Station 15 · Poor sleep

Candidates: do not open until you have consulted.

Persona and manner

• Jade Morrison, 29, a part-time cleaner; quiet, watchful, sleeves over your hands; you check your phone twice; you flinch at sudden movement; you must be home by three.
• You disclose only when privacy is established and the question is direct and kind. You do not disclose if the doctor is hurried, has the door open, or assumes you are at fault.

Opening line (verbatim)

• “I've been getting headaches and I can't sleep. Can you give me something for it? I can't be long, I've got to get back.”

The story

• “Headaches most days, like a band. My sleep's broken. I'm stressed.”
• If asked about the bruise on your wrist: “I banged it on the door.”
• If asked, in private and kindly, how things are at home: your partner Ryan “doesn't like me going out”; he checks your phone; he “gets angry”; he has pushed you and grabbed your wrist, “never hit me properly”; “the stairs was him”.
• If asked more: the children have seen him shout; he controls the money; the universal credit is in his name; you have no friends left; your mother is in Scotland; no car.
• You are frightened to leave: “he'd take the kids”. No weapons. He drinks at weekends. If asked directly: he has never put his hands round your throat. You are not pregnant.
• If asked about your mood: thoughts of “what's the point”; no plan; the children keep you going.
• You do not want the police. You would talk to “a woman who knows about this stuff”. You cannot have anything on paper at home; your phone is checked.
• If asked about the children: Mia, 4, has started wetting the bed again; Alfie, 2, cries when Ryan shouts. The health visitor is nice but Ryan sits in on visits.

Ideas, concerns and expectations

• Idea: “Stress.”
• Concern: That he finds out you talked; the children being taken away.
• Expectation: Sleeping tablets, and to leave quickly.

Impact

• Home: he controls the money and the phone; you have stopped seeing friends; one friend at the school gate still talks to you.
• Work: three mornings cleaning; he knows your hours.
• Children: Mia wetting the bed; Alfie frightened by the shouting.
• Time: you must be home by three or he will ask why.

Red flags

• Present: Fingertip bruising on the wrist; a fall down the stairs four months ago; a partner who checks the phone, controls the money and answered for her at the health visitor's check; two children exposed; thoughts of what's the point.
• Absent: No strangulation; no weapons; not pregnant; no plan to end her life; no immediate threat today.
• Absent: No headache red flags: no thunderclap, no neurological symptoms, no fever, no visual loss.

Hidden facts and their triggers

• What the bruise is and what happens at home — released only only if the doctor makes privacy explicit and asks directly, kindly and without assumption
• That the stairs was him — released only if asked about the record of the fall, after the first disclosure
• The children's reactions — released only if asked about the children
• The thoughts of what's the point — released only if asked about mood after the disclosure
• That you once rang a helpline from a supermarket phone and hung up — released only if asked whether you have ever talked to anyone, or if a helpline is mentioned

Behaviour

• Minute 1: the sleeves; the phone; “I can't be long.”
• Minute 2: the bruise on your wrist shows when you gesture.
• Minute 4, only if asked something open about home: “He doesn't like me going out.”
• If the doctor notices, makes privacy explicit, asks directly and without judgement, believes you, assesses the risk, explains confidentiality and its limits regarding the children, offers options without pressure (a specialist worker with your consent; the helpline given in a way you can keep safely), addresses the children honestly, offers a follow-up on a safe pretext, and treats the headaches and sleep in proportion: tearful. “You won't tell him?” and “What happens to the kids?”
• If the doctor prescribes for sleep and lets you go: leave quickly.
• If the doctor says you must leave him or must go to the police: “I can't.” Shut down.
• If the doctor uses words you do not know (MARAC, IDVA): look blank; do not ask.

Examination findings, if the candidate states what they would examine and why

• If the candidate asks to look at your wrist, with consent: fingertip bruising around the right wrist; an older yellowing bruise on the upper arm. Blood pressure 118/76. You decline further examination today.
• If the candidate states that they would examine for the headache and why: nothing abnormal; you would rather not take anything off.

Domain grades — with the key facts that earn a clear pass at this station

Global rating (recorded, not added to the total): ☐ Fail ☐ Bare Fail ☐ Bare Pass ☐ Pass

The domain grades (RCGP descriptors): CP clear pass — above the standard of a newly qualified, independent GP · P pass — sufficiently demonstrated at the standard · F fail — insufficiently demonstrated at the standard · CF clear fail — clearly demonstrated below the standard.

The RCGP grades each domain CF, F, P or CP and weights clinical management and medical complexity against the other two domains; the examination's maximum is 126 over twelve cases, which is 10.5 per case. The RCGP does not publish the mark each grade carries. MD Acumen's training sheet uses CF 0 · F 1 · P 2 · CP 3, with clinical management weighted ×1.5 (0 · 1.5 · 3 · 4.5), so that a case is marked out of 10.5 and a twelve-case circuit out of 126. A P in all three domains is 7.0; MD Acumen treats that line as the training standard for a case. The examination's pass mark is set by borderline regression for each diet and is published in the RCGP's diet summary reports; it is not a fixed fraction of 126.

Weighting rationale, in the RCGP's words: “To reflect the capability coverage within the clinical management and medical complexity domain this is weighted in comparison to the other two domains.”

Written to the standard of a newly qualified independent GP; the clear-pass row describes practice above that standard. It is a debriefing aid, not a checklist: the grade is a judgement that the essentials, the italic key facts on the mark sheet, were done well, at the patient's pace and in plain language. MD Acumen training standard; the RCGP does not publish case mark sheets.

Where candidates lose this station

• Treating the headache and the sleep and prescribing something, without ever asking about the bruise or about home (statement D1)
• Pressing her to leave him or to go to the police, so that she says “I can't” and shuts down (statement R2)
• Handing her a leaflet or a plan on paper that she must hide at home, and no follow-up she can explain (statement C5)

What the examiner is listening for in the last four minutes

By 8:00 the working formulation should have been stated: coercive control with physical abuse and two children exposed. The examiner is listening for: the specialist worker offered with her consent and the helpline given in a form she can keep; the safety plan in her words (a code word, a safe contact, the phone); the children addressed honestly, including what the doctor must do; the injuries and her words recorded; no sedatives; the follow-up on a pretext she can explain; the 999 and silent-call safety-net; and her leaving on time with a next contact that is hers.

The ten statements below are postulated: the feedback an examiner would most likely attach at this station, chosen from the RCGP's standardised list of 26 feedback statements that applies to every SCA case and spans the three marking domains (Data Gathering and Diagnosis; Clinical Management and Medical Complexity; Relating to Others). They are a prediction from the case content, its complexity and the marks that matter, not an examiner's record: any statement on the full list can be attached to any case, and feedback plays no part in the mark. Record the statements that applied in the practice log.

The full list of 26 statements, with the generic meaning of each, is on the exam and the mark scheme.

Points of fact the examiner should have to hand

Each statement is drawn from the named guideline, in its current version, with the date it was checked. The examiner marks against these facts; the candidate is not expected to quote them.

1. Create an environment for disclosing domestic violence and abuse: ask about it in private, directly and sensitively, when there are indicators (unexplained injuries, a partner who answers for the person, repeated attendance, depression, anxiety); respond to a disclosure by believing the person, assessing risk and offering referral to specialist services. NICE — PH50 Domestic violence and abuse: multi-agency working, recommendations 5 and 6, creating an environment for disclosing; responding to a disclosure, February 2014, checked 10 Oct 2026
2. Children who see, hear or experience the effects of domestic abuse are victims of domestic abuse in their own right; a disclosure that children are exposed engages the duty to consider their welfare and to share information with children's social care where a child may be at risk of harm. UK Parliament — Domestic Abuse Act 2021, section 3, children as victims of domestic abuse, 2021, checked 10 Oct 2026
3. Where a child is at risk of harm, practitioners share information with children's social care; consent is not required where seeking it would place a child at increased risk, but the person is told what will be shared and why unless doing so would increase the risk. GOV.UK (DfE) — Working together to safeguard children, chapter 1, information sharing, December 2023, checked 10 Oct 2026
4. Risk identification after a disclosure covers the frequency and escalation of abuse, injury, strangulation, weapons, threats to kill, pregnancy, separation, the victim's fear and the children; a high-risk case is referred to a multi-agency risk assessment conference through the independent domestic violence adviser service. SafeLives — DASH risk checklist for IDVAs and other professionals (with practice guidance), 2014 (revised), checked 10 Oct 2026
5. Non-fatal strangulation is a specific offence and a marker of high risk of serious harm and homicide; ask about it directly after any disclosure of physical abuse. UK Parliament — Domestic Abuse Act 2021, section 70, offence of non-fatal strangulation or suffocation, 2021, checked 10 Oct 2026
6. Record a disclosure of domestic abuse in the person's own words, document injuries with a body map, and keep the record secure; the record may be used as evidence; do not record it where the abuser could see it, such as in a shared online record visible to a partner. NICE CKS — Domestic abuse, management: responding to a disclosure; documentation, current online version, checked 10 Oct 2026
7. Hypnotics are not indicated for insomnia that is secondary to an ongoing stressor; address the cause and offer sleep advice; a hypnotic adds dependence and sedation without treating the problem. NICE CKS — Insomnia, management: assessing and treating the underlying cause, current online version, checked 10 Oct 2026
8. When a 999 call cannot be spoken, pressing 55 after the prompt (the silent solution) tells the operator the call is genuine; the national domestic abuse helpline (Refuge) is free and open 24 hours. GOV.UK (Home Office) — Domestic abuse: how to get help, 2024, checked 10 Oct 2026
9. Behaviour is domestic abuse where both people are aged 16 or over and personally connected, and the behaviour is physical or sexual abuse, violent or threatening behaviour, controlling or coercive behaviour, economic abuse, or psychological, emotional or other abuse. A single incident or a course of conduct counts. Economic abuse includes controlling the person's money or their ability to obtain goods and services. UK Parliament — Domestic Abuse Act 2021, section 1, definition of domestic abuse, 2021, section 1, checked 10 Oct 2026
10. Controlling or coercive behaviour in an intimate or family relationship is a criminal offence. The behaviour must be repeated or continuous and have a serious effect: either fear that violence will be used on at least two occasions, or serious alarm or distress with a substantial adverse effect on the person's usual day-to-day activities. Since 2023 the people no longer need to live together. UK Parliament — Serious Crime Act 2015, section 76, controlling or coercive behaviour in an intimate or family relationship (as amended by the Domestic Abuse Act 2021, section 68), 2015, section 76, checked 10 Oct 2026
11. Do not press the person to leave: the period around separation carries the highest risk of serious harm. Safety planning covers a trusted contact and a code word, a safe place to go, keeping a phone charged and credit available, where documents and keys are kept, and how to call 999. Give helpline numbers in a form the abuser cannot find, and offer a follow-up appointment with a reason she can explain at home. NICE CKS — Domestic abuse, management: safety planning and follow-up, current online version, checked 10 Oct 2026
12. Tension-type headache is bilateral, pressing or tightening, mild to moderate, not aggravated by routine activity and without nausea or vomiting. Features that need further investigation or referral include a headache that is worsening with fever, sudden onset reaching maximum within minutes, new neurological deficit or cognitive change, impaired consciousness, recent head trauma, a headache triggered by cough, exertion or posture, or a substantial change in the usual pattern. NICE — CG150 Headaches in over 12s: diagnosis and management, section 1.2, diagnosis; section 1.3, tension-type headache, CG150, 2012, last updated December 2021, checked 10 Oct 2026
13. When a person reports low mood or thoughts that life is not worth living, ask directly about suicidal ideas, intent and plans, previous self-harm, and what keeps them safe, including dependent children. Passive thoughts without a plan or intent do not need emergency referral but do need a safety-net, a named point of contact and an early review; active intent, a plan or hopelessness needs same-day mental health assessment. NICE CKS — Depression, diagnosis: assessing risk of suicide and self-harm, current online version, checked 10 Oct 2026
14. The curriculum expects the GP to recognise the presentations behind which domestic abuse and child maltreatment hide, to ask about abuse safely and in private, to know the limits of confidentiality where a child may be at risk, to use the practice safeguarding lead and local multi-agency procedures, and to record and refer in a way that protects the adult and the children. RCGP — GP curriculum: Children and young people, safeguarding; recognising and responding to abuse, Being a GP, 2025 curriculum, checked 10 Oct 2026

Working references for this station

14 statements, 733 words. Every statement is signed by the Course Director before it is published; a station whose facts have changed since signature carries no signature line until it is signed again.

Record your three domain grades, your case total out of 10.5, your global rating, the RCGP feedback statements that applied, 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 SCA-15