Sometimes doctors are asked to provide statements and reports regarding medical situations they have witnessed.
These guidelines are intended to cover general witness statements and reports, in other words where you are describing as a witness what occurred, albeit in a medical event. Separate advice should be sought on statements for use in civil or criminal court proceedings.
Statements may be headed ‘Confidential’ and should be addressed to the requesting individual or office. Remember that the reader will not necessarily know who you are, so your position must be defined.
A witness statement should generally include the following elements:
- Heading – i.e. “Report Concerning … by …” or “Report on Clinical Incident, [Date], by …”
- Brief introduction / biography of the writer, to set the writer’s role in context for the reader – i.e. “I qualified in [year] from the University of … and at the time in question was working as a consultant in … for … at … I had commenced this post on …”
- Paragraph on how each encounter with the patient came about – “[Patient name] was referred by her GP for admission on [date] and I saw her on arrival, as I was the on-call medical intern that day.” Reports for forensic post-mortems are likely to need much more background information, including full medical history and details of all appointments in the lead up to the death.
- Chronological information - The report or statement should then follow chronologically, sticking to facts and concentrating on the writer’s involvement.
- Outline last encounter – The report should normally end with the last encounter between the writer and the patient, unless further detail aids clarity.
Avoid uninvited criticism of colleagues, and use the first person singular (I intubated Mr Smith) rather than the passive (Mr Smith was intubated), as it minimises ambiguity.
Ideally, statements should not be written without access to the relevant records. Information may come from direct recollection, the medical records and also the writer’s usual clinical practice (an example of the latter would be a record entry of “Head injury advice”, after which the writer could add “By this I would usually say …”).
State the sources of information on which your statement relies. If a report must be written from memory (usually in exceptional circumstances only), then say that you have not had access to the records. Alternatively, if you have no recollection of the patient, state that you are relying on the records.
Split the statement up into short paragraphs, which may be numbered for ease of reference.
Sign and date it, and keep a copy.
Seek advice from senior colleagues, partners and Medical Protection as needed, particularly if you have concerns about potential criticism which may be directed towards you.