Steve Macabee (00:00.133)
Welcome back to the P-Pod, the partnership podcast from the Somerset Safeguarding Children Partnership. Now, the Domestic Abuse Act in 2021 brought about a number of really significant changes relating to the safeguarding of children. Some of the most well-known changes, including the definition of what domestic abuse actually involves, and that expanding to include controlling coercive behaviour and the very important fact that children who witnessed domestic abuse are classed as victims of that abuse. Now, one thing that isn't so widely known is about the additional knock-on effect that this legislation had on the Serious Crime Act of 2015, which was amended to introduce two new sections, Section 75A and B, which creates a whole new and specific criminal offence on the topic of non-fatal strangulation and suffocation. So the question is for today, what does this have to do with safeguarding children?

Well, it follows concerns that perpetrators were avoiding punishment as the act often leaves no visible injuries, making it hard to prosecute and take action under existing offenses such as ABH. But additionally, studies have shown that victims are seven times more likely to be murdered by their partner if there has been non-fatal strangulation beforehand. And in domestic abuse, up to 44 % of victims have reported being strangled. And homicide reviews show that victims of non-strangulation are seven times more likely to be killed at a later date. So to talk with us today about this really important topic, we have Dr. Lou Newbury, the named doctor for child safeguarding, who is passionate about this subject and keen to talk with us today. So Lou, welcome along to the Peapod. Great to have you joining us today.

Dr. Lou Newbury (01:48.512)
Hi Steve, thanks for having me. It's great to be here.

Steve Macabee (01:52.205)
No, thank you. I know this is an area that you're really passionate about. before we get into the subject of today's episode, could you just kind of explain what your role is and sort of your involvement in the Safeguarding Children Partnership and wider?

Dr. Lou Newbury (02:06.326)
Yeah, so I'm the named Doctor for Safeguarding Children for Somerset Foundation Trust. It's a really big trust now. We've got two acute trusts, the hospitals. We've got all the MIUs, CAMs and several other services within our trust. So it's a big old unit, Somerset Foundation Trust. So I am the medical advisor to the team. We've got a big team.

of safeguarding professionals and I'm the medical advisor for that team, both for the doctors and nurses that work in the trust, but also for the multi-agency working that we do within the partnership as well. So I provide medical advice for that too. And I've come from a background of general pediatrics. I was a general pediatrician for a number of years. And then I went off for a couple of years to work in sexual offenses. So...

and that's where I first became interested in strangulation as part of that work down in Devon and Cornwall. And then I've come back to Somerset for this role.

Steve Macabee (03:09.093)
Brilliant. Thank you, Lewa. It's great to have you here because I know you're a wealth of knowledge and experience, which brings a lot to the work into the partnership and safeguarding children. So thanks for joining us here. And before we kind of really get into the subject, could you explain, kind of laying the baseline really, of what is non-fatal stand-glation and why is it such a significant concern? I guess both in the context of safeguarding children and protecting adults as well.

Dr. Lou Newbury (03:13.262)
you

Dr. Lou Newbury (03:37.294)
So it's really interesting. The definition of strangulation is a tricky one. And for a long time, the courts were quite hung up on the definition of strangulation. But luckily, they have removed that now. And the criminal justice system is quite clear that actually what it reports to is pressure on the neck. And that's basically what strangulation means, pressure applied to the neck. And that is the

definition of the act where pressure is applied to the neck. That's different from suffocation. In fact, the two parts in the act are slightly separate, suffocation and strangulation. Suffocation is impeding air or oxygen to the person, but is not the same as strangulation, which must have the pressure to the neck. Both have the same effect.

But the effects of strangulation are not just a lack of oxygen or a lack of being able to breathe, but also lack of blood flow to the brain. And that's the really devastating part of strangulation as opposed to suffocation. And the difficulty is the real trouble with strangulation. I'm sorry, I have to stop. Let me do that bit. think, sorry, I'm waffling. Go back, I think. Yeah, sorry, I'll start again.

Steve Macabee (04:55.781)
That's fine, not a problem at all. Do you me to ask the question again, start from the beginning? No, it's not a problem at all, honestly not a problem. So let me just go up a little bit here. Okay, you good to go? So to begin with, can you just explain to us what is non-fatal strangulation and why is it so significant in concerning and in terms of the context of safeguarding children and adults, I guess?

Dr. Lou Newbury (05:24.696)
So that is really interesting. strangulation, really the definition of strangulation is application of pressure to the neck. And that's different from suffocation and the two parts are actually separated in the act, suffocation and strangulation. So suffocation involves reducing or emitting air to the person or oxygen to the person. But that's different from strangulation, which is specific to the fact that there is pressure to the neck.

They can have the same effects, so there is effect on breathing for both offenses. But the other real trouble with strangulation, and the thing that makes me really concerned when I hear that someone's body's been strangled, is the damage and effects on the other structures in the neck. And the neck is such a vital part of the body, because it has so many.

vital structures that are that if damaged or if pressure is applied to them can lead to death and can lead to catastrophic consequences. So it's not just the airway. So there's pressure to the airway which can which can result in lack of oxygenation to the brain but also pressure to the blood vessels and there's both arteries and veins in the neck. Arteries are thick walled, veins are much thinner walled.

The arteries take the blood flow to the brain and the arteries bring the blood flow away. If a more minor amount of pressure is applied to the neck, that then affects the blood vessels, the veins and the jugular vein, the amount of pressure applied to occlude the jugular vein and stop the blood coming away from the brain is about four pounds per square inch.

The pressure to occlude the carotid artery is much higher. So that's 11 pounds per square inch. So to stop the blood flow going to the brain is 11 pounds per square inch. Whereas to occlude the trachea, so to stop the air going up and down through the windpipe, is 34 pounds per square inch. So the amount of pressure varies as to which structures are affected. So that's just to stop them working. But then the pressure applied, it more than that again,

Dr. Lou Newbury (07:43.254)
actually can permanently damage those structures. And the difficulty is, the problem is with the carotid artery is that if you apply a lot of pressure to that, it can then lead to what's called dissection of the artery and the artery, the ballooning of the wall of the artery and the blood flow going to different places and outside the artery and big blood clot formation. And that leads to stroke and it's really dangerous. But equally,

pressure to the vein causes stagnation, a bit like having a dam in a river. You have blockage of the blood coming away, which eventually backs up and stops the blood coming into the brain, but also again increases the stroke risk, but also increases the risk of having a bleed inside your head. So those vessels are so important. If you block either of those, you affect your brain. If you affect your brain long enough, bad enough, you have brain damage and then you also can die.

it's not, but that pressure it sounds you know quite abstract what's four pounds per square inch, what's eleven pounds per square inch, what's thirty four pounds per square inch. To put it into context to open a can of coke it's twenty pounds per square inch. So you can occlude those blood vessels less than opening the pressure you put to opening a can of coke. And then an adult male handshake because you know we all know those men that we go and shake hands with and out our hand hurts afterwards. I'm sure you have one like that.

Steve Macabee (08:49.741)
Okay.

Steve Macabee (09:05.761)
There's a bit of a strange dominance thing that goes on sometimes with handshakes. I've got to be honest. It's a bit strange.

Dr. Lou Newbury (09:06.412)
See?

Yeah, yeah, yeah, there is. Well, the average male handshake is 60 to 80 pounds per scrunch. So actually to include your trachea, the windpipe is less than, much, is less, it is almost half of what an adult male handshake pressure is. So that pressure is not very high. So you don't need much pressure. And there are some bits, such structures in the brain, which are absolutely devastating if they get affected.

And then there's also other structures in the neck. So there's also these areas that affect how the heart works. So there are nodes which control heart rate. And if you apply pressure to those areas, the heart can just stop. And that's what's thought is why some

people are killed by strangulation but have no evidence of damage to their neck. And that's because the pressure on these areas in the neck affects, slow down the heart rate to such an extent that the heart just stops beating. And that pressure, we don't know exactly what that pressure is, but it's probably even less than that to occlude the blood vessels. So pressure to the neck is really, really dangerous. And that's why I get really upset when I find a heal at somebody's.

had pressure applied to their neck.

Steve Macabee (10:38.969)
Yeah, no, absolutely. And you mentioned around legislation and definitions. And sometimes when you sort of see a change to definition, seems sort of fairly minor. But like you said at the start, it's so important that that definition is correct. Because when things get to court, things can be very easily thrown out if it doesn't meet that exact definition, isn't it? And then we're in a very difficult position of kind of sometimes arguing semantics about why something is really important, but it didn't quite fit that. The same as we talked about the expansion of the

classification of domestic abuse, including controlling coercive behavior, because up until that point, when you get to court, it's really hard to sort of say, well, actually, this has had a big impact on a victim, even though it doesn't quite fit the current classification, which makes it very difficult. So I think it's really key when you see these changes, just understanding how important they can be sometimes, and like say, how, as you've already explained, how important this is for people to really understand, which is why we're keen to talk about it today, really. So I'm just...

Dr. Lou Newbury (11:33.186)
Yeah. Yeah. I think people are quite scared to use the word strangulation. first of all, of strangulation often don't use the words, don't use the words, I've been strangled. They, in my experience, they rarely say I've been strangled. They very, they never say I've been non-fatally strangled. So the definition for the act is very different from what people tell you. And it's very different from what the professionals use as well.

So children particularly, but adults too, do not say I've been strangled. They say I've been choked. They say I've had something put around my neck. They say my jumper was pulled around my neck. They say he put his hands on my neck. They say he leant on my neck. They say he, and I'm saying the word he because unfortunately this is a gender-based crime and overwhelmingly, unfortunately the perpetrators are men.

So the words used by the victim and victims are usually women, except when you come to children, which is really interesting. So children, male-female divide in victims is not the same as in adults. There's very little research on children at the moment. It's coming, but it's not there yet.

But it looks as if, certainly from my personal practice and from the stats that are coming out so far, the division is much less male to female for victims when they're children. But any victim does not say, I've been strangled. They say all of those other words. And actually, the definition of strangulation is interesting as well in that there are lots of different modes of strangulation. And that's really interesting too.

And depending on the mode, depends on what symptoms and signs we find in victims. So for example, you can have manual strangulation where one or two hands are placed around the neck. You can have a choke hold or a sort of a neck hold with the arm, which produces far less symptoms and actually that we rarely see, sorry signs, we rarely see signs of strangulation in the...

Steve Macabee (13:32.623)
Right.

Dr. Lou Newbury (13:54.506)
in the choke hold version of strangulation. There is ligature. a ligature isn't necessarily a rope or a cord. It could be a jumper. It could be the neck of a shirt, a school tie, we've had. Hanging, of course, which is different again, and there's different pressures and different modes of injury within hanging. And then pressure on the neck from a foot or a knee or a leg.

And actually that is as much in the act of non, in the definition of non-federal strangulation for the criminal justice system as is hands around the neck or an arm around the neck.

Steve Macabee (14:32.982)
And that's like we saw with George Floyd over in America, it? From his murder, being nailed on his neck.

Dr. Lou Newbury (14:36.524)
Yeah, of course.

Yeah, yeah. Kneeling is especially, again, if it's an adult male, kneeling on the neck can cause considerable amounts of injury.

Steve Macabee (14:49.445)
I'm just picking up from that. If we talked about in the introduction, often non-fatal strangulation often leaves no visible injury, as you've just mentioned. So with that in mind, are there any sort of common signs or symptoms or indicators of non-fatal strangulation that people should be aware of?

Dr. Lou Newbury (15:08.334)
Yeah, so that's really scary. about we know, we do know from adult victims that about 50 % of victims have no discernible injury on the outside, which is really scary. So, you know, I've heard time and time again, well, we don't, they said they've had something put around their neck, but we don't think they've been strangled because they've got no injury that we can see. But actually it is common not over 50 % have no injury at all.

Steve Macabee (15:18.201)
Mm.

Steve Macabee (15:34.469)
Because that's what I'm thinking, because often if somebody sees a bruise somewhere, I'm to put this in quotation marks, easy or easier to say, ah, okay, something has been committed. There's an injury there, we can see that and we can take action. But when there's no sort of physical bruising or injuries or marks, like I say, it's quite challenging, isn't it?

Dr. Lou Newbury (15:44.098)
Yeah. Yeah. Yeah.

Dr. Lou Newbury (15:54.922)
It is some, is really, yeah, it is much more challenging. But what's particularly challenging is that we know that almost one in 50 victims of strangulation have internal injuries. And that's the scary bit. So when I'm saying about you can have it damaged to your arteries, you can have damage to your vein, you can have damage to your windpipe, you can have a fracture of your windpipe.

Steve Macabee (16:07.674)
Right.

Dr. Lou Newbury (16:19.918)
those are all internal injuries and you can have all of those with nothing being seen on the outside. So about one in 50, what's really interesting is that goes up to considerably to 70 % of victims when you've had loss of consciousness. So if you have been rendered unconscious during your strangulation, you've got a 70 % chance of internal injury, which is far higher.

Steve Macabee (16:47.557)
Wow. Yeah. So.

Dr. Lou Newbury (16:50.638)
So we've gone from one in 50 to 70%, the 2 % to 70%.

Steve Macabee (16:54.553)
Yeah. So is this really sort of a case or am I right in thinking from what you've been saying then? There's nothing, no obvious sort of common, immediate kind of signs and indicators. Is that right? And it's more about sort of... Okay.

Dr. Lou Newbury (17:10.798)
There are some. So common signs of strangulation are bruising. So 50 % do have external injuries. So the common things to see are bruising or blood point or pinpoint bruising, which are called petechiae. So bruising or petechiae to the neck. then these little blood spots, petechiae to

the area of drainage of those vessels that were in the neck. So you're going to have them over the face. The face can look a different color. It can look kind of purple or blue. You can see these little tiny black or purple or red spots over the cheeks, over the eyelids, and over the forehead, and also sometimes around the ears as well. So you can have these little blood pinpoint

bruising over those areas. And then you can also have subconjunctival hemorrhage. You can have the red bits in the white of the eyes, the bleeding into the whites of the eyes as well can happen. And that's all through the lack of drainage of that area. And it was we talked to already that that's caused by a lesser pressure than the occluding the blood supply to the brain. But the

If the person is rendered unconscious, that means that they have had either occlusion to the blood vessels supplying blood, the arteries, or to the windpipe. And those things imply a bigger pressure than the blood spots. But as I said, 50 % have nothing at all. So for predicting internal injury, what we need to do is know those...

Steve Macabee (18:55.941)
Mm.

Dr. Lou Newbury (19:02.946)
those symptoms that people may have had around the strangulation event. So were they unconscious? Did they have incontinence? So did they wet themselves? Did they poo themselves? Did they have incontinence of feces? Did they have a fit? And have they got loss of memory? So loss of memory implies that they had a lack of oxygen to the brain or lack of blood supply to the brain.

Memory is stored in an area of the brain called the hippocampus and it works quite slowly, the hippocampus. So if you don't get blood supply to it, you lose memories. So people again may say they may well not say I was unconscious or I wet myself. They might say, I don't remember what happened. And if they say they don't remember what happened, then it's likely that they have had a reduction in blood supply and oxygen to their brain.

Steve Macabee (19:58.213)
And I guess, just going back to your introduction at the start there about your role in that advisory role, I guess a large part of it would be around the emergency departments, I presume, in terms of sort of what they may see coming through the doors.

Dr. Lou Newbury (20:12.074)
Yeah, yes, I get quite a few calls from ED saying, you know, what should we, you know, we've had somebody who's convicted of being sanguine, what should we do? And so what we have is a really clear risk assessment for victims of strangulation, which includes things like, have they got any bruising? Have they got any signs of reduced blood supply or reduced blood drainage from that area? And then about the symptoms as well. So were they unconscious? Were they? Did they have incontinence?

And based on those, will then potentially scan somebody with a CT angiogram of their neck and also think about whether they have an MRI or a CT of their brain as well. The angiogram of the neck is to look for those things I was talking about with the blood vessels where you can have a dissection of the artery.

because we know that that's a really high risk for stroke. And also we'll often start these patients on anti-stroke medication before we've even got to scan. we are, know, increasingly this is new guidance over the last couple of years. And this is, you know, we are really keen that these patients, if somebody complains of strangulation, they are seen medically as soon as possible. And we will start them on anti-stroke medication, sometimes just aspirin, but sometimes more advanced anti-stroke medication as soon as they come through the door.

Steve Macabee (21:10.5)
Okay.

Dr. Lou Newbury (21:31.822)
depending on their risk and then we will scan them either neck or neck and brain to look for complications of the strangulation. And that's so important because in the past only about 5 % of strangulation victims have come to medical attention and so we're really keen that anyone who's complained of having been strangled is medically assessed as soon as possible to prevent those.

those fatal complications, which can happen up to a month afterwards. So you can stroke up to a month after your strangulation. And it's thought that potentially young women who have had strokes, then it may be a real unknown number of those who have been strangled. Because women don't always say that they've been, you know, don't admit that they have been strangled as part of their domestic violence.

or don't admit to domestic violence at all, of course.

Steve Macabee (22:28.645)
Yeah. Yeah. I'm just, just thinking from what you were just talking about just then, and I think potentially there's a risk with this. Obviously we get a wide variety of different professionals listening to the P pod and I think there's a risk with this potentially that people might be listening to this thinking, okay, well, this is really a medical issue and it's not for us. But I guess from what you're, what you've been talking about already, I guess we've got kind of three layers to this already. First, the first layer about listening.

to victims or potential victims and understanding the language and what they might be selling us. And we talk about professional curiosity a lot of the time. So it's about that sort of curiosity about just exploring that a little bit. So you've got that sort of first layer. Then you've got that kind of second layer of triage, I guess, of asking those questions that we've been about, of, you know, do you remember what happened or, you know, all these kinds of things. And then that third layer, which is more of the medical intervention around potentially doing scans and what have you. So I...

I guess for me, of the kind of key parts of this is that anybody, as you've just been saying, can absolutely play a vital role in those first two aspects in terms of listening to victims and in terms of asking those curious questions and trying to do that kind of initial, triage is possibly too strong a word really, but just trying to understand the context a little bit and then having the alertness to say, okay, this is kind of ticking some boxes, which says there could be quite a significant medical risk here.

and then potentially sort of referring into the hospital or for medical intervention to look at those scans. Would you say that was kind of accurate?

Dr. Lou Newbury (24:06.222)
Yeah, definitely. you've got to remember this, two things. So there's the fact that there is a stroke risk for any victim of strangulation, that's really important. And then the second thing is that we know that if you've been strangled, you are seven times more likely to be murdered. So that, if you hear that somebody has been strangled as part of your professional work, you need to take this needs to be taken really seriously, both risk assessment globally for their long term health, for their long term health and well being.

you know, generally, but also medically, that they are at risk of stroke. And also, you need to deal with it quickly as well. This can't be something that can be, you know, if you hear somebody has been strangled in the last previous 24 hours, or previous couple of days, this is not something that can be just processed in your normal ways. you think this, know, for example, for instance, a child, could be part of physical abuse. This is not something to...

sit and have a stress in a refer for a strategy meeting in a number of days. This needs to be dealt with acutely. This needs to be dealt with on the day. As soon as you hear this person needs to be referred to police, to Children's Social Care and to medics for medical assessment. This cannot these victims cannot sit around waiting for a multi-professional response in four or five days time. This needs to be dealt with now here today and I would suggest if it happens out of hours it needs to be dealt with within hours of hours.

response as well. But it needs to go right the way through to, you know, also to health professionals, you know, that when we hear that someone has died in their 30s and are female of a stroke, we need to think, actually, has that person had a post-mortem? Have they had their neck vessels looked up because there is a risk that they have had strangulation as part of the causation of their death. So it has to go through, it goes through all the layers of practice.

Steve Macabee (25:56.709)
Mm.

Mm. I just, just taking this back a little bit, actually to something you said a moment ago about, sort of gender-based violence when it, when we're talking about adults. and often with, with that, we might be thinking about sort of, sexual violence as, as well. And I'm just thinking as you're talking, I know there's been numerous studies now around, modern pornography. And we've talked about that on some previous episodes and that showing that in that

quite significant increase in those trends around sort of domination of women, particularly as part of sexual acts, which often sort of includes choking as a sexual act. Is that something you see coming through in terms of, choking and how does choking, I'm gonna again use air quotations that nobody can see here, but how does kind of choking relate to kind of non-fatal strangulation and that kind of risk that we've been talking about?

Dr. Lou Newbury (26:55.886)
I I'm not 100 % sure which way round it is. So is it that there is a rise in choking as part of pornography, that there's then needing to increased choking or strangulation as part of gender-based against sexual assault? Or is it we're just hearing it more and we're more open to hearing about strangulation as part of and we're asking the question? And I think if you don't ask the question, you don't know.

But we know there's some really interesting stats out from St. Mary's, which is the largest center for seeing victims of sexual assault and rape. And they found that in adults, one in 11 women that they were seeing, strangulation was part of that. I say women, actually, some of these were men. So...

They had two out of 200 over 200 cases that they took for it was a they took a certain amount of time as a 200 just over 200 cases. They only had three cases where the offender was a female and two cases where they offended they didn't know where they were female or male. So actually this is this is again a male based offense.

But they found that one in 11 of their victims that they saw had strangulation as part of their offense. And that's a huge number more than certainly when I was doing the work. I've been working sexual offenses on and off for about 15, 20 years now. And those numbers are far higher than when I started, definitely. But again, I'm not sure that I ever asked the question specifically. But then what's really interesting is that it goes up to one in five.

if this offence was by a partner or an ex-partner. So is it that domestic violence is increasing or is it that this is part of sexual crimes from pornography? And I would suggest that the fact that it's higher from a partner or ex-partner is actually that domestic violence is increasing and also part of that and part that we're asking the question more often.

Steve Macabee (29:09.029)
No, it's interesting in there. And I think just picking up from the other thing you said a while back. So when we're looking at adults, like I say, often gender-based violence, believe, I might be wrong with this, I believe 90 % of victims are female in adults and about 10 % are male. So it's not exclusively sort of violence perpetrated from men towards women, but vast majority is. But then you mentioned when it comes to children, we see quite a different picture.

Dr. Lou Newbury (29:25.622)
Yes, yeah. Yeah. Yeah.

Steve Macabee (29:38.307)
And it's, and is it still mainly sort of perpetrated towards girls or is it boys or mix?

Dr. Lou Newbury (29:38.466)
Yeah.

Dr. Lou Newbury (29:43.83)
So no, so with children, it's very different. So if it's part of a sexual crime, then it's mostly girls again. So, for example, we see a group of where these are, there are teenagers, young women who are raped or sexually assaulted. then, and in that group, it is much more women than men. But in the younger children, where this is more, where there's the sexual

abuse or sexual violence is not part of the pattern that we're seeing in these children, then they seem to be much more equal and in fact almost slightly more boys that are affected than girls, particularly in the young teenage years, so at 10, 11, 12 it seems to more boys than girls. So it's really interesting, there's definitely different rates depending on the age of the individual that's been affected.

Steve Macabee (30:25.125)
Right.

Steve Macabee (30:43.461)
Do you see any sort of similarities or any kind of indicators around risks, around vulnerabilities around this? Or do you see quite a broad spectrum?

Dr. Lou Newbury (30:56.59)
I think it's broad for children. It is broad. Apart from, as I said, those spikes with young girls and teenagers with rape and sexual assault. And then in the younger children, it's much more broad, except that we definitely see an increase in those who are already living in a violent household. So if there is a history of domestic violence, there is an increased risk that there is going to be strangulation as part of the physical abuse against these children.

So if there is a history of domestic violence, if there's a history of strangulation against the women in that family, then definitely there's an increase in strangulation, both against girls and boys in those families. And then there's an increase, I think, in boys who've experienced trauma. And again, that's those often who are living in those households. So boys who've experienced trauma.

who have the sort of behaviour that's sometimes labelled as ADHD, or indeed boys who do have a diagnosis of ADHD, they seem to be more vulnerable for strangulation as part of either parental response to their behaviour or as part of further physical abuse.

Steve Macabee (32:16.225)
Thank you. I think the other thing that I'm thinking about is, yeah, we've talked about how challenging it can be sometimes to identify sort of risks when they're there and the importance of listening to people, listening to children, young people, listening to adults and trying to understand what they're saying and that sort of initial triage of questions. I guess the other key part of this, and you mentioned a moment ago about

the importance of agencies working together and health services, working with children's services, working with the police. And what would you say from your experiences is really key around that sort of multi-agency collaboration, communication when we're talking about non-fatal strangulation, if it's so difficult? what have you seen works, really works?

Dr. Lou Newbury (33:02.508)
I think there's two things. One is language. So it is about translating what the person has said to you using their own words, absolutely, but also putting with that a code for other professionals. This is strangulation. So sometimes, absolutely, one needs to reflect the words, wording used by victims, but also to translate that for other professionals. So.

If one were to make a referral saying this person says they have had something applied to their neck, that does not hold the same level of urgency as this person says they've been strangled. And I think it is absolutely vital to have the words that the person's used, but also to, as I said, to put up that red flag to say, this is strangulation. So it's about that interpretation. And then rapidity. If somebody tells you they have been strangled,

this needs to be an urgent response. There needs to be urgent referrals and then a multi-agency response needs to be urgent. And as part of that medicine, there needs to be medical attention. So it's really important to have that balance that you have to use the words the person's used, or the child or the adult has used, but also to just have that interpretation, that translation to set off the bomb.

Steve Macabee (34:25.529)
Mmm.

Dr. Lou Newbury (34:27.222)
that needs to happen within multi-agency services.

Steve Macabee (34:30.639)
That's what I'm thinking. Cause yeah, it's like you say, you could say, yeah, no, something happened and they were grabbed. They grabbed him around the neck. And it doesn't, like you say, you can kind of go, well, that's not, that's not good, but that's it. But like you say, the importance of people listening to this to understand actually how crucial that can be to pick up on that and understand.

implications of it and like say that the urgency then to actually deal with that situation respond to that situation not just are we grabbed around the neck full stop.

Dr. Lou Newbury (34:59.107)
Yeah.

Yeah, yeah. Because grabbing around the neck is serious and can have fatal and devastating consequences. And if not immediately, later on down the line. And so absolutely that needs and some of the most injured children I've seen have had has been around the clothing being tightened around the neck as part of a grab. And actually that can really cause significant injury. I hope we had a case.

of a child down in Devon who was really, really significantly severely injured. And that was again, yeah, a grab of her clothing around her neck, which caused the problem. So clothing is as dangerous. It is a ligature. It can be a ligature. So yeah, so it is about that translation and that urgency of response for me. That's so important.

Steve Macabee (35:48.108)
Mm, absolutely.

Steve Macabee (35:55.225)
Yeah. Have you got any sort of examples of where non-fatal strangulation was identified and how it was handled, either positively handled or not so well handled?

Dr. Lou Newbury (36:07.33)
Yeah, so there's quite a well-known case with part of the strangulation. So there is an Institute for Assessment of Strangulation and Advice within the US and they talk about a young lady who's quite happy to share her details, who was a nurse and she was strangled first time on honeymoon and then

her sucker tags were strangled. She, six days later, didn't feel quite right and had a bit of a sore neck, so attended, walked into an ED. And the examination, she just had a little bit of bruising behind her ear as part of this. But because she did have a sore neck, she was scanned. And she had almost complete, I've seen her imaging actually on a training event, and she had almost complete.

dissection of her neck vessels and also the bruising on the back of her ear was actually where her muscle had been pulled off the bone behind her ear. And she was at risk of having a stroke at any minute and luckily she had appropriate prevention against stroke and this has healed but it takes a long time to heal. So she had nothing else apart from one small bruise behind her ear. The images are really shocking.

Steve Macabee (37:12.611)
Wow.

Dr. Lou Newbury (37:32.366)
And then I saw a young lady, a 14 year old girl when I was working this arc, the sexual assault of her, was sent down in Devon, who just came, when she came, she was whispering to me and I, she didn't mention anything. She hadn't said anything to police before she'd given a full account to police before I saw her. She hadn't mentioned anything to police about being strangled. She had said that she had, but she did say she was grabbed around her neck as part of the...

as part of this offence. I just, it was just very interesting that she just was whispering throughout the consultation. I thought it was just that she was really traumatised by it. was a very violent offence. But actually, because she was, she did also say she had a bit of a sore throat. So she also had a bit of a sore throat. She didn't remember all of the event.

Steve Macabee (38:10.309)
Mm.

Dr. Lou Newbury (38:29.452)
So we're coming back to those things that I've said already, memory loss, sore throat, and then just this whispering. actually, if you've got to speak louder, then as I was examining her, was asking him more questions. If I asked her to speak louder, she did have a hoarse voice. And when we sent her for scan, we sent her in the end to A &E for a scan, and she had a complete fracture of her hyoid bone, one of the bones in her neck. And I would never have picked that up.

Steve Macabee (38:30.698)
Mmm, absolutely.

Dr. Lou Newbury (38:56.462)
from examining her neck at all. had nothing in her neck to suggest that, but just the symptoms. it's that people who've got problems, difficulty swat, she also had bit of difficulty swallowing, people who've got a raspy, a hoarse voice, people who don't remember what happened, memory loss.

Sometimes people who've been strangled are really restless and combative. And actually, sometimes they're combative is the reason why they were strangled in the first place and that carries on or is even worse. They can be quite agitated. It can lead to PTSD. This young lady did end up having quite severe PTSD. And I can lead, if you've been strangled repeatedly and you've not told anybody about it, that can happen in children sometimes. It can lead to a reduction in school performance, a reduction in intellect.

Steve Macabee (39:27.205)
Mm.

Dr. Lou Newbury (39:46.23)
is repeatedly having no oxygen to your brain. then fear, fear is really paralyzing. can really affect people, not only at the time of your strangulation. And people often don't struggle during strangulation because they're so scared. They have a huge proportion say, I thought I was going to die. And actually, they often don't struggle, which is really, really interesting.

Um, so they're not only is this risk of, of, of stroke, there's the risk of, of psychological trauma going forwards for the rest of your life. When you've been strangled, is, you know, can have problems, the vision, the problems, hearing. Often people will say, I've got like, had like ringing in my ears or sounds a bit bubbly or, um, my vision can be a bit blurred, but, they can hallucinate.

Steve Macabee (40:19.653)
Mmm.

Dr. Lou Newbury (40:38.638)
So lots, of kind of, know, and she had several of those, but it's only since I've learned about, and it was because of her case that I learned more about strangulation, which is why I'm so interested in it now. it's putting those things are quite nonspecific often and quite kind of, are quite nebulous symptoms. But actually, when you put it together with somebody that has been strangled, then that's really significant.

Steve Macabee (40:49.189)
Mm.

Steve Macabee (41:04.889)
Yeah, absolutely. And obviously, this isn't something that's new, as we talked about, but obviously with the change in legislation, sort of really highlighting this area. Is there anything that you can signpost to for other professionals or for parents to sort of better understand the subject, to understand it, to prevent it, to respond better to non-fatal strangulation? Are you aware of anything that's out there?

Dr. Lou Newbury (41:29.954)
Yeah, so the Institute for Addressing Strangulation in the US, and they, for a long time, have provided lots of training and education. And there is now a UK branch as well. So if you look online at the Institute for Addressing Strangulation, and we can put a link to it at the end of this podcast, then they run regular training events there online.

sometimes they run from America, sometimes they run from the UK. They are, I can't tell you how universally fascinating they are. They're multi-agency training. have lots of professionals from lots of agencies, not just me, but burbling on today. But they have, it's fascinating. They have psychologists and police officers and all sorts of people. So.

their training is, I can't recommend it highly enough, they do a one day, a two day and a half day sessions, but they also have lots of resources as well. And what's really helpful for your agency, if you want to think about how to pick up signs and symptoms, they have really good drawings of, they have a cartoon drawing of a child and an adult with the symptoms and signs on them of strangulation. And actually it really helps to focus.

the mind on what the person may have and what you should be looking for. And I've certainly done some training with the EDT for children's social care, and they have one of these pictures up on their wall. So it really helps to just think about that. It helps you to focus on what to look for and what to ask about when you come across somebody who's been strangled.

Steve Macabee (43:08.165)
Yeah.

Fantastic. Lou, thank you so much for that. think that's been so insightful, just understanding it better. Because like you say, I think quite often there's a habit of just kind of dismissing things, saying, it was just this, but actually the importance of it, like I say, not just the immediate risk, which obviously there is, but also that greater risk around further abuse or death. Then we've got the medical risks there, which can be really, really significant, but also that longer term impact. And so yeah, the importance of people listening to this and understanding it as a better as a subject and knowing how to respond to it better and quickly has been absolutely key and so good to hear your kind of insight into it all. Is there anything locally you can signpost to, any sort of local guidance or anything else?

Dr. Lou Newbury (44:18.642)
Yeah, so we're currently developing guidance, so watch the space, it'll be there soon.

Steve Macabee (44:24.537)
Perfect. Lou, thank you so much for your time today. Really appreciate it. It's been fascinating to talk about this. 

Dr. Lou Newbury (43:59.086)

Thank you very much for having me as I said, and hope that people can also of course always contact me if they've got further questions.

Steve Macabee (44:07.375)

Perfect, thank you  Well, yeah, if you're happy we'll pop your contact details in the link for this.