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Victims of violent crime
Victims of violent crime J. Shepherd
Violence is the leading cause of serious facial injuries in the UK. This paper outlines how and why the police and hospitals should, together, be doing more to protect the increasing numbers of victims. This paper is reproduced by kind permission of the author and the publishers of Policing Today, which is the journal of the Association of Chief Police Officers of England, Wales and Northern Ireland, Vol 3, Issue 2, June 1997. The majority of studies described in this paper were carried out by Professor Shepherd’s research team at the University Hospital of Wales in Cardiff. Professor Shepherd chaired the Victim Support working party which produced the national guidelines ‘Treating victims of crime’, circulated in I995 to all family doctors and A & E departments in the UK.
Jonathan
Shepherd Head of Department and Professor of Oral and Maxllofacial Surgery University of Wales College of Medicine, CardiR UK Manuscript 9 Oaober
accepted I997
Violent crime has increased substantially in the past 20 years, yet almost nothing has changed in the way the NHS deals with ever-increasing numbers of victims. The increase in recorded violent offences has been highlighted in the latest recorded crime data, published in March 1997. This ties in with the findings of the most recent British Crime Survey, published last autumn, which showed increases in muggings, stranger violence and acquaintance violence, and a small decrease in domestic violence since the previous 1994 survey. The substantial increase in violent crime over the past 20 years has been evident in British casualty departments. One study carried out in the Bristol Royal Infirmary’s casualty department showed that the number of assault
Accdenr and Emergency Nunmg (I 998) 6, I S- I7 Q Harcourt Brace & Co. Lrd I998
patients seeking treatment trebled between 1979 and 1991. However, little has changed in the NHS response to increasing violence, apart perhaps from a greater awareness of the risks faced by casualty department staff, particularly late at night and during weekends. This is despite the fact that health services should be responsive to changing social problems - in this case dramatic increases in violence. Former Home Secretary Michael Howard responded to the latest recorded crime data by emphasizing the need for partnerships between the police and society to combat violence. Nowhere is this partnership more urgently needed and more likely to pay dividends in violence detection and prevention than in relation to improved police-casualty department co-operation. There are clear opportunities to develop new working relationships to integrate casualty departments with community crime prevention initiatives and to increase access to victim support services. Unreported crime has been recognized as an important problem ever since the first British Crime Survey was published in 1983. It is now almost 10 years since my own research group confirmed the extent of unreported violence by studying victims treated in casualty departments. Our Bristol study showed that only about a quarter of assaulted victims who attended casualty departments for treatment were recorded by the police. The study also demonstrated differential recording rates - for example, assaults in licensed premises were less likely to be recorded, along with those occurring on particular days, and violence affecting women tended to be recorded by the police proportionately more often than violence directed against men. It is a continuing source of frustration for surgeons who treat patients with serious face injuries that more offences are not recorded or investigated. Medical evidence and publicity was key in the introduction of drink/drive and seatbelt legislation, but the considerable influence of the medical and nursing community has yet to be focused on the problem of violence, despite the fact that violence overtook road accidents as the leading cause of serious face injury in Britain in the late 80s. In a wider context, it is symptomatic of separately-focused medical and legal perspectives that the journal, Criminal B&U&W and Mental Health, declared: ‘Casualty departments are largely black holes into which victims are drawn, to be regurgitated back to their homes and communities without any attempt at prevention, protection, or support, or the apprehension and conviction of their assailants who
I6 Accident and Emergency Nursing
remain at liberty to inflict further physical and psychological harm.’ There are a number of reasons why the NHS is not, as yet, carrying the torch in the fight against violence - not least the constraints that issues of confidentiality place on health professionals in casualty departments. However, evidence indicates that this is often used as an excuse not to face up to important issues relating to the sentinel position of casualty departments in local communities. Evidence is emerging that, in effect, victims are often prevented from reporting offences when many would like to because they are sometimes kept in casualty departments for long periods without easy access to the police for themselves or those who accompany them. This is not to say that it is always straightforward for health professionals to establish the circumstances of violence and to understand issues such as culpability But establishing appropriate services for victims has not been helped by the attitudes of some casualty doctors. Research has found that some of them believe that the injured are largely responsible for their own injuries and others have stated that anyone hurt after drinking alcohol should be made to pay for their treatment. Access to medical treatment should be open to all who need it and it is no part of the work of health professionals to allow issues of culpability or personal risk-taking to affect decisions about medical treatment. What is also unacceptable is health professionals neglecting their responsibilities to society in relation to, for example, helping to deal with violent offenders who may injure someone else or drivers who are intoxicated and are a danger to others. Clearly, a small minority of assault ‘victims’ are, in fact, offenders who are injured in the course of committing an offence and there is no doubt that victims of assault are more likely to have a criminal record than those of a similar age who are injured in accidents. Delinquent behaviour leads both to offending and injury. However, during a recent discussion about ways in which joint working might be improved, one consultant felt it was unethical to report serious violence on the ground that victims would be ‘shopped’. He assumed that most were injured while breaking the law. It is often assumed that casualty departments are so busy that no time is available for interagency liaison about individual patients. However, no one seriously advances this reason for not instituting appropriate inter-agency liaison in relation to child protection. Why should there not be appropriate, ethically-sound interagency procedures adopted in relation to the far more frequent problem of violence affecting adults? On both sides of the Atlantic, violence and
the fear of violence have assumed such importance that it is surprising that formal casualty department/police joint working has not been considered before. Although only about five per cent of new patients who attend casualty departments have been injured in violent crimes -just over 3 000 a year in the casualty department through which my own patients come - every one provides an opportunity for supporting the victim and preventing future crimes. I propose five reforms to bring agencies together. First, a new Department of Health/ Home Office partnership to develop strategy in this area. Of crucial importance is the ownership and accessibility of front-line police officers and casualty health professionals to procedures which emerge from this. This needs statutory underpinning and the Crime and Disorder Bill is an excellent opportunity to provide this. Importantly, new local authority partnerships are a key objective of the new Government. Second, victims attending casualty departments should be encouraged to report offences if this is in their medical interests - for example, if there is a risk of further physical or psychological harm. Importantly, all victims should be given the opportunity to report offences to the police at the earliest time, for example, by means of a telephone link from the casualty waiting area to the police. The provision of such a link is standard practice in terms of casualty staff protection and the same level of access needs to be made available to injured patients. Third, casualty departments should be integrated into community crime prevention schemes by the universal appointment of police liaison officers and by making anonymous, casualty-derived information about violence in particular locations - such as bars or certain streets - available to licensing magistrates on a regular basis. Almost all casualty department staffwill be aware of occasions in which people injured in the same bar or night club seek treatment but where no one informs the police or licensing authorities. It would require a little extra work for casualty department managers to liaise with licensing authorities on a local community basis. Fourth, formal links between Victim Support and large casualty departments should be established in the same way that Crown court witness support schemes have developed. Since most referrals to Victim Support come through the police, those offences which are not reported or recorded will not normally trigger a referral. Services for this group of patients are rarely available, though psychological and social support is important and some victims go on to develop serious psychological problems such as flashbacks, sleep disruption,
Victims of violent crime
depression and post-traumatic stress disorder. However, because mental health resources would soon be overwhelmed if victims were referred in any number, a partnership between the voluntary sector and the NHS should be formed. Health authorities and social services are now able to buy this support in the same way as, for example, chaplaincy services. Fifth, casualty department computers should be standardized and networked, with the proper safeguarding of confidential information, to produce an annual report on violence to complement the British Crime Survey, There is no doubt that the publication of data on recorded crime and the British Crime Surveys go a long way in highlighting the importance of crime in modern society and the addition of data h-om a medical source would both help in this process and ensure that a new Home Office/Department of Health partnership is strengthened. Similarly, assessment by Crime Concern the national crime prevention organization - of crime risk would be greatly strengthened if casualty data were included. In a recent fourmonth assessment of city centre crime in Cardiff, Crime Concern identified only 125 recorded street assaults, whereas 448 people who had been assaulted in the same locations during the same period attended the casualty department for treatment. The research on which these reforms are based would not have been possible if it had not been for partnerships between medical, law and police researchers. Similar research partnerships in the US have strengthened the case for firearm legislation and have highlighted the effectiveness of, for example, locking up guns in the home as an important means of preventing accidental shootings of children in the US, where this has become a legal requirement. The time has come, however, for this partnership to be
I7
extended beyond the research community in Britain into criminal justice and health care practice. At the very least, a joint Home Office/Department of Health working group should be set up to make recommendations. Tackling violence was of key importance in the election campaign and the new Government now has the opportunity for an innovative and effective way of putting election promises into practice.
REFERENCES Shepherd J P 1994 Violent crime: The role of alcohol and new approaches to the prevention of injury. Alcohol and Alcoholism 29 Kellerman A L, Rivara F P, Somes G et al 1993 Gun ownership as a risk factor for homicide in the home. New England Journal of Medicine 329 Shepherd J P 1990 Violent crime in Bristol: an accident and emergency department perspective. British Journal of Criminology 30 Farrington D P, Langan P A, Witkstrom P 0 H 1994 Changes in crime and punishment in America, England and Sweden between the 1980s and the 1990s. Studies in Crime and Crime Prevention 3 Farrington D P, Langan P A 1992 Changes in crime and punishment in England and America. Justice Quarterly 9 Bastian I D, DeBerry M M 1992 Criminal Victimisation in the United States 1990. Bureau ofJustice Statistics, Washington DC Mirrlees-Black C, Mayhew P, Maung N 1997 The 1996 British Crime Survey. HMSO, London ShepherdJ P Shapland M, Scaly C 1989 Recording by the police of violent offences: an accident and emergency department perspective. Medicine, Science, Law 29 Clarkson C, Cretney A, Davis G, Shepherd J P 1994 Assaults: the relationship between seriousness, criminalisation and punishment. Criminal Law Review Jan 4-21 Rivara F P, Shepherd J P, Farrington D P et al Victims as offenders in youth violence. Annals of Emergency Medicine 26 Shepherd J P 1996 The casualty criminals. The Times 16
July
Violence is the leading cause of serious facial injuries in the UK. This paper outlines how and why the police and hospitals should, together, be doing more to protect the increasing numbers of victims. This paper is reproduced by kind permission of the author and the publishers of Policing Today, which is the journal of the Association of Chief Police Officers of England, Wales and Northern Ireland, Vol 3, Issue 2, June 1997. The majority of studies described in this paper were carried out by Professor Shepherd’s research team at the University Hospital of Wales in Cardiff. Professor Shepherd chaired the Victim Support working party which produced the national guidelines ‘Treating victims of crime’, circulated in I995 to all family doctors and A & E departments in the UK.
Jonathan
Shepherd Head of Department and Professor of Oral and Maxllofacial Surgery University of Wales College of Medicine, CardiR UK Manuscript 9 Oaober
accepted I997
Violent crime has increased substantially in the past 20 years, yet almost nothing has changed in the way the NHS deals with ever-increasing numbers of victims. The increase in recorded violent offences has been highlighted in the latest recorded crime data, published in March 1997. This ties in with the findings of the most recent British Crime Survey, published last autumn, which showed increases in muggings, stranger violence and acquaintance violence, and a small decrease in domestic violence since the previous 1994 survey. The substantial increase in violent crime over the past 20 years has been evident in British casualty departments. One study carried out in the Bristol Royal Infirmary’s casualty department showed that the number of assault
Accdenr and Emergency Nunmg (I 998) 6, I S- I7 Q Harcourt Brace & Co. Lrd I998
patients seeking treatment trebled between 1979 and 1991. However, little has changed in the NHS response to increasing violence, apart perhaps from a greater awareness of the risks faced by casualty department staff, particularly late at night and during weekends. This is despite the fact that health services should be responsive to changing social problems - in this case dramatic increases in violence. Former Home Secretary Michael Howard responded to the latest recorded crime data by emphasizing the need for partnerships between the police and society to combat violence. Nowhere is this partnership more urgently needed and more likely to pay dividends in violence detection and prevention than in relation to improved police-casualty department co-operation. There are clear opportunities to develop new working relationships to integrate casualty departments with community crime prevention initiatives and to increase access to victim support services. Unreported crime has been recognized as an important problem ever since the first British Crime Survey was published in 1983. It is now almost 10 years since my own research group confirmed the extent of unreported violence by studying victims treated in casualty departments. Our Bristol study showed that only about a quarter of assaulted victims who attended casualty departments for treatment were recorded by the police. The study also demonstrated differential recording rates - for example, assaults in licensed premises were less likely to be recorded, along with those occurring on particular days, and violence affecting women tended to be recorded by the police proportionately more often than violence directed against men. It is a continuing source of frustration for surgeons who treat patients with serious face injuries that more offences are not recorded or investigated. Medical evidence and publicity was key in the introduction of drink/drive and seatbelt legislation, but the considerable influence of the medical and nursing community has yet to be focused on the problem of violence, despite the fact that violence overtook road accidents as the leading cause of serious face injury in Britain in the late 80s. In a wider context, it is symptomatic of separately-focused medical and legal perspectives that the journal, Criminal B&U&W and Mental Health, declared: ‘Casualty departments are largely black holes into which victims are drawn, to be regurgitated back to their homes and communities without any attempt at prevention, protection, or support, or the apprehension and conviction of their assailants who
I6 Accident and Emergency Nursing
remain at liberty to inflict further physical and psychological harm.’ There are a number of reasons why the NHS is not, as yet, carrying the torch in the fight against violence - not least the constraints that issues of confidentiality place on health professionals in casualty departments. However, evidence indicates that this is often used as an excuse not to face up to important issues relating to the sentinel position of casualty departments in local communities. Evidence is emerging that, in effect, victims are often prevented from reporting offences when many would like to because they are sometimes kept in casualty departments for long periods without easy access to the police for themselves or those who accompany them. This is not to say that it is always straightforward for health professionals to establish the circumstances of violence and to understand issues such as culpability But establishing appropriate services for victims has not been helped by the attitudes of some casualty doctors. Research has found that some of them believe that the injured are largely responsible for their own injuries and others have stated that anyone hurt after drinking alcohol should be made to pay for their treatment. Access to medical treatment should be open to all who need it and it is no part of the work of health professionals to allow issues of culpability or personal risk-taking to affect decisions about medical treatment. What is also unacceptable is health professionals neglecting their responsibilities to society in relation to, for example, helping to deal with violent offenders who may injure someone else or drivers who are intoxicated and are a danger to others. Clearly, a small minority of assault ‘victims’ are, in fact, offenders who are injured in the course of committing an offence and there is no doubt that victims of assault are more likely to have a criminal record than those of a similar age who are injured in accidents. Delinquent behaviour leads both to offending and injury. However, during a recent discussion about ways in which joint working might be improved, one consultant felt it was unethical to report serious violence on the ground that victims would be ‘shopped’. He assumed that most were injured while breaking the law. It is often assumed that casualty departments are so busy that no time is available for interagency liaison about individual patients. However, no one seriously advances this reason for not instituting appropriate inter-agency liaison in relation to child protection. Why should there not be appropriate, ethically-sound interagency procedures adopted in relation to the far more frequent problem of violence affecting adults? On both sides of the Atlantic, violence and
the fear of violence have assumed such importance that it is surprising that formal casualty department/police joint working has not been considered before. Although only about five per cent of new patients who attend casualty departments have been injured in violent crimes -just over 3 000 a year in the casualty department through which my own patients come - every one provides an opportunity for supporting the victim and preventing future crimes. I propose five reforms to bring agencies together. First, a new Department of Health/ Home Office partnership to develop strategy in this area. Of crucial importance is the ownership and accessibility of front-line police officers and casualty health professionals to procedures which emerge from this. This needs statutory underpinning and the Crime and Disorder Bill is an excellent opportunity to provide this. Importantly, new local authority partnerships are a key objective of the new Government. Second, victims attending casualty departments should be encouraged to report offences if this is in their medical interests - for example, if there is a risk of further physical or psychological harm. Importantly, all victims should be given the opportunity to report offences to the police at the earliest time, for example, by means of a telephone link from the casualty waiting area to the police. The provision of such a link is standard practice in terms of casualty staff protection and the same level of access needs to be made available to injured patients. Third, casualty departments should be integrated into community crime prevention schemes by the universal appointment of police liaison officers and by making anonymous, casualty-derived information about violence in particular locations - such as bars or certain streets - available to licensing magistrates on a regular basis. Almost all casualty department staffwill be aware of occasions in which people injured in the same bar or night club seek treatment but where no one informs the police or licensing authorities. It would require a little extra work for casualty department managers to liaise with licensing authorities on a local community basis. Fourth, formal links between Victim Support and large casualty departments should be established in the same way that Crown court witness support schemes have developed. Since most referrals to Victim Support come through the police, those offences which are not reported or recorded will not normally trigger a referral. Services for this group of patients are rarely available, though psychological and social support is important and some victims go on to develop serious psychological problems such as flashbacks, sleep disruption,
Victims of violent crime
depression and post-traumatic stress disorder. However, because mental health resources would soon be overwhelmed if victims were referred in any number, a partnership between the voluntary sector and the NHS should be formed. Health authorities and social services are now able to buy this support in the same way as, for example, chaplaincy services. Fifth, casualty department computers should be standardized and networked, with the proper safeguarding of confidential information, to produce an annual report on violence to complement the British Crime Survey, There is no doubt that the publication of data on recorded crime and the British Crime Surveys go a long way in highlighting the importance of crime in modern society and the addition of data h-om a medical source would both help in this process and ensure that a new Home Office/Department of Health partnership is strengthened. Similarly, assessment by Crime Concern the national crime prevention organization - of crime risk would be greatly strengthened if casualty data were included. In a recent fourmonth assessment of city centre crime in Cardiff, Crime Concern identified only 125 recorded street assaults, whereas 448 people who had been assaulted in the same locations during the same period attended the casualty department for treatment. The research on which these reforms are based would not have been possible if it had not been for partnerships between medical, law and police researchers. Similar research partnerships in the US have strengthened the case for firearm legislation and have highlighted the effectiveness of, for example, locking up guns in the home as an important means of preventing accidental shootings of children in the US, where this has become a legal requirement. The time has come, however, for this partnership to be
I7
extended beyond the research community in Britain into criminal justice and health care practice. At the very least, a joint Home Office/Department of Health working group should be set up to make recommendations. Tackling violence was of key importance in the election campaign and the new Government now has the opportunity for an innovative and effective way of putting election promises into practice.
REFERENCES Shepherd J P 1994 Violent crime: The role of alcohol and new approaches to the prevention of injury. Alcohol and Alcoholism 29 Kellerman A L, Rivara F P, Somes G et al 1993 Gun ownership as a risk factor for homicide in the home. New England Journal of Medicine 329 Shepherd J P 1990 Violent crime in Bristol: an accident and emergency department perspective. British Journal of Criminology 30 Farrington D P, Langan P A, Witkstrom P 0 H 1994 Changes in crime and punishment in America, England and Sweden between the 1980s and the 1990s. Studies in Crime and Crime Prevention 3 Farrington D P, Langan P A 1992 Changes in crime and punishment in England and America. Justice Quarterly 9 Bastian I D, DeBerry M M 1992 Criminal Victimisation in the United States 1990. Bureau ofJustice Statistics, Washington DC Mirrlees-Black C, Mayhew P, Maung N 1997 The 1996 British Crime Survey. HMSO, London ShepherdJ P Shapland M, Scaly C 1989 Recording by the police of violent offences: an accident and emergency department perspective. Medicine, Science, Law 29 Clarkson C, Cretney A, Davis G, Shepherd J P 1994 Assaults: the relationship between seriousness, criminalisation and punishment. Criminal Law Review Jan 4-21 Rivara F P, Shepherd J P, Farrington D P et al Victims as offenders in youth violence. Annals of Emergency Medicine 26 Shepherd J P 1996 The casualty criminals. The Times 16
July