Dr Ellie Mein
Drafting a statement or medico-legal report needn’t be daunting if you follow a few straightforward guidelines.
The best way to approach writing a statement or report may well depend on what it is needed for. You might be asked to produce an account of your involvement in a patient incident for a Coroner’s inquest, an adverse or serious untoward incident (AI/SUI), a trust disciplinary issue, or to assist the trust legal team in assessing the merits of a negligence claim against the hospital.
While the style and content of your statement may vary according to its purpose, there are some general principles which broadly apply to most situations. Before you start, though, we recommend that you contact the MDU (or your medical defence organisation if you are not an MDU member) to request specific advice on your own case.
The primary purpose of most reports is to communicate a clear, detailed factual account of events based on the medical records and your own knowledge of the patient.
The aim of a report
It is important to bear in mind that the primary purpose of most reports is to communicate a clear, detailed, factual account of events based on the medical records and your own knowledge of the patient.
Reports might also be read and considered by people who do not know you, and of course multiple doctors involved in the care of a patient might also be asked to provide a report. Therefore, you should give your full name, professional qualifications and job description in the opening paragraph. This can be followed with an explanation of who has requested the statement and for what purpose.
The latter point can be important as statements written for one purpose, such as an SUI investigation, may find their way into other processes, such as a Coroner’s inquest, at a later date. It is for this reason that we would recommend you take advice at an early stage to ensure that a report perhaps only intended for an “internal” process is still of high quality. Making clear the purpose for which your report was written might allow a reader to understand why the style or focus may be different if it is later used in another process, or if new information has come to light since you wrote your original statement.
Next, explain which documents you have relied on in writing your statement and if any of it is based on your memory of events. While your recollections can help add detail to a statement, we would always advise that you read the medical records, if possible, when compiling your statement.
Factual, chronological account
Having set your statement in context, you can move on to the crux of it, namely an account of the relevant events. This should take the form of a clear factual and chronological description that covers each relevant point during the course of the incident(s).
In addition to the basic details of the event, there are other less obvious points that are helpful to include, such as:
- Were others present as witnesses?
- Specific dates and times, if possible.
- The full name, dose, route and lay description of any drugs mentioned.
- If others were involved, you can describe your understanding of what they did but it’s important not to criticise them.
- Any negative findings.
- If you wish to include anything that is not documented in the records then you should specify where these details come from. If you recall it, then you can explain this. Alternatively, if you think you did something but cannot recall it, you can explain what would have been your usual practice in the circumstances.
As well as considering what information should be included, there are some other practical points to bear in mind when writing a statement:
- It should be typed on headed notepaper or in line with any template that you have been asked to use.
- It should be capable of standing on its own so that the reader does not have to keep referring to supporting documents.
- Avoid using medical jargon/abbreviations.
- It’s good style to write in the first person – for example “I examined the patient”, rather than “the patient was examined”.
- Ensure your report is honest, accurate and complete – be mindful of the GMC’s guidance in paragraph 71 of the GMC’s Good Medical Practice (2013).
- Keep a copy of your final statement in case you are called to give evidence at a hearing or tribunal.
Dr Ellie Mein
MB ChB MRCOphth GDL LLM
Ellie joined the MDU as a medico-legal adviser in 2013. Prior to this she worked as an ophthalmologist before completing her Graduate Diploma in Law in Birmingham.
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