THE Rotunda Hospital in Dublin is home to the first dedicated sexual assault treatment service in Europe. It conducts 300 forensic medical examinations a year. Almost all of the cases are referred to the gardaí.
One-in-three of the victims it treats are from outside the Dublin area. Established in 1985, it has gained worldwide recognition as a centre of excellence. But staffing and funding issues pose a threat to the future of the unit. Difficulties in recruiting and retaining doctors have escalated. It is now dependent on a core group of just three doctors. Nursing staff are limited to a half-time nurse manager.
To make matters worse, the service has to depend on the availability of nurses from the gynaecological ward to provide out-of-hours service to victims. This causes a conflict between the gynaecology nursing services and those of the sexual assault treatment unit (SATU).
The Rotunda is also forced to restrict victims who are not filing a complaint to gardaí to attending the SATU by appointment only. This compounds the anxiety of victims who merely want assurance about sexually transmitted infections or risk of pregnancy.
Despite the invaluable work it does for the victims of rape and sexual assault, the SATU at the Rotunda has no funding from the Department of Health. Staffing levels are so poor in the unit, it is now at crisis point.
These are the stark findings of an unpublished review of our sexual assault treatment services, presented to Tánaiste and Health Minister Mary Harney last October and which she has yet to publicly act upon.
The review was equally critical of the problems posed by lack of funding to SATUs in other parts of the country.
Waterford Regional Hospital houses the newest of our SATUs and is operating since September 2004. In its first year of operation, the unit saw 52 victims of rape/ sexual assault. There are 14 GPs on the rota to carry out forensic examinations but there is no long-term funding in place to guarantee their salaries.
“Retention of doctors is therefore of major concern and poses a serious threat to the sustainability of the service,” the report says.
The limited budget available to the unit is used to fund the half-time post of nurse manager, on-call nursing costs and recurring equipment and training costs.
The SATU at Letterkenny General Hospital in Co Donegal was established in 1998. It was set up by a group of concerned nursing staff, the registrar from the A&E department, and supported by the goodwill of five local GPs. Funding to equip and furnish the unit was raised locally.
The unit has limited its catchment area to the Donegal region only, due to medical staffing issues and the difficulty of attracting GPs. The budget is sufficient to cover on-call nursing costs only.
The review warns the unit “is struggling to remain open with only two doctors providing the forensic medical examination services on an ad-hoc basis.” More alarmingly, it adds: “Cessation of this much needed service seems inevitable unless immediate steps are taken to address this crisis.”
The fourth and final SATU is in the South Infirmary Hospital in Cork. It is in the enviable position of being the one and only SATU in the country to receive funding from the Department of Health. This came about in 2001 during former Health Minister Micheál Martin’s brief.
Unlike the Rotunda, it has a full-time nurse manager and a team of nurses who provide an out-of-hours on-call service from 1pm to 9am on weekdays and 24-hour cover at the weekends.
The assessment of our SATUs is contained in a report entitled Sexual Assault Treatment Services: A National Review*. It was carried out by a subgroup of the National Steering Committee for Violence Against Women for the Departments of Health and Justice.
The report said SATUs had developed in a fragmented rather than co-ordinated way. It said: “This geographical lottery means that while some victims have access to organised dedicated services, many are still dependant on local ad hoc arrangements which can become a deterrent to the victim sourcing appropriate care to meet their needs and continuing with criminal prosecution.”
In the Mid-West, West and Midlands, where there are no SATUs, there are often long delays between the time the crime is reported to the gardaí and the carrying out of a forensic exam.
“Gardaí are frequently required to transport victims to a designated SATU, often taking 12 hours or more to make the round trip,” the report said.
Worryingly, areas without a SATU showed lower reporting rates to gardaí, in some cases less than half the national average of nine cases per 100,000.
The report was also critical of interview facilities at garda stations for victims making a statement.
“This is commonly taken in a garda station interview room which can portray a clinical, stark or hostile environment. Most garda stations do not have adequate facilities to accommodate these vulnerable victims who are often required to wait in a room that is used for other purposes,” the report says.
It recommends the Health Service Executive (HSE) provide a dedicated interview room in a garda station in each region “where victims of rape/sexual crime can feel safe and supported while giving their statement in advance of forensic medical examination.”
Retention of doctors who act as forensic medical examiners (FMEs) is identified as a major problem in the review. This is partly to do with the significant time commitment it requires should the case go to court, and partly because of the ad-hoc pay arrangements. Over reliance on a limited pool of doctors “increases the risk of fall-out in existing services”, the report warns.
Some areas are without GPs trained to carry out forensic exams. At the Mid-West Regional Hospital in Limerick, staff will allocate a cubicle for the duration of the forensic exam, but it is hospital policy that staff do not conduct it. If gardaí are unsuccessful in sourcing a GP, the victim will frequently have to travel to Cork. In 2003, 37 cases were reported and 28 victims had to go to Cork.
In the Galway/Mayo/Roscommon area, victims must depend on the goodwill of local GPs to carry out forensic exams. Alternatively, the victim faces a four to six-hour journey to the nearest SATU. The area has the lowest reporting rate in the country of 3.6 cases per 100,000. This is perhaps the main reason Galway city has been identified in the review as one of two locations for a new SATU.
The Midlands has the second lowest reporting rate of 4.4 cases per 100,000, making it the obvious choice for the second new SATU. If these new SATUs go ahead, the review recommends they be reviewed in 2007 to see if they have addressed gaps in the service.
Rape Crisis Network of Ireland (RCNI) spokeswoman Clíona Saidlear said they hoped that 2007 would see a further extension of SATUs.
The report also refers to the loss of a SATU at Kerry General Hospital, which commenced operation in 2002 but ceased in 2004, due to a lack of funding. Labour TD Breeda Moynihan Cronin has long campaigned for its reinstatement. The Kerry Rape Crisis Centre has said it’s prepared to raise the money itself. However, the report does not recommend that it re-open.
The report does conclude the lack of services “compounds the sense of guilt and self-blame they (the victims) express, which acts as a deterrent to them reporting the crime.” It recommends that newly established services are located so that no victim is more than a three-hour drive from a SATU.
The report makes a number of other recommendations. Key among these is the standardisation of existing services, including HSE on-call payments to doctors and nurses and standardisation of payment of doctors by the gardaí for forensic exams.
It recommends the appointment of a national medical director on a part-time basis to drive the recommendations of the report and the employment of a clinical nurse manager at each SATU.
It calls for the extension of SATU services to victims who have chosen not to make a report to gardaí and setting 14 as the minimum age for access to adult SATUs.
Ms Saidlear said the RCNI was very happy with the report’s recommendations. It remains to be seen if the funding and goodwill exist to drive them forward.
*The review was researched and written by Angela O’Shea on behalf of the Sexual Assault Review Committee.