ONE STOP CRISIS CENTRE

(OSCC)
PRESENTED BY
HO SHIRLEY THONG YEE LING
HO ASRAF
SUPERVISOR: DR NORIZAN/ DR AZIZOL
INTRODUCTION TO OSCC

OSCC service is an integrated and comprehensive multiagency

service centre established in all ETD of MOH for the management
of survivors of domestic violence, sexual assault, child abuse and
neglect.
OBJECTIVES OF OSCC SERVICE

To provide multidisciplinary care of the survivors

To identify and manage survivors of domestic violence, sexual assault, child
abuse and neglect.
To provide treatment and multilevel crisis intervention to survivors
To ensure the delivery of optimal care and evidence management for the
survivors
To ensure appropriate management of medico legal evidence. The OSCC shall
work with police to assist in evidence management for medico legal purposes
 COMPONENTS OF OSCC

RAPE AND SODOMY

SEXUAL ASSAULT

DOMESTIC CHILD ABUSE

VIOLENCE AND
NEGLECT
Hospital levels

. Level A :HKL and state Hospitals

. Level B :Other Hospitals with specialists
. Level C :Other Hospital without specialist
HKL and state hospitals

Headed by Paediatrician
Medical social worker responsible for paediatric
department
JKM officers @ Child protector
Specialist from Pediatrics,ETD,O&G,Psychiatry
and Forensic department
Pediatric and / or OSCC nurse / sister
Counselor,psychologist (If available)
Additional members may be added to the team as
appropriate (Deputy public
prosecutor,Hospital/School counselors)
Functions

Provide consultation / support to other professionals who are not

specialized in handling cases of suspected child abuse and / or neglect

Identify gaps in services and to participate long term planning for child
protection services and coorperation / consultation with other community
agencies

Accept referrals from B and C hospitals or direct referral

Other hospitals with specialists

Headed by Pediatrician
Specialists/ Medical Officers from O&G , ETD,
Psychiatric and Forensic department
Medical social worker
JKM officers @ Child protector
Police officer
Nurse preferably Sister of the pediatric ward or
equaivalent in authority and / or pexperience
Functions

Provision of such care in A hospitals although may involve

referral to A hospital
Hospitals without specialists

Headed by the Family Medicine Specialist / Hospital

Director
Senior nurses / Medical assistants
JKM officer @ Child protector should also be a
member ,wherever possible and / or a police officer
(preferably the same mebers of the District Child
Protection Team)
Functions

Consult or refer all cases of SCAN to hospitals with specialists

SCAN teams can communicate welfare and police

investigation findings to referral hospital
ROLES OF ED

Responsible for initial management of OSCC cases.

Includes: triage, history taking, physical examination, clinical stabilization,
treatment of injuries and evidence collection other than that obtained form
vaginal examination.
Evidence obtained shall be managed and handled to police with preservation
of chain of evidence
ED shall coordinate the management of OSCC cases including referrals to
relevant team members.
Management of alleged rape and sexual assault
RAPE is dealt under section 375 of the Malaysia Penal Code. According to this section a
man is said commit “rape” when he has sexual intercourse with a women under the
following conditions
AGAINST HER WILL
WITHOUT HER CONSENT
With her consent when consent has been obtained by putting her in fear of death or
hurt to her or any other person, or obtained under misconceptions of the fact and the
man knows or has reason to believe that the consent was given in consequence of such
misconceptions
With her consent when the man knows that he is not her husband, and her consent is
given because she believes that he is another man to whom she is or believes herself to
be lawfully married or to whom she would consent
With her consent through deception
With her consent, when at the time of giving such consent, she is unable to understand
the nature and consequences of that to which she gives consent
With or without her consent, when she is under sixteen years of age ( Statutory rape)
SEXUAL ASSAULT

A criminal offence
Under section 354 of Penal Code → assault or use of criminal force
on a person with intent to outrage modesty
 STATUTORY RAPE

Any Sexual intercourse with or without consent with a girl who is under the age of
sixteen years ( Under Penal Code 375 )
Police report must be made urgently
If the child protector from Social Welfare Department requests the child to be
examined, examination can be done without a police report with a written request
from the child protector ( Borang 4)
Refer to social welfare department ( Borang 9 ) / Medical social worker
Refer child psychiatrist for psychological support, Paediatric SCAN team / O&G
team
 WORK PROCEDURE FOR HANDLING RAPE AND SEXUAL ASSAULT CASE

1. Survivors may present to hospital in different ways

Walk in through triage: with/without police report
By parents/guardian/teachers/child protector
Pregnant
Brought in semi critical or critical
Referral from level C hospital(hospital without O&G specialist) or health clinics
ED
POLICE REPORT

Must be made whereby the police will release BORANG POL59 (request dr to examine and collect evidence
with consent to aid investigation.
Examination can be done with only BORANG POL59 when police report not available yet
Survivors present to ED without police report, can be done in OSCC room and should not be made to go
police station for privacy and confidentiality.
18y/o and above who do not wish to make police report, should be counselled and advised to make police
report, if refused then proceed with examination, treat injuries and collect samples with consent, arrange for
counselling and f/up. May refer to other teams when needed.
All cases alleged statutory rape (16y/o and below) police report must be made stat: in hospital settings( by
MO/SP), in health clinic (nurses with first contact)
Survivors who critically ill/ mental unstable , police report can be lodged by MO/SP
 CONSENT

Must be obtained prior to clinical examination and evidence collection: legal age is 18y/o and
above
For 18y/o and above: use the consent form in rape form, and if critical/semi critical case consent
can be given by police/ attending sp
For 18y/o and below: taken from parents/ legal guardians/ police office and child protector
DOCUMENTATION OF PERTINENT HISTORY

Let the survivor tell her story and write every detail as soon as possible.
Do not write down after the survivor has narrated her story FULLY by memory
but write down as the history is being taken.
Record precisely, in the survivor’s own words, important statements made by her,
such as reports of threats made by the assailant.
Include the name of the assailant, and use statements, such as “survivor states” or
“survivor reports”.
Questioning should be done gently and at the survivor’s own pace.
Avoid questions that suggest blame, such as “what were you doing there alone?”
Take sufficient time to collect all needed information, without rushing.
Take a detailed history. The questions asked while the history is being taken
should not be judgmental, moralistic or opinionated.
ACUTE CASE:
Acute(fresh case) are up to 72 hours from the time of incident (WHO 2004)
COLD CASE:
Cases that present more than 72H from the incident
However forensic evidence may be available >72h after the assault
Examination to collect forensic evidence should be based on the facts of the case, victim’s history, likelihood
of recovering evidence that will be needed for a successful persecution
72 hours cut off should only be used as guideline and not a rigid policy
Some cases between 72-120 hours can be considered as fresh case for urgent evidence sampling
 Specimen collection for fresh case

Blood for viral screening (HIV/ VDRL/HEP B AND C)

FTA card: chemically treated filter paper for the collection, preservation and shipment of
biological sample for DNA and RNA analysis
Urine sample for :uFEME, UPT and urine C&S
Vaginal swab for gonococcus: external and internal swab
Vaginal swab for spermatozoa
Vaginal swab for DNA
Universal bottles: scalp hair, pubic hair, finger nail clip
 Survivors: within 72h of incident

1. Document injuries and collect samples eg: blood, saliva and swab for DNA
within 72H is helpful to corroborate the survivor’s history. The earlier to
approach the patients the more findings could be obtained
2. All info to be recorded in the medical record
3. Police officer should be present at the time of examination to collect forensic
specimens.
4. Injuries requiring immediate treatment take priority over forensic samplings.
5. If requiring EUA for wounds that requiring suture should be consented before
undergoing procedure.
Survivor presents more than 72H

72H cut-off is a window of opportunity to treat the survivors successfully for STI and
any pregnancy that can be caused by the sexual assault.
The amount and type of evidence that can be collected depend on the situation
All information should be recorded carefully in the survivor’s medical report.
DNA specimens required only on case to case basis, if swabs for DNA have been taken,
blood sample for DNA should also be sent
Do UPT , USG examination to confirm pregnancy
STI screening - HIV / HbsAG and VDRL/TPHA
Abx for high risk group / HIV prophylaxis if indicated
Hospital management of domestic violence
 Introduction

OSCC management of domestic violence in Malaysia incorporates the treatment of physical,

psychological and financial abuse or neglect by a spouse or family member as stated in DOMESTIC
VIOLENCE ACT OF 1994.

DOMESTIC VIOLENCE (Amendment) ACT 2012 is the commission of one or more of the following
acts
1. Willfully or knowingly placing or attempting to place the victim in fear or physical injury
2. Causing physical injury to the victim by such act which is known or ought to have been known would
result in physical injury
3. Compelling the victim by force or threat to engage in any conduct or act, sexual or otherwise from
which the victim has right to abstain
4. Confining or detaining the victim against the victim’s will
5. Causing mischief or destruction or damage to property with intent to cause or knowing that it is likely to cause distress or
annoyance to the victim
6. Causing psychological abuse which includes emotional injury to the victim
7. Causing the victims to suffer delusions by using intoxicating substance or any other substance without the victim’s consent or if
the consent is given, the consent was unlawfully obtained ; or
8. In the case where the victim is a child causing the victim to suffer delusions by using any intoxicating substance or any other
substance; and
9. By a person whether by himself or third party against

-His / her spouse

- His / her former spouse
- A child
- An incapacitated adult
- Any other member of the family
WORK PROGRESS IN MANAGEMENT OF
DOMESTIC VIOLENCE
STEP 1: TRIAGE
Triage according severity of the injuries that sustained. Critical and semi-critical survivors shall be triaged in yellow or red
zones respectively. Non critical survivors to OSCC and secondary triaging of vital signs shall be performed immediately.
STEP 2: History taking
Take chief complaint, mechanism of injury, past medical and surgical history and relevant social history
Avoid confronting abusing spouse or family member
Ask questions in non judgemental manner not in the presence of survivor’s spouse to detect domestic violence
STEP 3: PHYSICAL EXAMINATION
Starting with primary survey followed by secondary survey and document all injuries
.
STEP 4: INVESTIGATION
Blood and urine investigation, radio imaging
If toxicology specimen is needed , police report shall be lodged and the police officer will send the specimen for
investigation STEP 5: REFERRAL
Refer to other clinical specialties if necessary
Referral to social welfare
Advice to seek additional assistant from relevant NGO,
STEP 5: REFERRAL
ALL survivors shall be referred to medical social worker/social welfare department
Referral to psychiatric if there are sign of acute psychosis or suicidal ideation
Additional assistance from relevant NGOs eg: AWAN(All women’s action society Malaysia), women’s aid
organization(WAO)
STEPS 6: FURTHER CARE AND PROTECTION
If still at risk of further injury from spouse, unsafe to be discharged home and no social support, temporary lodging or safe
shelter home should be arranged for them.
STEP 7: LODGING A POLICE REPORT
Survivor shall be assisted to lodge police report if needed
Police report could be made at any time and shall not delay treatment
STEP 8: SUPPORT AND INFROMING FAMILY
Shall inform family for survivor with life threatening condition regardless they refuse.
STEP 9: FOLLOW UP BY HEALTH STAFF AFTER DISCHARGE
Home visit or contacted by phone by social worker for high risk domestic violence
Non high risk domestic violence further f/up by phone or home visit can be done if needed
 Child Abuse and Neglect
Child -all those age blow 18 years old
Child Abuse or Neglect -all forms of physical abuse and / or emotional
ill-treatment ,sexual abuse ,neglect or negligent treatment or commercial
or other exploitation,resulting in actual or potential harm to the
childhealth,survival,development or dignity in the context of a
relationship of responsibility, trust or power
Suspected Child Abuse and Neglect (SCAN) team

Multidisciplinary team of hospital staffs compromising

-Pediatricians
-Gynecologist
-Mental health professionals
-Accident and emergency staff
-Forensic pathologists
-Nurses and Medical social workers who works closely with Jabatan Kebajikan Masyarakat (JKM)
-Police officers
General functions
To serve as multi disciplinary referral team within the hospital

To assess the childhood of abuse or neglect for referral cases

To provide coordination amongst the various agencies in case evaluation,management and reporting of child abuse cases

To develop and review hospital policies and precedures for handling of suspected or actual cases of child abuse and / or neglect

To provide and organize echo training for the state

To maintain a database on cases handled by the team

To enhance community awareness on the prevention and reporting of SCAN cases

 Child Act 2001 Malaysia

In relation to criminal proceedings

-Person who has attained the age of ciminal responsibility as prescribed in
Section 82 of Penal Code (Act 574)
(Act of child under 10 years old -Nothing is an offence which is done by a child under age of 10 years old)

-Section 83 of Penal Code (Act 574)

(Act of child above 10 and under 12 years old who has not attained sufficient maturity of understanding-
Nothing is an offence which is done by a child above 10 years old and under 12 years old who has not attained
sufficient maturity of understandung to judge of the nature and consequance of his/her conduct on that
occasion)
An abused / neglected child may initially referred for

Medical illness (eg ; Convulsion , per vaginal discharge ,fracture)

Behavioural problem

Psychological oproblem (eg ; Depression,anxiety attack)

-or a request for vaginal examination
-Disclosure of sexual contact
-Parental anxiety about “Loss of virginity”
-Allerged sexual abuse in custody case
Allerged abuse / assault
Found abandoned or wandering unattended in public places
 Triage system in ETD

CRITICALLY OR SEMI CRITICAL STABLE

Should be attended to the acute area of ETD and then to He / she will be directed to the OSCC
be transferred to ward
/ ward wher ethe child will be first
attended by nurse
Police report should be done urgently for all cases that
occur <72h after incident and all cases where child’s life Doctors from ETD / Pediatric
is at risk department will contact relevant team
that need to be involved
Medical officer should lodge a police report in such
cases if parents is non immediately available / unwilling
to lodge one

In ‘COLD case’ report can be done 24-48H after

examination done
 Cases that will require admission are
When the child requires medical treatment
When safety is a concern (as in intra familial abuse or other concerns about physical safety or neglect or lack of supervision)

All cases of sexual abuse

-for medical management of acute physical and emotional trauma
-for examination by experienced medical staff and when the child is more settled (especially in chronic. cases of sexual abuse where the last
incident is > 72 hours prior to presentation)
-to obtain further information from the child survivor
-to rule out possible incest
-for post traumatic stress counselling of child and family
-for counseling of social and legal ramications following the abuse
-to determine the most suitable placement for the child

Presentation after office hours enable review by SCAN team and to ensure a satisfactory initial assessment and safe place to child
 Important thing regarding documentation

Clear and complete documentation

-Timing of examination
-Examination findings and circumstances involved
Photography and video-culposcopy of abnormal physical and genital examination (if available)
-To ensure written consent by parent / guardian is required prior of taking any imaging
-Name of photographer should also be documented
-Video tape should be labeled and secured

Specimens labelling should be correct and completely labeled under name and time of doctor who took
the specimens,police officer who received and dispatched time of the specimens
Consent for medical examination and treatment
Consent from parent or guardian
By police officer with written order for examination (Borang P59)
If ordered to by a Child Protector (gazetted JKM officer)
A child is brought for examination by parents or guardian
eg.for pain in genitalia or on passing urine.Police reports are not required. per se instance child has
not given a history of sexual abuse
Parents should be around during the time of examination and this should be documented in the
patients note
Doctors should lodge a police report themselves after examination if there is a strong suspicions of
sexual abuse and parents reluctant for report
Consent and / or coorperation by child is essential before examination to avoid further
traumatize .EUA may be necessary in younger distressed children
SODOMY
 Sexual intercourse between 2 persons by introduction of penis into the anus of another person

Malaysian Penal Code (Kanun Keseksaan) Section 377 (a)

-any person who has sexual connection with another person by introduction of penis into anus or mouth of another person
is said to commit carnal intercourse against the order of nature
Section 377 (c)
-when the above act committed witout the consent or against the will of another person , or by putting the other person in
fear of death or hurt to the person or any other person
Section 377 (CA)
-The above offences is committed by introduction any objects into the vagina / anus of the other person without the other
person’s consent
Acute case

Also known as fresh cases

Up to 120 hours from the time of incident
Triaging in ETD

Stable patient ( Presented within Victims > 120hours since

specific time frame ) assaults
-Assigned priority in triage then -Complete examination should still
directed to OSCC done to examine injuries to the
-To be seen within 90mins upon bodies and genitalia
arrival at OSCC -To offer treatment and provide
information for support resource
Semi critically and critically ill
victims
-Attended at acute area at ETD and to
be transferred to respective
department
Collection of clothing

Survivor clothing collected in paper bag

Each item to be packed in individual paper bag with label , sealed and documented

Method of collection
1. Survivor to stand on 2 sheets of clean paper on floor
( Protect evidence on clothing from being contaminated by debris or dirt on floor)
2. Remove shoe prior to stepping on paper , shoes to be collected and packages separately
3. Clothing collected should not be shaken to avoid loss of microscopic evidence
Laboratory examination

Blood taken for DNA

Blood send for STD screen , Toxicology and drug abuse

UPT ,toxicology and drug abuse

All trace evidences, clothings , swabs, blood samples for toxicology are to be
sent to Department of Chemistry

STD profiles and swabs for culture to be sent to hospital pathology laboratories
Forms used in OSCC
References
Thank you for your attention
KINDLY ASK FOR ANY QUESTIONS