Writing a statement

Doctors and other healthcare professionals will be approached from time to time to write statements relating to their involvement in 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 may be 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.  These may include to assist in a complaint response or clinical negligence claim, or where a patient’s death is being investigated by the coroner or procurator fiscal, or for disciplinary or regulatory proceedings.  Other situations might include as part of an adverse event review or duty of candour process.  You might also be asked to provide a statement for the police, or for other legal proceedings.

MDDUS has separate Medical Advisory Guides on Complaints, Coroner’s Inquests, Fatal Accident Inquiries and Claims.  If you are providing a statement for any of these purposes, you may wish also to review these for further guidance.

Core principles when preparing statements

There are a number of aspects of the GMC’s core ethical guidance Good medical practice that may apply when a statement has been requested.  The guidance states that doctors must co-operate with formal inquiries 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 you have any queries about your obligations, then ensure you seek advice.

The GMC guidance goes on to state that when writing or signing forms, reports and other documents, a doctor must be honest and trustworthy and must make sure that the information they are providing is not false or misleading.  Reasonable steps must be taken to check the information is correct and relevant information must not be deliberately left out.  Knowingly providing inaccurate information or intentionally withholding relevant information could result in an investigation of a doctor’s probity.

It is also important to ensure that any information you provide is within the limits of your competence.

The GMC provides more detailed guidance on providing witness statements as part of legal proceedings as well as guidance on writing reports in relation to employment, insurance and similar purposes.

Patient confidentiality

Where providing a statement will require sharing medical information with someone other than the patient, careful consideration must be given as to whether 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 whether consent is required, you should check with the person requesting the statement if they have obtained the appropriate consent, and if not why they believe you should disclose without consent. In the absence of consent, you should carefully consider any reason they provide to decide whether this justifies disclosure.  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 influenced significantly by the purpose of the statement. Therefore, in addition to understanding the process for which your statement is required, 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 – for example, 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 information 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 will often involve seeking medical records and/or call recordings, which are usually provided on request.
  
It is generally advisable to provide a statement only once you have reviewed all the relevant information. However, if the medical records or other information you might need are not available, you can still provide a statement. In doing so, you should ensure you make clear what information was (and was not) provided to you and the limitations of your knowledge.  
 
You should generally seek authorisation to access information to draft a statement, even if you are able to obtain 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? 
 
The statements you provide will often be part of a wider investigation, with 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, and consideration of relevant local and national protocols and guidelines, 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. It would usually be beneficial to include reflections when providing statements for complaint responses, adverse incident investigations or a disciplinary/regulatory process. They are generally not required where the statement is for the police or a clinical negligence claim. It can sometimes be helpful to include any learning points when providing statements for coroner’s inquests, the procurator fiscal or fatal accident inquiries, but we would recommend seeking advice before doing so. 
 
It is not uncommon for doctors to be anxious about how their reflections may be used subsequently. There is information about reflective practice on the GMC website, which also signposts other resources. MDDUS provides related educational resources and is pleased 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. 
 
For clarity you could include each consultation or interaction in a separate paragraph. Numbering the paragraphs can be helpful in enabling a reader to easily identify a section (please see the Medical Advisory Guide for specific advice about a statement for the coroner or a fatal accident inquiry). 
 
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. It should include, where possible, the justifications for any actions you took. 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 arising from your statement. 
 
In many cases the statement required is a purely factual account of your involvement in the care of the patient. You should ensure that you restrict it to the facts that are known to you. This would often be from the medical records, but you can also rely on any clear recollections or your usual practice, as long as you make this clear, for example by starting ‘From my memory of events...’.  or ‘My usual practice would be...’. You can comment on the actions of others, where it is relevant to your involvement, but you should avoid giving opinions on what they did or did not do.  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:

• An introductory paragraph setting out your name, qualifications, your current role and length of time in this role, and an outline of your role at the time of the incident if it is different from your current role. 
• 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, review of relevant guidelines or policies at the time, discussion with colleagues. 
• Where appropriate, depending on the circumstances, and the purpose of your statement, you might include an acknowledgement of the concerns raised, an expression of regret and/or condolences or sympathy, an apology for harm and distress suffered, and/or an expression of thanks for the opportunity to contribute. 
• The main body of the statement, including the facts of your involvement, set out as separate paragraphs that are not each overly lengthy:  

o A paragraph setting out any information you were aware of before your involvement such as relevant present and past history, and medications. You should also include a description of how you came to be involved in the care of the patient. 

o 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 practice. It can be helpful to refer to any relevant guidelines. 

o Where appropriate as considered above, detail of reflections and learning points taken from the case.  

• In some circumstances, where the statement is being provided for potential legal proceedings, for example where you are providing a statement for a coroner’s inquest, fatal accident inquiry or the police, you should 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.