MD Acumen · PLAB 2 OSCE / CPSA course · free practice resources
Practice case P2-04 · Face-to-face · simulated patient
Follow-up after an emergency department visit — adult safeguarding
A 30-year-old woman attends after an emergency department visit for a forearm injury. The discharge letter says the injury did not fit the story.
Reviewed and kept current
Station family: Safeguarding, ethics and law · 8-minute station · 1 min 30 s reading · Last editorial review: 19 September 2026 · Next scheduled refresh: 11 April 2027.
Candidate instructions
Read this as you would outside the room
You have 1 minute 30 seconds to read, then 8 minutes. Candidates: everything below this section is folded away — leave it closed until you have finished the station.
| Information | |
|---|---|
| Your role | Foundation Year 2 doctor in a general practice |
| Patient | Ms Sana Rahman, 30 |
| Reason for appointment | Follow-up after attending the emergency department last night with a forearm sprain and bruising. She has come alone. |
| ED discharge note |
|
Your task
•
Explore the mechanism and context of the injury.
•
Assess for domestic abuse and her immediate safety.
•
Explain what you think is happening and agree a plan, including the support available and your safeguarding responsibilities.
•
Do not examine the patient.
Folded away
For the actor and the examiner
1 · Actor script — role player only
Candidates: do not open until you have consulted.
Persona and manner
- Sana Rahman, 30. Married to Imran for six years; one daughter, Aisha, aged 4. You gave up your job as a teaching assistant two years ago because Imran preferred it.
- Anxious, quiet, apologetic; you avoid eye contact and keep your sleeves pulled down. You check the time — you need to be home before he rings the landline at one o’clock.
Opening line — say this verbatim
- “Hello doctor… I’m sorry to bother you. A&E said I should follow up with you.”
If asked about the injury
- First answer, quick and rehearsed: “I slipped down the stairs. It was clumsy of me.”
- If gently challenged or told the pattern does not quite fit: pause, look uncomfortable — “It’s nothing… I just want to go home.”
- About the older bruises: nervous laugh — “I bruise easily.” (If asked: no nosebleeds, heavy periods or bleeding gums; no blood-thinning medicines; no family bleeding problems.)
Disclose only to sensitive, non-judgemental questions
- If the doctor explains that they ask everyone, that this is confidential, and asks whether anyone at home has hurt or frightened you: lower your head — “…Sometimes things get a bit heated at home.”
- “My husband can be short-tempered. He doesn’t mean it. It’s my fault sometimes — I make him angry.”
- With continued gentleness: “This isn’t the first time.” “He pushed me yesterday — that’s how I hurt my arm.”
- “He checks my phone. I’m not allowed to see my family without him. He keeps the bank cards.”
- “He said if I told anyone he’d make things worse.”
Only if specifically asked
- It is getting more frequent — every couple of weeks now. It is worse when he has been drinking.
- Once, about six weeks ago, he put his hands round your throat. You did not pass out or wet yourself; your voice, swallowing and breathing were normal afterwards; you have had no headaches, weakness, numbness or problems with your sight or speech since.
- He has never used a weapon. He has not threatened to kill you in so many words. You are not pregnant.
- Aisha has not been hurt, “but she gets scared. She hides behind the sofa.” She was in the room yesterday.
- Right now: “He’s at work. I’m okay for the moment.” Going home today: long pause — “I don’t feel safe when he’s angry.”
- Your mother lives 20 minutes away and would have you; Imran does not like you going there.
- Mood: tearful most days, poor sleep. No thoughts of harming yourself — “I couldn’t leave Aisha.”
Impact on daily life — home and work (only if asked)
- You have no money of your own since giving up work; you have to ask for everything.
- You have stopped seeing friends and rarely leave the house except for nursery.
- You sleep badly and jump when the door goes. Aisha has started wetting the bed again.
- The arm hurts to lift her; you cannot say so at home.
Ideas, concerns and expectations
- Idea: you did not plan to say anything; you came because the hospital told you to.
- Concerns: that he will find out; that “social services will take Aisha”; that no one will believe you.
- Expectation: something stronger for the pain in your arm, and to get home on time.
Cues to deliver, timed
- Minute 2: glance at the clock — “I need to be home by one.”
- Minute 4, if Aisha has not been asked about: “She gets scared.”
- Near the end, if emergencies have not been covered: “What do I do if he finds out I came?”
If the doctor summarises and asks whether you want to add anything
- If strangulation has not been asked about: a long pause — “There is one more thing. About six weeks ago he put his hands round my throat.”
- If it has: “Aisha saw it yesterday. She was in the room.”
How to respond to the doctor
- If the doctor believes you, says it is not your fault and explains the help available: “…I didn’t realise there was help.” “I want things to change. I just don’t know how.”
- If the doctor names what is happening — abuse, including the controlling behaviour — calmly: you cry quietly. “I never thought of the phone and the money as… that.”
- If safeguarding is explained honestly — that the aim is to keep you and Aisha safe and together, that you will be told before anything is shared: frightened, then accepting — “As long as he doesn’t find out it came from me.”
- If the doctor offers a leaflet or to text you: “He looks at everything.” Accept a number written as something else, or memorised.
- If the doctor asks how to contact you safely: mornings, on your mother’s phone.
- If the doctor says they must tell the police, or pushes you to leave him today: shut down — “I shouldn’t have said anything. I need to go.”
- If the doctor accepts the stairs story: thank them, ask for painkillers, leave.
Do not
- Disclose anything to blunt or rapid questioning (“Does your husband hit you?” as an opener → “No! Of course not.”).
- Volunteer the strangulation or that Aisha was present unless asked about them or invited to add anything.
2 · Examiner mark sheet — generic scheme plus the key facts for this case
Domain marks — with the key facts that earn a 4 at this station
| Domain (GMC wording) · key facts for this case | 1 | 2 | 3 | 4 | Score |
|---|---|---|---|---|---|
1 · Data gathering, technical and assessment skills
| ☐ | ☐ | ☐ | ☐ | /4 |
2 · Clinical management skills
| ☐ | ☐ | ☐ | ☐ | /4 |
3 · Interpersonal skills
| ☐ | ☐ | ☐ | ☐ | /4 |
| Station total | /12 |
Domain score (educational construct):
| Score | Descriptor |
|---|---|
| 1 | Unsatisfactory (did not achieve safe FY2 standard) |
| 2 | Borderline (just achieving minimum safe FY2 standard) |
| 3 | Satisfactory (competent and safe FY2 standard) |
| 4 | Good (exceeds FY2 standard) |
This 1–4 domain score and its descriptors are an Acumen educational construct: the GMC publishes the three marking domains and the four-mark maximum, but not the descriptors its examiners use, and it does not publish station mark sheets. See Legal & Regulatory.
Marks are 1 to 4 in each domain; the generic descriptor for each mark is on the mark scheme page, and the structure of the eight minutes is on the 8-minute station page. The full standard for this case is in section 3 and the GMC feedback statements, with examples from this case, are in section 4.
3 · Expanded station-specific marking standard — what earns 4, 3, 2 and 1 here
The top row is the full picture of what a competent FY2 could do at this station, including the working diagnosis with its justified differentials, the safety-net and the follow-up; lower rows describe how performance falls away. It is a debriefing aid, not a checklist to recite: nobody says every line in eight minutes, and a 4 is a judgement that the essentials — the italic key facts on the mark sheet — were done well, in plain language and at the patient’s pace. Acumen training standard — the GMC does not publish station mark sheets.
| Mark | Domain 1 · Data gathering, technical and assessment skills | Domain 2 · Clinical management skills | Domain 3 · Interpersonal skills |
|---|---|---|---|
| 4 |
|
|
|
| 3 | Disclosure achieved; control and immediate safety explored; one of high-risk markers, the child, the impact on her daily life or her mental health not covered. | Abuse named; safety plan, specialist support and child referral addressed; one of consent/confidentiality explanation, safe contact, senior discussion or a specific follow-up missing. | Empathic and non-judgemental; safeguarding explained clearly but plan more clinician-led than shared. |
| 2 | Some exploration but leading or rushed questions; risk to the child or immediate safety touched on only superficially; ICE not elicited. | Helpline given and sympathy offered, but no safety plan, or the child not addressed; no clear statement of what is happening; safety-net vague. | Kind but rushed; some leading or judgemental phrasing; limited response to her fears about social services. |
| 1 | Asks about abuse bluntly once, accepts denial, moves to the arm. Or unsafe: accepts “fell down the stairs”; no safety assessment. | Treats the arm; vague “you know where we are”; or promises total confidentiality that cannot be kept. Or unsafe: suggests couple counselling or speaking to the husband; hands over an obvious leaflet; pressures her to leave today or reports to police against her wishes without explanation. | Interrogative style; visible shock; pressure. Or unsafe: blaming, disbelieving or dismissive (“it’s a private matter”). |
4 · GMC feedback statements — where underperformance was identified — with case-specific examples
A feedback statement marks where underperformance was identified in the consultation. With PLAB 2 results the GMC may attach any combination of the ten statements to a station — none, one or several. The right-hand column shows what each one looks like at this station. Record the statements that applied in the practice log.
| GMC feedback statement | Underperformance it signals (generic) | Case-specific examples |
|---|---|---|
| 1 · Consultation | Disorganised or unstructured consultation | Opens with “Does your husband hit you?”, then jumps between the arm, the child and the police; confidentiality explained only after she has disclosed. |
| 2 · Issues | Key issues or priorities not recognised | Treats the station as a forearm-sprain follow-up — analgesia, a sling, advice on rest — and never reaches her safety or Aisha’s. |
| 3 · Time | Poor time management | Spends the station coaxing a disclosure and has no time for a safety plan, the child, or how to contact her safely. |
| 4 · Findings | Abnormal findings or results, or their implications, not identified | Reads “pattern inconsistent with mechanism” and “multiple older bruises” and does not act on it; hears “hands round my throat” and does not recognise a high-risk marker. |
| 5 · Examination | Physical examination or use of instruments not competent | Told not to examine — a candidate who insists on looking at the bruises uses her limited time and risks her trust. |
| 6 · Diagnosis | Working diagnosis or differential diagnoses not correct | Accepts “I bruise easily”, or calls it “relationship difficulties”; does not name domestic abuse and coercive control, or explain why this is not an accident. |
| 7 · Management | Management plan not reflecting current best practice | Suggests couple counselling or talking to Imran; hands her a leaflet; promises that nothing leaves the room; no referral for Aisha; no 999 / helpline safety-net; follow-up letter sent to the home address. |
| 8 · Rapport | Rapport and sensitivity to the patient’s feelings and concerns not shown | “Why don’t you just leave him?”; visible shock; a lecture on what she ‘must’ do. |
| 9 · Listening | Verbal and non-verbal cues not used; poor active listening | Misses the glance at the clock and “I need to be home by one”; misses “she gets scared”; carries on with a checklist while she is crying. |
| 10 · Language | Language or explanations not understandable; understanding not checked | “I’ll do a DASH and refer to MARAC and the MASH” with no explanation; does not check she understands what will be shared, with whom, and what happens next. |
5 · Examiner points of fact and guidelines
Points of fact the examiner should have to hand
- Domestic abuse includes controlling or coercive behaviour, economic abuse and threats — not only physical violence (Domestic Abuse Act 2021). Children who see, hear or experience the effects of the abuse are victims in their own right.
- Ask in private — never with the partner, a relative or a child old enough to understand in the room, and never through a family interpreter (NICE PH50).
- High-risk markers include non-fatal strangulation (a specific offence since 2022), escalation in frequency or severity, threats to kill, weapons, pregnancy, recent separation and stalking. The DASH risk checklist structures this; high risk → MARAC referral.
- Strangulation is a medical problem as well as a risk marker: around half of victims have no visible injury, and carotid artery dissection or stroke can be delayed. Institute for Addressing Strangulation guidance (2025): if it happened within the last four weeks, or she has symptoms at any time, screen for red flags — loss or near-loss of consciousness, incontinence, voice change, painful or difficult swallowing, breathlessness, neck tenderness, bruising or petechiae, neurological or visual symptoms — and any positive means the emergency department the same day for CT angiography. Beyond four weeks and symptom-free, as here, imaging is not routine; safety-net. Strangulation on its own justifies a MARAC referral.
- There is no general legal duty in England to report domestic abuse of an adult who has capacity. Seek consent. If she has capacity and refuses, the GMC says you should usually respect that, even if the decision leaves her (but no one else) at risk of serious harm — and keep offering support. Sharing without consent is justified when others are at risk (a child: children’s social care must be told), when a high-risk case goes to MARAC in the public interest, or, very exceptionally, to prevent an imminent serious crime against her. Take senior or Caldicott Guardian advice, and tell her first unless that is unsafe (GMC Confidentiality, disclosures for the protection of patients and others; GMC Protecting children and young people).
- What to say: “I believe you.” “This is not your fault.” “You are not alone.” What not to do: advise couple counselling or mediation; confront the perpetrator; ask why she stays.
- Safe practice: agree a safe way to contact her; do not send letters or texts home; ensure the consultation cannot be seen through online record access; document her words verbatim, with injuries described precisely.
- National Domestic Abuse Helpline (Refuge): 0808 2000 247, free, 24 hours. An IDVA is a specialist advocate for people at high risk. A silent 999 call from a mobile is put through if the caller presses 55.
- An FY2 would discuss this with the practice safeguarding lead the same day. Say so in the station.
Where candidates lose marks at this station
- Opening with “Does your husband hit you?”
- Promising that nothing will leave the room.
- Forgetting there is a four-year-old.
- Handing over a leaflet she cannot hide.
- No plan for tonight and no safe way to reach her next week.
Guidelines for this station
6 · MLA content map tags for this case
| MLA content map | This station |
|---|---|
| Domain 1 · Areas of clinical practice | General practice and primary healthcare · Child health · Acute and emergency |
| Domain 3 · Clinical and professional capabilities | Safeguarding vulnerable patients · Legal and ethical responsibilities · Capacity, consent and confidentiality · Managing risk · Using and recording information safely |
| Domain 5 · Patient presentations | Domestic abuse · Bruising · Soft tissue injury · Child abuse and neglect |
| Domain 6 · Conditions | No single condition — professional capability station |
| Appendix A · Body system | None — professional capability station |
| Interpersonal skill (GMC PLAB 2 guide) | Involving the patient in decision-making · Dealing with anxious patients or relatives · Explaining diagnosis, investigation and treatment |
| Station family | Acute care, ethics and safeguarding — Safeguarding, ethics and law |
7 · My marks and reflection — practice log form
Record your three domain marks, your station total, the GMC feedback statements that applied (where underperformance was identified), and what you will keep and change. The form is already labelled with this case and its web address; a copy of your entry is emailed to you, so your practice log builds up in your inbox and can be downloaded.
Record my marks and reflection for P2-04
Revision link for this case: mdacumen.com/plab-2-osce/case-04-injury-follow-up-domestic-abuse
Independence & scope. Independent, formative training material from MD Acumen Ltd. Not affiliated with, endorsed by, or delivered on behalf of the General Medical Council. The GMC does not publish its station mark sheets: every mark scheme and descriptor on these pages is an Acumen training tool calibrated to the GMC's published marking domains, feedback statements and the MLA content map. Practice scores are not a prediction of examination performance. Clinical content reflects UK guidance at the date of editorial review — always check the current guideline. All patients are fictional. This course never provides, and will never ask you to share, real GMC exam content — full regulatory statement: Legal & Regulatory.
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