Writing reports

Writing reports shouldn’t be a daunting task, says MPS Claims Manager Hilary Steele. Here is everything you need to know

An adverse incident can be investigated in many different ways. For example, as a complaint, a clinical negligence claim, a criminal case, a disciplinary matter by an employer with referral to the GMC, a coroner’s inquest (England and Wales) or fatal accident inquiry (Scotland). Your written report may be the starting point of an investigation into the circumstances leading to or surrounding an incident. This article sets out how to provide a detailed, clear and objective report.

Circumstances when a report may be required

You may be required to provide a report:

  • for your employer as part of an internal investigation
  • for a solicitor
  • for the police
  • for the procurator fiscal (Scotland) investigating either a criminal matter or death, which might result in a fatal accident inquiry 
  • for the Crown Prosecution Service (England and Wales) 
  • for the coroner (England and Wales) 
  • for the patient’s employer or insurer.

Disclosure of information – are you authorised to disclose this data?

While it is tempting to discuss an incident with your colleagues, even those of the strongest character will be influenced by the views of others

The first point to consider is whether you are authorised to disclose the data being requested. Disclosure of personal data is subject to the Data Protection Act 1998. The legislation applies regardless of age, format or origin of the information. It covers files, letters, databases, reports, photographs, etc. A report will, more often than not, involve the disclosure of confidential information about a patient.

Before disclosing information you must be satisfied that you have the necessary authority to do so; for example: 

  • you have obtained the patient’s consent – check they are clear about the extent of the disclosure 
  • you believe it is in the wider public interest (for example, assisting the police in preventing or resolving a crime) 
  • the disclosure is required by law (statutory obligation or to comply with a court order).

Fact vs opinion

It is likely that you will be asked to provide a statement of fact, ie, giving your account of events leading up to and including the incident. This is not an opportune time to criticise your colleagues. You should only report the facts as you know them. If, however, you are asked to give an opinion, you must only comment within your area of expertise.

Basis of your report

Your report should be based on: 

  • your own recollection of events 
  • the medical records
  • your usual practice.

Honesty is the best policy

While it is tempting to discuss an incident with your colleagues, even those of the strongest character will be influenced by the views of others. When writing your report you must write your report honestly and take all possible steps to ensure that you are not influenced by the views of others. It is therefore important to write your report as soon as possible after the event, while the incident is still fresh in your mind, and ensure that you only include details of events in which you were personally involved. If the report is required because of a complaint or claim, make sure that you have seen:

  • A copy of any correspondence detailing the allegations surrounding the complaint or claim. 
  • Details of any court proceedings before writing your report.

What should your report include?

  • Your personal details. Include your full name, date of birth, address and contact details, graduating university, qualifications and relevant clinical experience. 
  • Relevant local factors. If, for example, your hospital is on two sites and this has affected time taken to get to the incident, or if the incident has occurred in an environment where it has been difficult to assess and treat the patient, for example a police cell.
  • Details of other healthcare professionals involved. Where possible, include your colleagues’ full names and discipline, eg, staff nurse X, the nurse in charge, and Dr Y, lead consultant. 
  • The patient’s details. 
    • Name, date of birth and age 
    • When recording the patient’s presentation, include the following:
      • Dates and, where possible, times using a 24-hour clock.
      • Findings on examination and other relevant factors – if the patient was very difficult to examine because he was agitated and aggressive, provide details of how that behaviour was exhibited, eg, “The patient was lying on the trolley and attempting to punch and kick staff nurse X and me. He shouted: ‘I’m going to come back at the end of your shift and kill you’.” 
    • Diagnosis and whether a differential diagnosis was considered. 
      • Investigations and subsequent management, including dates. 
      • Follow-up arrangements and information given to the patient and relatives.
  • Other relevant facts. Your opinion is only relevant if the person requesting the report specifically asks for you to provide an opinion. You must not comment on behalf of others. You can, however, include statements made by your colleagues such as “Dr Y said....”

Providing a good impression

  • When drafting your report, it is important to consider who will be reading it and tailor it accordingly. However, a good rule of thumb is to address the report to an intelligent lay person. 
  • Write your report in the first person singular: “I did this....”
  • It is advisable to avoid the use of abbreviations and jargon. If you do use them, use only approved abbreviations. 
  • Bear in mind that the patient or their relatives are likely to see the report and, therefore, you should avoid personal remarks. A flippant remark might be the deciding factor in persuading a judge that you did not take a professional clinical approach to the care of the patient. 
  • Ensure that your use of medical terminology is correct. Inaccurate terminology, such as describing a surgical wound as a laceration, might have serious consequences for the outcome of a criminal trial.
  • Check spelling, punctuation and grammar before submitting your report. A sloppy report may reflect badly on your clinical practice. 
  • Your report should be typed, signed and dated. 
  • Keep a copy of the report in your notes and a note of how, when and to whom you submitted it.

Changing your report

It may be necessary for you to provide a supplementary report to deal with issues that come to light after you have written your original report. Before commenting on these issues, review your original report, the medical records and any new documentation.

A second opinion

Finally, you should strongly consider showing your report to MPS before submitting it.

About the author: Hilary is a solicitor based at the MPS Edinburgh office.

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