Writing a statement

All doctors and other healthcare professionals will be approached from time to time to write statements relating to their involvement of the care of patients, and there will often be a professional obligation to respond.

Such requests often arise from situations where things may have gone wrong. They can be an unwelcome intrusion into a busy day, and the consequences of the process are often uncertain. These factors can generate understandable anxiety, but by following some general principles and using a structured approach the task may feel less daunting, and the outcome can be a significant and helpful contribution to the process, personal learning, and patient safety.

When a statement might be requested

There are various situations when statements may be required, including complaints, formal duty of candour procedures, disciplinary processes involving you or colleagues, significant adverse event reviews, clinical negligence claims, and coroner’s inquests or fatal accident inquiries (these are both considered in greater detail in separate Medical Advisory Guides). Statements could be considered as part of local, regional, or even in some cases national processes.

Core principles when preparing statements

There are a number of aspects of the GMC’s core ethical guidance, Good medical practice, that could apply when a statement has been requested. The guidance states that doctors must co-operate with formal enquiries and complaints procedures, and subject to a few exceptions this means you will have to comply with a request for a statement; there can also sometimes be an obligation to respond under an employment contract or similar agreement. If there is any doubt, then ensure you seek advice.

The guidance goes on to explain that when writing reports, and when completing or signing forms, reports and other documents, a doctor must be honest and trustworthy and must make sure that any documents written or signed are not false or misleading. Reasonable steps must be taken to check the information is correct and relevant information must not be deliberately left out; this could be considered a probity issue. Supplementary guidance on writing reports that requires you to restrict reports to areas in which you have direct experience or relevant knowledge will usually also be applicable.

Patient Confidentiality

Where providing a statement will require sharing medical information with someone other than the patient, careful consideration must be given to whether or not consent is required from the patient or someone else with the authority to consent – this is particularly important when the statement is requested by an external organisation.

In some situations, consent may not be required, such as if the disclosure is required by law or is permitted or has been approved under a statutory process that sets aside the common law duty of confidentiality. Where a patient lacks capacity to consent or has died, you need to ensure you can justify disclosure of information in line with the GMC’s guidance on Confidentiality.

Where you are unsure about the position in respect of consent, ask the requester if consent has been obtained, or in the alternative if they have a position on why this is not required. Decisions regarding disclosure of information can sometimes be complex and we recommend seeking advice from MDDUS if you are unsure.

Understanding the purpose of a statement

Your approach to writing a statement will be significantly influenced by the purpose of the statement. Therefore, in addition to understanding what type of process the statement is going to be used in, try to gather as much information as possible about what the issues may be.

Factors you may want to establish include:

• Did something go wrong in a specific aspect of the case?
• Was there an adverse outcome?
• Is, or has there been, a complaint?
• What are the concerns or allegations that are being considered?
• What is being asked of you in relation to your involvement – e.g. does it relate to one particular episode or the entirety of your involvement in a case?
• Are you able to obtain written copies of relevant correspondence such as a complaint, summary of the concerns, or an adverse incident report/Datix?

If you feel your input will not further an investigation/enquiry you should discuss with those making the request. If they still require your statement then you should try to comply, but do not be tempted to include comments outside of your knowledge or experience in an attempt to ‘meet the brief’.

Being fully informed

It is essential you have as much information as you need to draft your statement. This may involve seeking medical records and/or call recordings, which are usually provided on request. Often receiving background information can trigger recollections of further details you can include in your statement.

If the medical records, or other relevant information, is not available then you should still provide a statement but highlight the limitations on your knowledge.

You should generally seek authorisation to access information to draft a statement, even if you are able to access it directly. This will avoid any suggestion of inappropriate access to patient information. If you are provided with copies of patient information, ensure you handle these securely and in line with data protection requirements and any local policies.

Should reflections be included in a statement?

Writing a statement about your involvement in clinical care will often be part of a wider investigation. Such investigations provide opportunities for organisational and individual learning. Whenever you are involved in a potential adverse incident, it is imperative that you take time to reflect on the case, identify learning points, and consider any changes to future practice. Discussing the case with colleagues, particularly if you are in a more junior or training position, will often aid the reflective process.

Whether to include reflections in a statement can be a difficult decision. If they are not specifically requested, you could ask whether they are needed, or take advice from senior colleagues and/or MDDUS. Reflections are usually required in complaint responses, adverse incident investigations or a disciplinary process. They are generally not required in statements for coroner’s inquests and fatal accident inquiries, or when you are involved in a clinical negligence claim.

It is not uncommon for doctors to be anxious about how their reflections may be used subsequently. There is helpful information about reflective practice on the GMC website, which also signposts other resources. MDDUS is also happy to advise you if you have concerns or queries.

Drafting your statement

In some instances you will be provided with a template on which to complete your statement. If in doubt, it can be helpful to check with the organisation requesting your statement to ensure you comply with their policy.

It is important to keep in mind that your statement may be reviewed by people with limited or no medical knowledge. You should therefore draft your statement in clear and simple English, avoiding medical jargon or abbreviations where possible. If you are referring to complex medical terms, try to include a brief explanation.

The use of short sentences and concise paragraphs will help the reader. You should also use full dates (and where necessary, times), correct spelling and grammar, and write in full prose rather than note form. Ideally your statement will sound like conversational English if read out aloud.

A well-written statement will provide clear and detailed information that does not leave any significant follow-up questions in the mind of the reader – for example, if it is relevant to include that you made a referral for a patient, explain your rationale and the outcome of that referral. This approach may prevent a query/concern from arising.

In many cases the statement required is of a purely factual account of your involvement in the care of the patient, restricted to the facts that are known to you. Where relevant you can comment on the actions of others based on the records/recordings, but you should avoid giving opinion on the involvement of other healthcare professionals. For example, you should not explain why someone else acted as they did (which would be speculative) or provide an assessment of whether it was appropriate to do so.

Where a template has not been provided, the structure of a statement can be broken down into the following main sections. Numbering the paragraphs can be helpful in enabling a reader to easily identify a section (please see the specific Medical Advisory Guide for specific advice about a report for the coroner or a fatal accident inquiry).

• An introductory paragraph setting out your name, qualifications, length of time in current role and outline of role at the time of the incident.
  
  
• A paragraph setting out the purpose of statement (who it has been prepared for, and why). This enables a reader to understand why you have written your statement as you have, for example why you may have restricted your statement to a particular episode of care.
  
  
• An explanation of the resources used to prepare the statement (for example, medical records, telephone recordings, consideration of your recollection of events, discussions with colleagues).
  
  
• Where appropriate, an acknowledgement of concerns, an expression of regret and/or condolences or sympathy, if appropriate an apology for harm and distress suffered, and an expression of thanks for the opportunity to contribute information about the care provided.
  
  
• The main body of the statement, including the facts of your involvement, set out as separate paragraphs that are not each overly lengthy:

• A paragraph regarding any relevant history, such as how you came to be involved in the care of the patient, including any review of medical records that you undertook and any relevant past medical history identified, including about medications.
  
  
• A detailed chronology of events with key data included such as history and examination findings, medications and doses prescribed, referrals made, investigations ordered, management plans agreed, and safety netting advice given. If it is not self-evident you should explain the reasons for your actions, either based on the records, your recollections, or your usual practise.
  
  
• Where appropriate as considered above, detail of reflections and learning points taken from the case. Include rationale and explain decision making (refer to guidelines if applicable).

• Include a statement of truth at the end of the statement such as “I believe the facts outlined in this statement are true to the best of my knowledge and belief”.
  
  
• Ensure you include a signature and date on your report.
  
  
• There is no need to include any personal information or contact details in your statement. Rather, provide professional contact information either within your statement or supplementary to it (such as in a covering email or letter).

Before submitting your final statement

You should carefully review your statement once finalised to ensure that it addresses the requirements of the request. If the statement has been requested by an external organisation, consider whether someone within your organisation, such as a senior colleague or a member of the legal team, should check it prior to sending. A trusted colleague may also be willing to proof-read your statement – it is easy to overlook simple issues when you have spent a long time drafting something and read it multiple times.

MDDUS is happy to review draft statements for our members and provide expert advice before submission.