Dr Rosie Riley
One twilight shift in the Emergency Department is as busy as ever. I pick up the notes of the next patient to be seen in Majors, a 17-year old female with abdominal pain. Her observations are stable. I notice that the triage nurse has documented that she is accompanied by her husband who is translating on her behalf. She is from Romania. Red flags are waving frantically in my head. My pulse races and my hands become sweaty. Vulnerable patients have this effect on me, almost as much as when a patient is critically unwell. I need to be ready to use all the safeguarding tools in my toolbox.
I mention to the nurse in charge that I’m going to take them round to the Urgent Care Centre, an area for minor injuries and ambulatory patients who are usually seen by Emergency Nurse Practitioners. The reason we head round there is because they have consultation rooms, not just bays and curtains. This is vital. The couple don’t know this of course. They think this is routine, all part of what happens in A&E. I also borrow the nurse’s portable phone, clipping it to my lanyard. I’ll need this later.
We walk round and take a seat in what could be a GP consultation room. Very private. I introduce myself and ask about their reason for attending the Emergency Department. The husband immediately takes the lead, explaining that she doesn’t speak English.
She’s been suffering with abdominal pain, mainly on the left side for the past 10 days and she’s not opened her bowels for this long. No systemic symptoms of concern. Nothing in the history suggests that she is clinically obstructed or that this is anything more than just constipation. I’m already confident of the diagnosis, but as always will examine her, then check her urine for infection and pregnancy. The husband claims that they have no children at home, and that she’s never been pregnant before.
OK, my safeguarding hat is perched invisibly on my head. I note that although she is timid, she seems familiar and comfortable with her husband. She looks only at him, never at me. There seems to be a normal, kind dynamic, nothing out of the ordinary between them.
I ask the husband to explain to the patient that I want to examine her abdomen. As routine and as naturally as possible, I turn to the husband. “If you pop outside to the waiting room, I will be about 5 minutes and I’ll call you back in when I’ve finished the examination.” Slightly disgruntled, but oblivious, the husband accepts and I lead him out of the room.
Now alone, I ask the patient if she understands any English. She doesn’t. I mime making a phone call and dial the telephone translation service. It takes approximately 2 minutes to have a Romanian translator, unfortunately a male voice, on the end of the line.
Via the translator, I ask my patient if she feels safe, does she feel fearful, is there anyone she feels threatened by, more specifically, does she feel safe with her husband. I look into her eyes, through them she can see that I care about the answers. The doctor-patient rapport means everything now. Then the translator repeats the questions, unemotionally, almost gruff. My heart sinks and I have to work hard to prevent this from breaking our rapport. I reassure her that this is a safe place and that I wouldn’t tell anyone unless I was worried that she was in danger. Her response is reassuring. She looks a little confused and denies everything in a way that seems quite genuine. Finally, I ask if anyone has made her do anything she doesn’t want to do. She denies this too. My closing statement whenever safeguarding a patient is “if you ever feel threatened or unsafe in anyway, you can always come to the Emergency Department and get help.” She nods. “So if you lie back on the couch, I’ll examine your abdomen, then we can get your husband to come back in.”
Was I being too cautious? Maybe. Was there anything to be concerned about? Maybe not. Despite the red flags, these questions are a routine part of my medical clerking. Whether I’m talking to a homeless man, a teenage boy, an English student. Even last year as a Senior House Officer on my General Surgical rotation, when routinely screening for abuse, I was surprised when a female patient with acute alcoholic pancreatitis disclosed that she was a victim of intimate partner violence. Safeguarding should not be exclusive to those triggering red flags.
Even in this case however, some may say there was nothing to suggest abuse, and maybe there wasn’t. The couple looked very comfortable together. However, what if there was something going on underneath it all? What if the exploitation hasn’t happened yet? It may have been vitally important to instil in her, that the Emergency Department is a place of safety. That if she were to ever feel threatened or afraid, A&E was somewhere she could get help.
Modern slavery and healthcare
Young women from Romania and other eastern European countries have been identified in the UK over the past years . They fell in love, came with their husband or boyfriend, excited for the opportunities that awaited them here. However when they arrived, their passports may be taken, very subtly they’re manipulated into believing that there have debts to pay back for travel, and the only way they can do that is by having sex for money, or making pornographic content. After a few occasions the exploitation may become more frequent, until it becomes a lifestyle and occasionally the victim doesn’t self-identify as a victim at all.  Alternatively, they may be forced into working, subject to brutal physical control. Many girls and women in sexual exploitation have no control over the hours they work, the number of clients and which client they accept, when they sleep, what they eat, whether they are able to protect themselves with condom-use . They may be subject to unpredictable, severe physical punishment . Recovering female survivors have disclosed that the betrayal they experienced was the most challenging element to their recovery. How could they have been fooled? How could he have been exploiting her, he loved her?
Modern slavery is a global nefarious injustice. It is the movement of people, by force, fraud, coercion, or deception with the aim of exploiting them . Men, women and children are bought and sold for the purposes of forced prostitution and sexual exploitation, forced labour, domestic servitude, forced marriage and other forced criminal activity. Often lured, manipulated and deceived by the promise of work, love or a better life. The monstrous reality however, being forced to work exhausting hours, in shameful conditions to pay back huge debts, under the threat of punishment or violence to themselves or their love ones. They may be told that the lawyers are in the trafficker’s pockets, that the police are corrupt or that they will be deported by the authorities or imprisoned. Force and fear prevent the victims from escaping their traffickers.
Whilst remaining unseen, unheard and unacknowledged, more human beings live in slavery now than at any other point in human history. The most recent global estimate being 40.3 million victims at any given time. One in four are children. 
This is a growing, thriving market. High supply continuously fuelled by high demand.
Due to its hidden nature, no one knows the true prevalence of trafficking in the UK. The Home Office estimated between 10,000-13,000 victims, however the Global Slavery Index estimate of 136,000 may be closer to reality. Two per thousand people.  The National Referral Mechanism, the framework devised by Government to identify and protect victims identified in the UK, received 5,145 referrals of potential victims of modern slavery in 2017. 2,118 of these referrals were children . From January to September 2018, 2,183 children were identified [8,9,10], not including data from October to November that hasn’t yet been published. The numbers increase by approximately 35% each year, although it is unclear as to whether this is from the growing scale of trafficking or from better awareness and identification.
Each number however, represents an individual human being, subject to atrocious psychical, psychological and sexual abuse. As a result, there is high prevalence of mental and physical health consequences. Studies looking at these consequences for trafficking in sexual exploitation specifically, found that 29% reported one or more pregnancies while trafficked, 42.8% of those reported at least one termination of pregnancy. 77.0% suffered from PTSD, 54.9% depression and 48.0% anxiety . There was also a high prevalence of headaches, fatigue, dizziness, weight loss, memory problems, back pain, stomach pain and dental pain .
Victims of modern slavery are presenting in our healthcare settings. In 2015, a survey of 782 NHS healthcare professionals revealed that one in eight reported previous contact with a patient they knew or suspected of having been trafficked. One in five in maternity settings. Yet eight in ten felt they hadn’t had enough training and 95% were unaware of the scale of trafficking in the UK .
This survey suggests that healthcare professionals are indeed seeing victims of modern slavery and yet do not feel equipped with the knowledge or confidence to know what to do and how to appropriately safeguard. I believe this is due to the current lack of emphasis on safeguarding as a whole, and specifically the quality of training.
As a junior doctor in the NHS, I have already experienced my fair share of safeguarding training. Annually, I need to complete two online modules, each taking approximately 45 minutes to complete. Each time, I feel more frustrated after reading the lists of red flags and indicators, methods and forms of abuse of adults and children, cases and examples, yet feeling no more equipped to know what to do when a child or adult is sitting in front of me. Despite the scale and severity, only a few brief paragraphs define modern slavery and usually this sits adjacent to a few quick paragraphs on Female Genital Mutilation. Modern slavery is not simply a concept to define. These patients are presenting in Emergency Departments, Primary Care services and maternity settings all over the country . Online modules may be disseminated easily, be cost effective, scalable, measure compliance effectively, but they impact minimally on my clinical practice and safeguarding experience.
Sadly, I feel that safeguarding has become a tick box exercise, disengaging previously passionate healthcare professionals. Safeguarding a vulnerable patient should be as much a priority as looking after someone who’s critically unwell. Training needs to be integrated into every level of specialty training with a maximum focus on trauma-informed care during the consultation. What do you do when the patient is sitting in front of you? How do you remove the accompanying person from the room without raising their alarm bells? These are examples of skills I use every single shift in the Emergency Department, because I’ve decided to make safeguarding a routine part of my medical clerking. Not because I’ve memorised a list of indicators and red flags.
For safeguarding to become a priority, time and money must be allocated to delivering simulation training as early as university and consistently throughout specialist training. From practicing and prioritising these trauma-informed skills, patients at risk of or currently experiencing modern slavery and other forms of abuse, will receive the care and support they need. Even if it’s just a confidential, private space, an independent translator and the power of the doctor-patient relationship.
Click here for References
Listen to Rosie talk about VITA training on the PonderMed Podcast
Dr Rosie Riley, Junior Clinical Fellow in Emergency Medicine, NHS England Clinical Entrepreneur.
Founder and CEO of VITA Training Ltd (Victim Identification and Trafficking Awareness)
Twitter – @DrRosieRiley, @VITA_Training
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