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

At some stage in your career, you are likely to be required to write a report following an adverse incident. An 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

You must write your report honestly and take all possible steps to ensure that you are not influenced by anyone else. 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.

Hilary is a solicitor based at the MPS Edinburgh office. If you need urgent medicolegal advice, or help with writing a report, MPS has a 24-hour medicolegal helpline that is available to all its members. Become a student member for free

Can you film patients without telling them?

Well the answer is, of course a resounding no, and even more so in a number of simple scenarios and clinical situations which are covered by the new guidelines on the making of patient audio/visual recordings. So the UKs General Medical Council, are issuing new advice to doctors which comes into effect on the 9th of May 2011 for the United Kingdom. The guidance relates to the making of audio or visual recording in the UK. This updates previous guidance and intends to cover the audio and visual recording of patients, the general principles of which are of course  intended for doctors but highly relevant to doctors in training.

GMC guidance from May 2011 on audio and visual records for patients

Helpful excerpts include advice regarding materials for teaching, patients who lack capacity, radiology and endoscopic images, and covert recording of patients by doctors. They include advice such as the following on radiographs:

You may disclose or use any of the recordings listed in paragraph 10 for secondary purposes without seeking consent provided that, before use, the recordings are anonymised; for example, by the removal or coding of any identifying marks such as writing in the margins of an X-ray (see paragraph 17).

The guidance is complex, and the excerpt above can only be taken in the context of the complete document: you can read a PDF of the guidance here, or visit the web pages here.

This is of particular importance to medical students who have a blog, use Twitter and Facebook, and sometimes write reports about their day to day practices: be careful. It supplements the already heavy advice from the GMC on patient confidentiality, ethics, and both formal and informal advice from Medical Indemnity organisations such as the MPS (see their article on ‘tweeting into trouble’ here).

A contributor for Medical Educator is quoted as follows:

This is of course particularly important for students as well as doctors: there are lots of anxieties, for example for using an anonymised chest radiograph for teaching purposes, by a doctor, under the guidance is ‘definitely’ allowed, however the guidance also provides useful information for those considering making audiovisual recordings in different settings. The advice is complex, intended for practising doctors, and carefully tip-toes through what is an ethical minefield. Our advice to any student is: always follow trust and University guidelines, read the GMC guidance, and when it comes to recording any medical images, you should always have the full support and first hand documented supervision of the clinician responsible for the patient prior to considering any audio/ visual recording. In general, unless you are absolutely certain, your GP or consultant is watching you (and documenting it), and you have informed written consent from a competent patient, we suggest keep your iPhone in your pocket and out of the clinic room!

Image source: Wikimedia Commons

The reality is simple. Poor handovers create discontinuities in care that can lead to adverse events and subsequent litigation. Poor handovers are associated with delayed diagnosis, medication errors, inaccurate diagnosis and increased length of stay.

A New Zealand study of clinical handovers in a tertiary hospital found that the majority of house officers encountered a clinical problem due to poor handover between 7 and 14 times in their previous three-month rotation. This was put down to inadequate systems, poor leadership and lack of specific handover locations.

It can be argued that good handovers have never been so important.

Last year the European Working Time Directive came into force, limiting the number of hours a doctor can work. It has posed major challenges to the way care is delivered. Many royal colleges have been outspoken about how the EWTD has disrupted the continuity of care patients are receiving, as more and more patients are handed over.

In the Casebook article “Dropping the baton” Sara Williams draws on the research that has been done by patient safety leads and practising clinicians to examine how a patient can be handed over effectively, highlighting the salient points that doctors need to bear in mind when handing over a patient.

A valuable source of information for doctors and students

MPS is not just a sponsor for Medical Educator, but a valuable source of ethical and practical information for doctors. They publish a series of educational publications including Casebook, New Doctor magazine and GP Registrar.

MPS is a mutual membership organisation which provides comprehensive professional advice to doctors, dentists and other health professionals in more than 40 countries around the world. As a not-for-profit organisation, MPS supports its members with medicolegal advice and education relevant to their professional practice.

Joining is free for all medical students

Remember joining the Medical Protection Society is free for all medical students. Why not check out their pages here to see what they can offer you.

One of the contributors to the site describes his experiences of being a member of MPS:

“I’ve been a member with the MPS since I was a medical student, and now I am 7 years post qualification, and on the speciality register. The MPS were helpful not only in my postgraduate studies, but were able to give me advice on my elective project and what needed to be done in this instance. As I was conducting this abroad, it was a very useful service. MPS has also been a useful port of call when faced with challenging ethical and medicolegal problems that are unavoidable to practicing physicians”.

Professional support and advice

One of the founders of Medical Educator has this to say about the MPS:

“I really have valued the support of MPS in my professional career to date, and I am pleased that they are helping to develop the Medical Educator site. Medical Indemnity support is critical to both practising doctors and medical undergraduates. Professional support and expert advice is simply a phone call away. Casebook is helpful. As a doctor practising internal medicine it has some useful pointers on common medico-legal pitfalls. For example in the September 09 issue, two Orthopaedic surgeons cover the subject of Cauda Eauina syndrome.”

The article is available in full through the website but lets look at an excerpt focussing on the diagnosis of CES:

Excerpt from Casebook: Cauda equina syndrome

CES is usually characterised by the following so-called “red flag” symptoms:

• Severe low back pain (LBP)
• Sciatica – often bilateral but sometimes absent – especially at L5/S1 with an inferior sequestration
• Saddle and genital sensory deficit
• Bladder, bowel and sexual dysfunction.

Three types of cauda equina syndrome have been identified:

• Rapid onset without a previous history of back problems.
• Acute bladder dysfunction with a history of low back pain and sciatica.
• Chronic backache and sciatica with gradually progressing CES.

Within these groups, CES may be complete or incomplete and its onset may be either acute within hours or gradual over weeks or months.

Providing you with content

We hope to provide some bespoke content on some medico-legal cases from the experts at the MPS as well as updating our own members in the monthly newsletter that’s sent out with some more relevant content. Expect to find updates and other relevant info from them. If you’re not already a member we would recommend choosing MPS to provide your professional indemnity.