Medical case study: A statement of fact

These case summaries are based on MDDUS files and are published here to highlight common pitfalls and encourage proactive risk management and best practice. Details have been changed to maintain confidentiality.

BACKGROUND

Dr C is a specialty trainee at a busy city hospital. On a recent nightshift, he helped care for a patient, Ms J, who was in the high dependency unit (HDU). During his shift the patient rapidly deteriorated and later died.

Dr C is informed that the hospital is conducting a significant clinical incident (SCI) investigation into the circumstances surrounding Ms J’s death and he has been asked to prepare a statement detailing his involvement in her care.

Dr C contacts the MDDUS advice line to ask how he should approach the statement and what sort of detail the hospital are looking for. He is anxious about saying the wrong thing or missing out key information.

ANALYSIS/OUTCOME

The MDDUS medico-legal adviser (MLA) reassures Dr C that MDDUS can provide step-by-step support and guidance in the drafting of the statement, beginning with some general advice on the structure of his statement.

He recommends that Dr C starts by explaining why the statement is being provided. For example, he could state that he is preparing the report for the purposes of the SCI investigation into the events surrounding Ms J’s deterioration in the HDU on the relevant date(s).

The MLA suggests that Dr C continues by providing an overview of relevant information from his CV, such as the university from which he graduated and the stage he is at in his training, including details of the post he was employed in at the time of the incident.

This can then be followed by an expression of condolence and a paragraph clarifying how Dr C has prepared the report, for example: “In order to prepare this report, I have carefully reviewed the medical records and have a good/fair/poor recollection of the events that took place at that time.”

The MLA advises that he should then provide a factual account of his involvement in the patient’s care, including dates and times. This should be written in chronological order and avoid using technical abbreviations or medical jargon.

With regard to his own assessments of the patient, it is important that Dr C provides as much detail as possible, taken from the notes and any clear recollections. Where he is including information from memory, Dr C should make this clear in his statement, for example by starting the sentence with “I recall that…” He should include the reasons for any actions he took.

The MLA advises that he should include details of any interactions he had with named colleagues, including any advice or assistance he sought and the time this occurred. The MLA suggests it is also helpful to include factual details (including times) of any interventions by colleagues that Dr C may have witnessed, although Dr C should avoid providing any opinions on his colleagues’ involvement. The MLA advises Dr C that his statement should usually conclude with: “I confirm this is a true and accurate account of my involvement in this patient’s care.”

Following the telephone advice, Dr C drafts a report and sends it to the MLA for review. The MLA suggests a number of amendments and a few drafts are exchanged before the final version is agreed.

Dr C submits the report and is reassured by the MLA that he can contact the MDDUS advice service if any further help is needed.

KEY POINTS

• Statements for clinical incident investigations should use clear, factual language and include relevant dates, times and names of those involved.
• Avoid jargon or other technical abbreviations when writing reports.
• MDDUS advisers are on hand to provide detailed advice and guidance in the drafting of statements.