Rarely Identified Violence Presentations in a Virtual Emergency Department
Family, domestic and sexual violence presentations almost disappeared into the background of a very large virtual emergency workload. Over one year at the Victorian Virtual Emergency Department, just 21 cases were identified among 173,936 presentations, a rate of 0.012%. For a service designed to widen access and reduce pressure on brick-and-mortar emergency departments, the finding is stark: violence-related care is present, but it is not being surfaced often enough.
The study examined presentations between 1 July 2023 and 30 June 2024 and used multiple data sources to capture eligible cases, including VVED records, injury surveillance, and clinician documentation. Records were filtered by age, sex, and injury intent before file review confirmed eligibility. That layered approach matters because family, domestic and sexual violence rarely arrives as a single obvious complaint; it is more often embedded in pain, injury, fear, or a carefully chosen explanation. A virtual emergency setting can make that even harder to detect, especially when the consultation depends on short encounters, incomplete visual examination, and the patient’s willingness to disclose danger at home.
Head and Neck Injury Patterns Framed the Presentations
All 21 identified patients were female, with a median age of 37 years. Most were born in Australia, at 86%, and 62% lived in socioeconomically disadvantaged areas. Intimate partner violence accounted for 81% of cases, making it the dominant violence context in this cohort. Injuries above the clavicle were the most frequent presentation, representing 53% of cases and involving the head, face, and neck.
Those injury locations are clinically important. Trauma to the face and neck can reflect direct assault, restraint, grabbing, choking, or repeated blows, and these regions also carry higher concern for occult injury, airway compromise, and escalating coercive control. In a virtual environment, the physical exam is inherently limited, so the burden shifts to history-taking, observation, and clinical suspicion. A bruise, swelling, or laceration may be visible on camera, but the broader pattern of violence, fear, and immediate safety risk can still be missed if the consultation remains narrowly symptom-focused.
Virtual Triage Did Not Eliminate the Need for Escalation
Most patients reached the service via healthcare professionals, accounting for 76% of referrals. One-third were directed onward to physical emergency departments, while most were managed virtually with follow-up arranged through general practitioners or other healthcare providers. In practical terms, the virtual ED was not a dead end; it functioned as a triage node, a place where some patients could be stabilized and referred, and others could be linked to ongoing care outside the emergency setting.
The challenge is that this model depends on recognition. If violence is not identified, the patient may leave with treatment for the injury but without safety planning, advocacy, or a pathway to specialist support. In that sense, the clinical consequence of under-detection is immediate and concrete. A missed disclosure can close off opportunities to ask about danger at home, assess the risk of repeat harm, and choose a safer follow-up plan.
Under-Detection Is the Central Clinical Signal
The rarity of identified cases does not suggest that violence is rare in the population using the service. It suggests that under-detection is likely. Virtual emergency services can lower access barriers for patients who may be unable or unwilling to attend a physical ED, especially when travel, surveillance by an abusive partner, or fear of exposure shapes care-seeking behavior. Those same features can also suppress disclosure. A patient speaking from home may be overheard. A brief video interaction may not leave enough room for sensitive questioning. Documentation may not capture the cues that would otherwise trigger safeguarding pathways.
There is also a demographic pattern worth attention. The concentration of patients in socioeconomically disadvantaged areas fits established clinical reality: violence disproportionately affects people facing material stress, unstable housing, limited transport, and reduced access to confidential support. Virtual care may help overcome some barriers, but it does not erase the social conditions that make disclosure difficult. When the service is mediated by digital access and brief review, the system must work harder to notice risk rather than assume it will emerge naturally.
Documentation and Training Became the Weak Link
The findings point directly to clinician training, documentation, and referral pathways. Those three elements determine whether a virtual encounter becomes a safe intervention or a missed opportunity. Training needs to help clinicians ask about violence in a way that is feasible in telehealth and virtual emergency workflows, while also recognizing injury patterns that should prompt concern. Documentation needs to be specific enough to preserve clinical suspicion and support downstream follow-up. Referral pathways need to be simple, visible, and ready to use when a patient cannot safely continue care through routine channels.
The study’s design reinforces that point. Cases were not pulled from a single coded field; they required review across multiple data sources and eligibility filtering. If researchers needed that much effort to identify 21 cases, routine clinical systems are unlikely to capture the full burden without deliberate process changes. This is where virtual emergency medicine either matures into a safer access point or remains a thin substitute for in-person care.
What the Cohort Means for Virtual Emergency Care
The cohort offers a precise warning for virtual emergency services in Australia and beyond. These systems can extend reach, but they can also obscure violence if staff are not trained to probe beyond the presenting complaint. Head, face, and neck injuries should raise suspicion, especially in a female patient whose story does not fully fit the exam. Referrals from healthcare professionals may already reflect some degree of prior recognition, yet even in that group, the pathway from identification to safe follow-up needs tightening.
The study does not provide outcome data on subsequent harm, recurrence, or patient safety after discharge, so it cannot quantify the downstream consequences of missed cases. It also captures only presentations that were identified through the service’s available documentation and review process. Even so, the clinical message is hard to ignore: in a virtual emergency department, violence does not announce itself often, and the system has to be built to look for it.