Supporting adults who present having experienced rape or sexual assault - draft clinical pathway: consultation analysis

Annexe 1: Focus group raw data

ID 40

• Feels more like a manual than a pathway –there’s nothing to actually follow
• Query hep B vaccine: usually offered only after a risk assessment
• 7.1.3.4: no evidence base, low national prevalence, so is the vaccination appropriate?
• Who benefits from the proforma—the victim or the quality improvement/data collectors?
• The form is too long and feels like a data-mining tool. It’s not trauma-informed to subject victims to a lengthy document with lots of repetition
• Feedback from SOLOs is that it’s too big, not person-centred and asks for a lot of information which isn’t also relevant. The form in general is prescriptive, with lots of questions and checklists, maybe missing something more valuable such as overall presentation, demeanour, natural conversation
• The doctor is there to gather evidence for court
• From a public health perspective, all of that data collected would be rich information
• Who has ownership of data?
• Doctors not happy about documentation to be handed over to the police—their opinion might change with reflection, and a legal report might be different to their views as noted in the proforma. Police usually meet with doctors after the examination for a verbal update
• The form doesn’t flow, jumps around from one section to the next from start to finish. Our doctors use the FFLM proforma, completed after the examination. Notes are used as an aide memoir
• Consent section: having signed consent feels like a legal disclaimer. For any other intimate examination, verbal consent would be enough without the person having to sign a form. The time would be better spent getting informed consent and chatting to the person to ensure they understood the process and what it means
• Consent to share data, more about GDPR than informed consent to examination
• Placement of some questions feels wrong: self-harm risk, thoughts and plans, should be captured with ‘recent and ongoing mental health issues’
• A lot of question to be asking a person at that time. The person is so traumatised and can’t always retain information. It’s too much for someone to take in
• Qs about drug use should be on p. 4 to follow mental state examination
• Data captured on referral form to Tayside sexual health---no point putting it in the proforma, as it wouldn’t show up for 2 weeks.
• It feels as though the national form informed the indicators rather than the other way around
• Q on demeanour needs to be nearer the front
• Positive about the SPA form at the back
• Need to think about who asks what and when
• Is the form mandatory?
• Child protection—would this question really be asked during the forensic examination?
• Most info on the form will be given to the doctors from the SOLO, most of the form is only relevant for self-referral process. Would it make sense for the police to fill in their part rather than the FME doing it?
• It’s not up to the document itself to be person-centred but the clinicians delivering the service
• Dispute whether the IUD is the most effective form of emergency contraception
• Key points on p. 25: the forensic examination should be first—before what? Healthcare needs? Full statement should be taken first so the examination doesn’t just swab everything—doing more than is necessary is re-traumatising and not person-centred. The person might have to go back again for more swabs—this is raised by Rape Crisis as traumatic for survivors.
• Re: corroboration, no reason for (male) nurse to be down the ‘business end’ of the examination—their role is to be with the survivor, reassuring them and talking them through the process, not watching the examination and corroborating bag numbers. Can’t practice trauma-informed care and corroborate at the same time.
• 7.3: presenting forensic evidence. Consider the role of Rape Crisis
• Re: consultation paper. Should be able to annotate the document, quicker and easier than answering the questions.

ID 41

• We more or less do the pathway, apart from self-referral
• It’s very difficult for the north and almost impossible for [Islands] to implement the pathway. It doesn’t take into account the skills updates, skills maintenance and facilities needed for such few people
• We can’t recruit—pathway is in place but can’t staff it [here] difficulty getting forensic medical examiners and nurse chaperones trained up
• It’s great to see the pathway there in black and white, and it’s good that there’s so much momentum behind change and improvement
• The pathway is obstructive in rural areas—used to be that local GPs assisted police doctors, now they’re concerned about being called to court and are not comfortable about giving evidence. Would like to see the Crown being more proactive, and giving more training and reassurance to new forensic examiners in providing evidence. This is people’s professions and they don’t want to face an adversarial system where they are hauled over coals—they don’t see it in the same way as people such as the police or FMEs from [another service] who are in court all the time
• GPs don’t see themselves as experienced after they’ve done the training and there are so few cases to gain experience. Don’t want to be asked their experience in a witness box. Why would they put themselves through being in court—most of them run a mile? The crown should be supporting FMEs at a much earlier point
• The national form and the pathway document conflict. The form is in the wrong order and there’s no logical flow, you need to jump backwards and forwards when filling it in
• The very first page should be where the consent form is, not on p. 16
• Doctors are logical thinkers, the form is not logical. Not all examinations go the same way, and while we’re trying to be person-centred the length of the form extends the examination. The form is not helpful for new recruits or examiners either, as many would use it as a prompt for the examination process, but it doesn’t follow a logical order, or the order of an examination
• We don’t need to be putting sample/log numbers in bags, or details of what was prescribed.
• Is it really necessary to record the SOLO’s age and date of birth?
• Divide into male/female forms?
• If you’re seeing someone, the explanation of what the examination is and the consent comes first, you need to tell them that what they say might be used in court.
• Simple things—like it’s hard to find where to put the person’s name
• The form that goes to the labs is duplicated by the police—the police re-key the data from production and enter it on an evidence label. So why are we putting bag numbers too?
• The statement is taken officially by the police, often the FME takes the police statement. The FME asking the person for details again is asking them to re-tell their story, just to record it on the form.
• The pathway has issues with psychology, and there are a lack of services for people to co-ordinate. There is 1 psychologist on Shetland and he has a waiting list of 18 months, so access to support is difficult. Third sector specialist organisations might have a 6 month waiting list, and the rape centre tries to see people very quickly initially, but then can’t see them again for 6 months. This isn’t person-centred either—it brings it all back if they are contacted out of the blue and go for counselling 6 months later
• Social care/social support is not available.
• Section 1.2, consider the wording: before legislation, isn’t ‘forensic medical’ with the police not the NHS?
• 7.1.1 some GPs are conscientious objectors to emergency contraception, this isn’t mentioned and no advice is given
• P. 5 Appropriate Adult present might delay an examination, and it’s hard to get engagement with social services
• It’s difficult to strike a balance between working towards a service where the examination is close to where people are, or flying them to a centre of excellence and them having a specialist examination. There’s no one size fits all—people should be given a choice. I’m keen for a pathway where clinicians came up, but people should still have the choice to go off island and be anonymous. This shouldn’t be on a chartered transport, but emergency transport in the same way that someone would be transported by helicopter to the mainland for medical treatment.
• Doctors in rural areas find it hard to gain and maintain skills where there are so few cases, and there’s a question of professional competency. No clinicians lead or teach. Can be traumatised from doing the examinations when they’ve only had the training in theory
• Huge barriers to people coming forward on the islands
• Re: forensics, evidence doesn’t prove or disprove consent. Most of the time, the case hinges on the issue of consent and not the presence of injuries
• P. 24 reference to early evidence kits isn’t adequate. This is critical and it’s underlined in the pathway and not the key points. Early evidence might swing a court cases, and it needs to be noted that mouth swabs etc. can be taken. Also to clarify who has responsibly for this—can the police do it?
• FFLM guidelines for taking swabs are updated every six months, so the date should not be stated in the pathway. Significant revisions are in the new guidance, coming out soon
• The form needs consideration that examinations are not undertaken in ideal settings—we’re at risk of losing people by asking someone so many questions when all they want to do is go home. It’s not the FME’s job to take all of these details, and people can distracted by the forms. It gets in the way of making a human connection and providing that trauma-informed care. The form is burdensome and makes it worse, and the doctor flipping back and forth doesn’t inspire confidence.
• Maybe thinking about having a separate form for self-referral and reporting? Or it needs to be more coherent
• I’m not sure I’m happy with giving my opinions during the examination, as the form will be handed straight to the police and then I have to defend it in court. Need time to think and review, reduction in work might not justify the reduction in quality. Verbal update given to the police, and the report should be written on reflection in the cold light of day.
• GDPR consent needed, especially with sharing of information and auditing. Also, is there a process by which the consent to sharing data can be withdrawn?
• The information provided in the pathway giving the guidance and research is good, especially for new recruits.
• We treat suspects differently—we’re improving services for victims so you have a situation where the women or the complainant is in the health centre up the road and having a trauma-informed focus, and someone who is not proved guilty will be in a cell without support, healthcare or understanding. Sometimes they are both young people, or vulnerable, and when no evidence is found to charge the person they are left without any access to services, while the complainant has access to the pathway. That’s a major health inequality—especially in cases where there was no evidence or likelihood that the suspect would ever be charged.

ID 42

• Who is the contact for the pathway—the doctors or the SOLO? It’s been a challenge getting doctors involved: assumption that most of the service is done by the SOLO
• In relation to the preference of gender: our doctors and new nurse chaperones are mostly female, so what happens if a male requests a male FME? Need to emphasise that it’s not an equal choice
• We feel as though the islands aren’t listened to: promises are easy to make, need resourcing for island and remote areas. We’re smaller boards, which comes with limited resources, yet have the same governance and therefore the same expectations. We have additional costs when it comes to covering small teams, or providing extra training and travel for people
• We have a low prevalence—there are around 5 reports per yet, but we are expected to have doctors/nurses on call 24 hours
• We’re developing a brand new service, so we are relying on the pathway group to be providing evidence and information. We assume it’s correct
• People are unwilling to come forward because they think if they wait more than a week they won’t be put on a plane. Forensics on the island might change this and increase the number of reports. People know about the new services and the standards but are misinformed—are people going to be expecting an FME within 3 hours, as it would be elsewhere? Are we failing people because of misinformation or expectations?
• Trauma-informed care is essential to the pathway, but we can’t deliver it. There has been a refusal from anyone to come on island and deliver the training to us---they want us to go to them and will cover the costs, but it’s challenging logistics and huge problems with covering rotas with so many people off island getting the training. Money isn’t enough to solve this—we need people to come to us
• GPs/A&E provide sexual health services. We will link with local sexual health clinic, but it’s a private practice. Need to think more about the practicalities of the pathway—mostly out of hours, we have difficulties
• Referrals can be done by the new nurse chaperones Education Scotland, but we don’t have people to refer them to. SOLO is responsible for the follow-up care in the pathway e.g. to social work. Do the police have the skills to make extensive referrals?
• What about self-referral? It’s not clear in the pathway how this will work.
• In our community, people want to limit the number of people who know. All those referrals are not person-centred here, but we agree that people should have that choice. In the immediate aftermath of an assault, people might find it difficult to make decisions. Is there capacity for follow-up?We are considering the ongoing role of Rape Crisis, including information on the national helpline for more anonymity
• For referrals, the police responsibility needs to balance, so that responsibility does not overwrite the pathway—are people doing things twice?
• Whose responsibility is it to get people home? Especially on the island where it can be dark and bad weather and there is no good public transport. The pathway isn’t clear on these things—do we let people just walk out of the door? But is it traumatic to put them in a hotel by themselves with limited support?
• Clothing and bedding could be given. We’ve heard report from survivors about bedding being taken from their homes as a crime scene and they return with no bedding
• For long-term follow-up, how is that governed? Our service will be geared towards forensics, mental healthcare isn’t part of immediate services nor the responsibility of the forensic examiner. Who is responsible for acting as an outreach worker? Need consent, but probably the GP will act in this role, and there’s ongoing role of local Rape Crisis service

ID 43

• Few referrals to and from statutory agencies. Few people report and if they do report, it’s a long while after. Huge barriers to reporting, from the way that the community reacts to people who report. Some places […] have no police presence at all.
• General feedback from survivors is that the police and healthcare practitioners are not trauma-informed. Information can be over-shared with people, leading to family members and other people being traumatised by being told details they don’t need to know. People are sometimes told the complexities of organising arrangements. People only need to know the final arrangement—they get themselves ready for one arrangement, then it changes, which is confusing and can be traumatising (i.e. they think they have to go on a public flight and be off island for three days, so need to think of reasons)
• Survivors want the number of people on the island who know what happened to be limited, many people have connections e.g. the NHS admin support booking flights, or the SOLO.
• Statutory services don’t refer people to Rape Crisis services. Most people hear about us from friends and family, but we have been involved in the design of the new comfort room in the new hospitals’ forensic suite, so are thinking of new ways of approaching people.
• Information given to survivors needs to be in a way they want—large leaflets aren’t what people want, as it’s not subtle. Survivors prefer information in pocket-sized cards that fold out, containing information about support but also grounding techniques and practical things. We provide an ‘emotional first aid kit’ in the forensic suite, containing toiletries, nice smelliest, bubbles, information, a notebook etc. It is designed for people to build on at home.
• As a matter of people’s human rights, this pathway should be implemented everywhere. There’s no reason not to aim for it—it’s aspirational, but important
• Forensics on the island might be good for changing people’s behaviours, if they think that they might get caught. With the self-referral legislation and forensics, we might see an increase in reporting. What we see now is just the tip of the iceberg—it’s not the case that this stuff doesn’t happen [here].

ID 44

• This is similar to the pathway used in my area. It is 24 hours but we still send people home during the night. Sometimes there is a doctor but no nurses or vice versa.
• [One service] staff excellent.They are now asking for more follow up in terms of aftercare – a bit disconnected at times.FMEs are reluctant at times to carry out forensics at times.There may only be a male on duty (general agreement to that).
• We only have male FMEs and night service is ok.Nurses available 24/7 and they facilitate.
• If you contact an FME during the day and it is nearing the end of their shift they don’t want to travel too far.Sometimes you have to wait for the next shift to start before you get someone.
• If we speak to someone to take a statement and they haven’t been able to wash and are feeling shattered, we do not get the best from them and we are not able to do our job properly.
• If you come in to a live enquiry, you try to be first in the queue at [one service] as you don’t want to miss a slot so you get no chance to digest the enquiry.
• We have had a few issues with [one service] staff.We got a complaint from a woman who was made to sit and wait for an hour after her medical while the building was forensically cleaned.The FME left and nurse could not be left on her own.Doctor refused to prescribe the morning after pill to a 15 year old because they did not believe in it.The mum had to go the next morning and ask for it pretending it was for her.
• People are given the message go home, don’t wash and we will see when we can get you a medical.A medical can take 2 hours.[The service] is a good facility but it only has one examination room and covers a large area – 5 police divisions.
• In the past we had a suite at division which worked better.Police carried out the SOLO role and never had any issues getting a FME – easier and quicker as you can take the statement while waiting.It would be better if [the service] had somewhere you could start taking a statement.
• When Baird Street went it impacted everywhere.[One service] are looking to move but no decision or timescale.If they move to a better facility it might alleviate some of the issues.
• Forth Valley are getting a new facility – not new build but redesign of existing building.
• It is not workable if no medical facilities.FME could not be on their own.
• One woman would not go to [the forensic facility] unless she could take her 3 young children.She had no one to take them.Police would need to babysit them in the room next door to the examination being done.Although you do not want to take children there normally, new facilities should have provision for kids.
• Forensically cleaning was an issue.Who was responsible and who would do it.
• Need to have everything in one place.Archway repurposed in other facilities would be good.Need to feed these comments back to them.
• [Our local area are] looking at a facility.There is a place in [the hospital] which is good.NHS went through procurement to get this and it worked well.They got equipment, including a VRI suite.
• The suite [in our local] police station was convenient for police but not victim focused.
• Leaving [one service] is not good.You walk out with production bags to put into the car and people know something is up, and although we have had no reports, it can’t be person-centred to be so exposed.
• We had a complaint from someone about that saying that you had to press a buzzer and wait, you were standing there with two police officers and a police car.They felt the whole process was poor and thought everyone would know why they were there because of the production bags.
• We usually take statements at police stations because people do not want to do it at home.
• We had an ex-police house which was down a lane and no one would know it was there.There was couches, a medical room, one for VRI and a room for children.It was very discreet.
• Everyone agreed discretion was most important.
• [Our local service] manage it.There is no cross over.You don’t see the next person.Location and facilities need to be looked at as the need has increased greatly in the last few years.
• The pathway is very good.There are FME issues.It is not good if you phone at 12 and don’t get someone until 7.
• It is more the availability of the doctors than the facilities.
• We phone the nurses hub and you get different information.There is a break in communication and FMEs can change.
• We phone the control room and ask who is on call, then phone the service and repeat the information.All very repetitive.
• I think the section on additional services is very good.
• [One service] ask questions and information is shared so that is good.
• [One service] ask if they have somewhere to go back to and the nurse does this too.
• Nurses share information that they have been told which is good.
• FME do sometimes but generally my opinion is that information is not shared.There is a different attitude.
• Pathway would work if the facilities had the right staff.
• Nurse on their own, can’t be there by themselves locking up at night so it falls down.Not victim centred.
• Not much difference between Out of Hours in my area.It is done in police headquarters so not an issue with security.
• [Here] it is done locally.We have on call FMEs and find it easier to get a hold of them out of hours.We have a medical suite, VRI and family room so no real issues.
• We don’t use the form.[The service] fill it out.
• FME complete this.
• I think it is better to standardise this.
• It is quite lengthy, 50 odd pages.
• It looks similar to what we have.
• FGM has been added.It was not in the last form.
• At [one service] police go into the doctor with the complainer and give them information a summary of what they have been told, they fill it in on the form and complete the rest as part of the examination.
• I would say the police require it to be straightforward; accurately report of what police have told them verbally; breakdown of the injuries, and needs to have doctor and nurses’ statements attached for court.
• It all comes in a pack.
• Police get an abbreviated report at the start and the full report comes later.
• The conclusion needs to be concise of what the findings of the exam are. Some say injuries consistent with the events given by the complainer.
• There needs to be enough information that the injury could be caused by something else.
• If the new form is lengthy, the longer the person is sitting waiting which in turn means less people can be seen.
• Medical terms and the hand writing can make it difficult to understand and read.
• Electronic form would be better but can take longer depending on the person’s typing abilities.
• If it goes to court, can they understand hand writing? Does it look very professional?
• Police can wait 1-2 days for a report in some areas.
• In other areas – a longer wait but they are given a verbal report.
• 6 months down the line still trying to get a statement from FME that has not been provided with report.
• We get the FME’s email addresses and then police compile statement and email to FME who approves, signs and returns.
• The form covers all the points and might help as a reminder to the FME to ask the questions. If shared with other agencies then that would improve consistency.
• Repetition for the person is a concern. They tell the police, then tell the FME. Could FME just ask if what they told the police is correct?
• So much repetition sometimes 3 or 4 times. It can’t be helpful.
• Add “Do you want to tell me anything that you have not told the police?”
• The whole process for the victim needs to be improved. VRI for victim statement. They can sit for 6 hours.
• What is initially disclosed is not always what happens. Repeating it gives a better idea of that. If it changes again with the doctor then we can be aware of that.
• There are people who are repeat complainers.[One service] after 3 medicals make a referral through MARAC to Social Work.
• Difficult to cover these people. Only through the investigative process can we clarify this. We need statement, CCTV etc. to do this.
• Should be able to feed the result into the pathway and other agencies
• I charged someone recently with wasting police time. She wanted to go for a medical but it was a complete fabrication.
• A female reported to a doctor at hospital and they said she should go to the police. [One service] said no to a medical, she needed a psychiatrist.[The service] has a dedicated person who they can link to – a psychiatric service. Sometimes police are in the middle if medical services disagree.
• Significant amount of mental health issues being dealt with. We need to look at capacity and appropriate adult. Need to look at health records. We are flying blind for a lot of the time. It can be a waste of police time as they investigate.
• Forensic cleaning for suspects is not as rigorous.
• Some suspects are not charged and have not raped.
• It is right that they are offered support. Had an allegation of rape and he had not done it. His mental health was poor and he needed support. He was badly affected by it.
• With the Human Rights Act we need to do it – get ahead of it.
• Biggest headache is that we need to get warrants all the time to get a suspect’s medical done. It is very time wasting.
• People usually agree if you ask them as say you will get a warrant if they refuse.The idea of obstructing a police enquiry is alien to some suspects.
• The forensic examination is often key to the case.
• There should be a focus on pathway.The process is not as robust for accused as victim.It is a human right.
• Can I ask if there is a way of using FMEs from other areas?We had one refuse to come to another area as it was not in their local authority.The suspect was in custody and we had to release him because of the law and then rearrested when we had a FME available by which time he had washed.

ID 45

• The document is very long and tends to lose sight of its role. Is it targeting who it is supposed to be?Who is it aimed at—this isn’t clear
• If this is a clinical pathway, then the people reading this will know the job anyway (e.g. forensic guidance).
• The document might act as a good point of reference for nominated leads
• When using the document, I skipped to the parts most relevant to me.
• There is so much information on sexual assault in general and on the legal side e.g. the need for corroborating witnesses. Do we need all of this? Who is it aimed at?
• As an educational document it is useful, and if I hadn’t done t [the forensic exam process] before, then the document would be useful. There is a lot of guidance—wouldn’t this be covered in the NSS guidelinesand National Education Scotland training? Are we better to link to existing documents (e.g. BASSH guidelines) and keep the pathway document shorter?
• The pathway is more like a manual. I think it would also be useful to standardise services, and useful in setting up localised services.
• Goes along with the HIS standards
• The diagram on p. 24 is useful—it flows and makes sense. Most of the pathway would be up to individuals, using common sense, on a case-by-case basis.
• Section 7.1 ‘unprotected sex’ should be rephrased as ‘sexual assault’ or ‘a risk’. Anxious about the phrasing to ‘consider’ prophylactic antibiotics—this is something we would want to avoid. But wouldn’t clinicians know that anyway? Clear links needed for emergency contraception evidence from FSRH (the link from p. 26). For STIs, need a link to current guidelines—if the link is there, do we need the guidelines too? Maybe think how this can all be condensed.
• Section 9.2 disclosure of records—wouldn’t the national proforma be separate anyway?
• We suggest that a form could be emailed or given to someone which would include: things you had done, things you need to do, names of officers/support workers, other agencies that have been identified as being useful (minimal information, just contact details or agencies or national/local helpline). People could then give this to the GP/agencies to save explaining what they have been through, and so that they know about what the forensic examination does, what treatment/vaccinations they were given etc. Is this what is meant by the summary of attendance? On p.45 of the pathway, the list of information to be given included services contacted, numbers to phone, care of injuries etc.—this isn’t reflected in the form and seems to be lost in the document, when we feel that it is important
• The information and follow-up section is not with the section on psychosocial risk—you need to look for each section, when the psychological/wellbeing components should be put together. Also need to link follow-up care to HIS standards. Needs one singular chapter on immediate and long-term follow-up, separate from the forensic examination section.
• 7.6.1 Question the use of the phrase ‘should the need arise’—how do we know? The section on support to attend is important but also lost within the document
• p. 34-35 should be included in 7.6
• 7.2.3 The document needs to highlight the relevant guidelines and pathways. We do the GP summary and psyche risk assessment before the forensic medical examination—you need to know the assessment and address capacity etc. before the examination.
• p. 59 Chaperones cannot corroborate—this is the role of the nurses. Nurses are part chaperone and can corroborate & attend court.
• p. 60 corroborating witnesses—highlight that chaperones are not an option and cannot corroborate evidence. Clear link to the legal section—not explicit what section 9 is. For clarification, link to FFLM and training for role definition of forensic nurses
• Should there be something in the pathway on regional modelling pf services? Maybe consider updating the service model/ethos section in line with progress in this area.
• If this is a larger manual it might also be useful to add in a section about how other aspects of the taskforce e.g. legislation or service design link together.
• Blank pages are needed between the sections of the forms if they are to be sent different places
• The forensic exam section was amended on our service form so that it started on page 1, we found this necessary if going to the police
• Suggest we rename the first (blue) section as ‘confidential medical/clinical/health assessment’ and the second as the ‘forensic medical documentation’.
• We tested the form in training—candidates spent a lot of time toing and froing constantly.
• Use of CHI number—issues with confidentiality, and also worth remembering that not everyone has one
• Tick-box for consent form attached, why is it in clinical notes? Where is the consent form?
• Re: list of vulnerabilities. Homelessness/prostitution is not recorded, which we see often in our service. What about trafficking, or whether they are looked after/accommodated, or have refugee status? Is neurological condition a vulnerability? Normally you would write down after talking to them what you believe their vulnerabilities are, so why is there a list? Is this used to match to a dataset? The list is not all inclusive and does not reflect practice
• The location of incident is usually: their home/suspect’s home, other home, and outdoors. Why the extensive list is needed—is it up to date? We think that information such as the location of incident is better being obtained by the police. The question could be leading, especially for self-referral. We’re not statement-takers, we would usually just ask what happened and where.
• In PESE section, the section on guidelines is additional and doesn’t need to be there
• The form asks who people have disclosed to, but it would be helpful is it also asked whether or not the people they have disclosed to are supportive or helpful/might be harmful
• At the end of the blue section, the list of information given needs to be up to date. The handbook is no longer in print, and we don’t yet know what will be in its place.
• In the forensic examination section why is clinician detail needed? I would just write ‘see statement’.
• It would be useful to note the rank/division and contact details of the SOLO rather than their date of birth etc. Need to be able to contact them and know who they are
• The gender of examiner request met/offered should not be part of the forensic exam—this is done by police before the person gets to the examination, and we wouldn’t necessarily know. It’s not meaningful to ask in the examination ‘is it okay if I am a woman/man’
• Maybe add in office briefing (completed by the police)—briefing needs to be before the examination
• Length of fingernails is recorded, but need to add in whether fingernails are damaged/broken as this is forensically important
• Why is ‘disability’ in the body survey?
• Hymen question should be about whether the hymen is present or not rather than tissue/remnants— some myths exist about the hymen and sexual assault which we should not enforce
• Add in circumcision in male examination
• p. 23 Intimate images are only taken by a clinician using a colposcope. Suggest use of the term NHS photographer or clinical photographer
• p. 24 Suggest the wording be changed to ‘summary of findings & professional opinion’—no need for the term ‘lead’ when the examinations are not joint
• p. 26 Suggest the term ‘guardian’ be changed to health/welfare power of attorney
• Details of incident given to the police—what about self-referral?
• Name of assailant does not appear on the form, or any suspect details (e.g. if the person is known)
• Terminology for use of the term ‘complainant’ in the context of self-referrals
• SPA support form—questions about previous sexual intercourse does not specify if this is the suspect or not. This question comes across as quite judgemental, and FMEs need to make sure that the person knows this is to eliminate any consensual intercourse partners from the investigation. There is a stray asterix in place on the form— maybe use it to add in necessity for explanation?
• p. 33 diaphragms are not use often, no provision for mooncups etc. Suggest a generic term such as sanitary protection or other devices
• p. 34 what is the evidence bag number for? Contamination, or control testing? It would be good to get clarity from SPA on this
• The mouth rinse is not intended for gargling, but rather to collect evidence between teeth/braces. Suggest wording changed to remove ‘gargle’
• p. 40 Toxicology for 1 urine sample is incorrect—suggest it be changed to < 72 hours
• Need to explain abbreviations (this also relates to the pathway) for terms such as VIPER

ID 46

• Might get examined by a male doctor and/or by someone who isn’t trained properly
• Not being believed
• Blamed
• Lots of people being in the room
• Worried about presenting at A&E and them not being able to understand
• Good that you don’t have to involve the police in some services
• 24 hours (query regarding whether can access services outside office hours without a referral?)
• A pathway that doesn’t involve the police makes it more open to people who don’t want to report
• Some people don’t access medical support as don’t want to report and are worried they would be made to or the medical staff would report without their consent.
• May have to travel far to access services
• Waiting to access archway if not accessible overnight or doesn’t want to be examined by a man – don’t want to wait until the next day – challenges of not washing - someone said they wished there was somewhere nice to wait until the next day
• The forensic examination is often described as the worst part – not knowing what to expect, not knowing what will happen or when – this can be scary
• Have people who contact us accessed healthcare or forensics?
• Yes – often if referrals from the police
• In general less so if have contacted the helpline without a referral
• Someone who went to A&E had a nurse contact the police without her consent.
• Apprehensions about accessing healthcare can limit survivors getting help – some people may not get the help they need as a result.
• If there are options of accessing forensics and healthcare without reporting it can help people with accessing healthcare.
• If self-referring – what else are barriers for people accessing?
• Initial responses – if someone gets a positive response and still feels they have choice and control then it will greatly improve people’s experiences.
• Trauma informed
• What does trauma informed look like? – addressing the power imbalance. Professionals having an awareness of how they come across. Ensuring survivors maintain control.
• The questions are asked and the way that they are asked them. EG. Police asking questions but not explaining why. The speed of how they ask them an impact as can be hard to take things in when experienced trauma.
• Less of a focus on evidence gathering. For example, being asked about how much they were drinking can make someone feel like they’re being blamed for drinking. No explanation or context about why the question is being asked.
• Environment very important – warm, nice, age appropriate, something to eat, something to drink
• If clothes may be taken away or the survivor doesn’t want to wear them home – having clothes in different sizes for people to change in to.
• Important that people know that the facilities are there – the information is out there – for example info at GPs surgeries etc. Not just something people find out about once something bad has happened.
• Important to have information leaflets to take away – hard to take info in at the time so useful to have info to take away.
• Support contacts to access afterwards.
• Knowing what’s going to happen next – if there’s a next step knowing what this is. This is often something we get asked as survivors don’t always know.
• Useful for helpline workers to have info of the pathway to support survivors in understanding what to expect and what’s happening.
• It’s about power & control, knowledge.
• What else is important for a service?
• That the staff are all trained about rape and sexual violence – impact, gendered analysis of sexual violence
• A measured response by staff – not being shocked by what they hear
• Staff understanding prevalence – the high levels of experience of sexual violence, how this may impact on how people access and experience health services in general (for example, being aware when you’re doing a smear test that someone may have experienced sexual violence and they may not have disclosed this to you – or anyone)
• How do people access archway? A lot of people don’t know about it, most of the people we hear of who access [one service] are via police direct referrals. Low awareness that the service exists.
• Consistency of experience – in terms of members of staff that people see.
• GP is a big source of knowledge about different services, this knowledge can be quite patchy. Sometimes distrust from health professionals about non-statutory services?
• Often survivors don’t know what will happen after – sometimes it may have been said but the individual couldn’t take it in at the time. People don’t know what to expect.
• If people don’t report they can fall through a gap. If report to police can find out about what supports are available.
• If people do report they can be waiting a long time before they even find out if the case is going to trial. A lot of waiting in the system.
• In terms of knowledge of other services, follow up – what do people know?
• Survivors can have a lot of related issues that are linked to their experience of sexual violence but this isn’t immediately obvious. For example, can be impact on home, employment, family etc. It can be quite bitty in terms of support. Being able to find holistic advice about a range of services.
• Often the professionals don’t know what survivors can access. Example of Police officer contacting us as they were concerned about a young survivor being housed in a hotel in town and didn’t feel it was safe for her.
• Pathway – should include that the professional should ensure somewhere safe to go to – unrealistic to find somewhere – emergency housing not always appropriate – how can we expect professionals to meet this expectation from the pathway without changes to housing services / emergency accommodation?
• Big problem with waiting lists – more or less all services have long waiting lists.
• A pathway will only work with appropriate funding to support and develop it.
• One stop shop model??
• Difficult if there’s a one stop model if all the services involved have long waiting lists.
• People all in one place, well resourced, trauma informed, gendered analysis, continuity of care.
• Not having to retell your story lots of different times (unless you want to).
• One person who can guide you through the service.
• Someone who’s accountable. Named person. To prevent there always being blame on other services if something doesn’t work. Really important. Consistency. This person doesn’t need to be from within statutory sector – could be someone outwith but appropriately trained (example given of veterans services where this happens. Also the Link Worker for people newly diagnosed with dementia).
• Should be close to home – not flying people across the country to access services.
• Continuity across the country -we want to feel comfortable that people across Scotland can access the same service.
• Confidence in storing systems, security of data, anonymity.
• There would need to be increased resources for rape crisis centres and the RCS helpline as an improved pathway will lead to an increase in demand for support.
• We anticipate that once a new pathway comes in to place it will open the floodgates to people accessing the pathway and associated services.
• Big variables in people’s experiences across the country – even in the same area there can be big variability between experiences.
• Sometimes issues such as the room not being nice aren’t so important if the member of staff is kind, can make a big difference.
• NHS 24- can be helpful or a barrier. Questions asked can put someone off accessing service again. Needs to be trauma informed. The importance of gatekeepers (receptionists etc.)
• Being aware that people may drink or take drugs to build up the confidence to access services. Not judge the person based on this.
• Clinician being aware that what they ask and what they write may have long term impact for survivor – for example clinician writing ‘they were calm’ could be used negatively at a later stage in court.
• Being believed very important.
• For the survivor they may not distinguish between different services, sees them all as professionals.
• The professionals may not always identify issues to be related to sexual violence.
• My Body Back trauma informed smear clinic – good example of trauma informed NHS service
• Forensics shouldn’t be the headline factor – care for survivors, holistic care is important. Survivors accessing the healthcare they need.
• Forensics are about getting evidence for a trial, on convicting the perpetrator. The focus should be on the needs of the survivor. Shifting the focus may mean more survivors access the healthcare and support they need whilst they need it. Could forensics be something that’s offered whist in this environment as opposed to the primary focus?
• First question survivors are often get asked by different people is ‘have you reported to the police’? It would be good if this wasn’t the main focus of the pathway. By placing forensics at the heart of the pathway it puts reporting at the centre, whereas the survivor should be at the centre.
• Person centred – the individual in charge of what they want and what they need.