how to set up, deliver and assess their effectiveness. Lead training sessions, drills and role plays set up & running of skills training set up and running of scenario training set up and running of fire drills Participate in the setting up and running of clinical skills training, scenario training and fire drills. Log of experience and training sessions 14

Section 6: Clinical governance and risk management Learning outcome: Understand and demonstrate appropriate knowledge and skills in relation to clinical governance, risk management and revalidation Knowledge criteria Clinical competence Professional skills and attitudes Training support Evidence / Assessment Clinical Governance - organizational framework at local, commissioning bodies and national levels - standards e.g. NSF, NICE, RCOG guidelines - clinical effectiveness - principles of evidence based practice - grades of recommendation - guidelines and integrated care pathways formulation advantages and disadvantages - clinical audit - patient / user involvement - types of clinical trial/evidence classification Participate in risk management investigate a critical incident by reviewing the case and taking appropriate statements write a time line perform a root cause analysis assess risk formulate recommendations write a response/report feed back to staff & families Participate in the investigation and respond to a complaint (this may be an historical example for CBD provided by trainer) Demonstrate: - Ability to practice evidence based medicine - Ability to report and investigate a critical incident - Ability to respond to a complaint in a focused and constructive manner. - Ability to perform appraisal Observation of and discussion with senior governance team. Attendance at risk management meetings DoH, RCOG and Trust publications An Organisation with a Memory (DoH 2000) NPSA Website Log of experience and competence Case based discussions Risk management - incidents/near miss reporting - methods of analysing incidents including root cause analysis - complaints management - litigation and claims management Participate in the performance of staff appraisal Human Error: models and management. Reason, BMJ 2000; 320, 768-770 15

Appraisal and revalidation - principles - process 16

Skill Competence Level Level 1 Level 2 Level 3 Date Signature Date Signature Date Signature Legal and Clinical competencies Demonstrate effective legal report writing Prepare statements Manage initial contact Identify domestic violence presenting in the clinical setting Advise victim on options for management of sexual offences outside criminal justice system Have knowledge of the rights and means of dealing with victims declining involvement of other services Obtain consent Clearly document history and examination Appropriate collection, labelling and storage of 17

Skill Competence Level Level 1 Level 2 Level 3 Date Signature Date Signature Date Signature evidence Appropriately manage any urgent health needs that should take priority over management of the sexual assault, taking account of optimum preservation of evidence. Ensure appropriate post-coital treatment for genital infection, Hepatitis B and HIV. Ensure appropriate care pathways to provide HIV postexposure prophylaxis and counselling are in place Ensure appropriate follow-up and counselling as guided by account of incident and examination findings Provision of the service Ensure appropriate, structured care pathways are in place Demonstrate the ability to ensure that evidence kits (urine testing kits and mouthwash)are used 18

Skill Competence Level Level 1 Level 2 Level 3 Date Signature Date Signature Date Signature appropriately in relevant departments Demonstrate the ability to ensure that suitable premises are available within departments Identify any service needs Demonstrate the ability to ensure that local and national agency information is available to victims. Leadership of the service Ensure colleagues are aware of how to manage cases of domestic violence safely and appropriately Allocate staff appropriately Coordinate daily running of the service Effective use of clinical audit Implementation of clinical guidelines Communication, team-working and leadership skills 19

Skill Competence Level Level 1 Level 2 Level 3 Date Signature Date Signature Date Signature Be able to recognise and positively influence a dysfunctional team Communicate effectively with colleagues Work well within and lead a multidisciplinary team Training, assessment, skills and drills Assess basic competencies Set staff training objectives Assess staff progress against objectives Deal with difficult learners Use multisource feedback effectively Use Mini-CEX effectively Perform case-based discussions Give feedback appropriately Set up and run skills training Set up and run scenario training base training 20

Skill Competence Level Level 1 Level 2 Level 3 Date Signature Date Signature Date Signature Clinical Governance and risk management Perform a risk management case review Ability to respond constructively to a complaint Perform appraisal Completed clinical audit cycle Write or revise clinical guideline Training Courses or sessions Title Child Protection Level 3 Sexual Assault/Domestic Violence/Rape course Attendance in Court Signature of preceptor Date 21

Attendance at a multi-agency public protection arrangements (MAPPA) meeting Attendance at a domestic violence forum Attendance at a serious case review Optional Society of Apothecaries of London Diploma in Forensic and Clinical Aspects of Sexual Assault (DFCASA) Diploma of the Faculty of Sexual and Reproductive healthcare (DFSRH) 22

Authorisation of Signatures please print your name and sign below Name (please print) Signature 23