One incident can be investigated in a number of different ways – as a complaint, a clinical negligence claim, a criminal case, a disciplinary matter by your employer, a Coroner’s inquest or a complaint to the medical council. An important starting point is your written report on the circumstances of the incident.
This factsheet gives doctors more information about writing an incident report.
Writing a report
As a medical expert you should be aiming to produce a report which is free standing – from which the reader can glean the key issues in the case, understand the evidence available and reach a clear understanding of the range of expert opinion, without needing to look at any other document.
Your report should be:
- Detailed – it is better to provide too much information than too little
- Clear – avoid ambiguity and be clear about who did what and when
- Objective – state the facts. Do not use the report to criticise others or make general comments on hospital politics.
Your report should be based on:
- The medical records
- Your own recollection
- Your usual practice.
Why might a report be required?
There are various situations in which you may be required to write a report:
- For your employer, possibly after something goes wrong
- For the coroner
- For a solicitor
- For the police
- For a patient’s employer or insurance company.
You may be required to write a report, either as a lay witness or a professional witness. If you are writing as a lay witness, this means you are writing as a member of the public. If you are the doctor involved in some aspect of the patient’s care, you will be asked to provide a report as a professional witness.
Facts or opinions?
The majority of reports that you are asked to provide will be statements of fact – giving an account of what took place. You should only report the facts as you know them. If you are asked to give an opinion, you must only comment within your expertise.
Disclosure of patient information
A report will, more often than not, involve the disclosure of confidential information about a patient. You need to make sure you have the authority to disclose this information, by getting your patient’s consent and checking they are clear about the information you will be providing and why it is necessary.
What should the report include?
- A title page – including:
- the date of the report
- the date of the examination
- the identity of the parties to the action
- the full name (and date of birth) of the claimant
- the party providing the instructions
- the nature of the report.
- Numbered pages, short numbered paragraphs and appropriate subheadings.
- Your personal details, name, current post and summary of previous experience.
- Statement of the opinion you have been asked to provide and details of your relevant knowledge/experience enabling them to comment on the issues.
- List of documentation considered and relied upon in reaching your opinion on the case.
- Chronology and summary of the relevant evidence:
- Giving exact dates wherever possible
- When referring to important parts of the records, quoting relevant entries verbatim, if possible (identifying it as a direct quote – e.g. using italics)
- Identifying disputed facts and stating the sources of the information set out eg “history given on admission to hospital on 01.02.2005”
- Explaining relevant technical terms and abbreviations
- Reviewing the evidence for a sufficient period of time before and after the incident/period of alleged negligence – to put the events in context and highlight other relevant features of the history.
- Where you have undertaken an examination or performed other investigation(s):
- Say who carried out any examination, measurement, test or experiment which you have used for the report, give qualifications of that person, and say whether or not the test or experiment has been carried out under your supervision
- Record relevant positive and negative findings
- Maintain a clear distinction between the history given, the history recorded in the records, your own findings and your interpretation of those findings
- Focus on the significance of the findings for the claimant’s everyday life
- Give timescales for probable improvement/deterioration, treatment options available, etc
- Refer back to the pleadings, if appropriate, to ensure that all relevant matters have been addressed.
- The opinion:
- Comment on each question or allegation of negligence separately quoting the question or allegation whenever possible
- Where the question/allegation appears to repeat or overlap with another or seems misdirected, explain why and refer to other relevant paragraphs
- Justify the conclusions reached by reference to the evidence in the case, your specialist knowledge and any published references you relied on
- When dealing with an issue on which there are a range of opinions, provide reasons for the view expressed and state those opinions
- Where you take sides in an area of factual dispute, give an explanation of why you favour one version over another
- Where there is evidence undermining your opinion, outline that evidence and explain why it is not persuasive
- When commenting on the opinions of other experts:
- Summarise the areas of agreement and disagreement
- Point to evidence supporting or undermining the views given
- Avoid giving a view on matters outside your area of expertise
- Remain focused on the facts of the particular case
- Confine your report to the scope of your instructions and your own expertise
- Distinguish between questions of fact and of opinion
- Distinguish clearly between known facts and assumptions made.
- The concluding paragraph:
- Avoiding further repetition of the facts but summarising the opinions reached
- Returning to the issues you have been asked to consider and/or the pleadings, to make sure that an opinion has been given on all relevant matters with proper attention to the legal tests to be applied
- Conclude with a statement of truth.
The report should be clearly dated, and must be signed by you.
- Exceed your level of competence.
- Deliberately conceal anything – this will cast doubts on your integrity and will make subsequent comments less credible.
- Write your report honestly; don’t be influenced by others
- Write it as soon as possible after the event, while the incident is still fresh in your mind
- If the report is a result of a complaint or claim, make sure you have seen the complaint or Letter of Claim, or details of any court proceedings, before writing
- Only include details of events that you personally were involved in
- Only include relevant facts; your opinion is only necessary if specifically asked for
- Don’t comment on behalf of others – you can say “Dr X said… .”
Report writing tips
- Write in the first person singular – “I did this…”
- Address the report to an intelligent lay person; avoid jargon and abbreviations
- Bear in mind that the patient or their relatives are likely to see the report; avoid any pejorative, humorous or unnecessary subjective remarks
- Organise the report chronologically – give actual dates, and use either a 24-hour clock to give times, or state whether you are referring to am or pm
- Give each incident or event a separate paragraph or section
- Check spelling, punctuation and grammar before submitting
- 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.
Making a supplementary report
Sometimes it is necessary to make a supplementary report to deal with issues that come to light after you have written your original report. Before doing this, make sure that you review your report, the medical records and any new documentation.
If you have any questions or concerns about what you have been asked to produce, you should contact Medical Protection for further advice.