You may be required to write a factual report or statement if you're involved in a case that is investigated, for example, by your employer, the coroner or procurator fiscal, or a claim for clinical negligence.
This guide provides general guidelines for writing a factual report. There is a different approach for writing a response to a complaint. You can also read our separate guide on writing a report for the coroner.
General principles
The ethical principles are set out in the GMC's 'Good medical practice' (2024) and 'Providing witness statements or expert evidence as part of legal proceedings'.
Paragraph 88 of 'Good medical practice' (2024) says:
- "You must be honest and trustworthy, and maintain patient confidentiality in all your professional written, verbal and digital communications."
Paragraph 89 goes on to say:
- "You must make sure any information you communicate as a medical professional is accurate, not false or misleading. This means:
a. you must take reasonable steps to check the information is accurate
b. you must not deliberately leave out relevant information
c. you must not minimise or trivialise risks of harm
d. you must not present opinion as established fact."
And, as a witness, you must make clear the limits of your knowledge and expertise (paragraph 92).
In 'Providing witness statements or expert evidence as part of legal proceedings', the GMC sets out:
- "When providing evidence as an expert witness, you have a duty to the court which requires you to act independently and to be objective and impartial. This overrides any obligation you may have to the person instructing you or paying you to provide an expert opinion." (Paragraph 22.)
- "You must not allow any personal or professional relationship with, or personal views* that you might have about, individuals or organisations, to affect the objectivity or independence of any statement or evidence that you provide." (12.8)
*This includes your views about a patient's lifestyle, culture or their social or economic status, as well as the characteristics protected by legislation: age, disability, gender reassignment, race, marriage and civil partnership, pregnancy and maternity, religion or belief, sex and sexual orientation.
Doctors have a duty to cooperate with formal inquiries. But it's also important to remember your duty of confidentiality, which extends beyond death. If you need any advice about whether it is appropriate to provide a report, please contact us.
When you have agreed to provide a report, it's important to do so in a timely way. If you foresee a delay, keep in touch with the person who has requested the report. It's best to write reports as soon after the events as possible, while your memory is fresh.
Most requests for a factual report will not include a request for opinion, so stick to the facts. If you are asked for your opinion, remember to comment only within your knowledge and expertise.
Format of your report
Your report can be written on headed paper. If you don't have headed paper, make sure to include your personal details (including GMC number).
- Start with an introduction of yourself; for example, "My name is… my qualifications are…". Include your qualifications as abbreviations and full text.
- Then give your status at the time of the incident you are describing - for example, "At the time I cared for the patient, I had been working as a [your role or position at the time] at [name of trust/practice] for 15 years". Specify the nature of your contact with the patient, including if you saw the patient on the NHS or privately, for clinical or forensic purposes.
- It might be helpful to indicate who has requested your report and why, and to list the documentation you have used in preparing it. Check you have reviewed all relevant records before writing your report. If you're asked to produce a report but do not have the material you need, please ask us for advice.
- Describe the events chronologically, basing your description on the clinical records. It's also reasonable to include details from your memory or usual practice (see 'Report writing tips' below for more detail).
- Describe each relevant consultation or contact in a separate paragraph. Include dates and times, and for each encounter, include details of history, examination, your working diagnosis (and/or differential diagnoses) and plan. Where possible, mention whether you saw the patient alone or with another person.
- Describe any referrals you made, identifying the name of the person to whom you referred the patient. Where possible, include significant negatives as well as positive findings, and describe what information you gave and what follow-up arrangements you made.
- Make sure you don't leave out anything relevant.
- If you need to include details of care provided by other people (for example, to explain the context of your own involvement), make it very clear who did what and confine yourself to details from the clinical records. It's not usually appropriate to comment on the adequacy of what other people did.
- Be clear when your involvement with the patient ended.
- Remember to sign and date your report when you are ready.
For more info, watch our video on writing a medico-legal report.
Report writing tips
- Each report should be capable of standing alone. Do not assume that the reader will know anything about the case, the context, or have access to records.
- Make sure your report is unambiguous. It's much clearer to the reader who did what if you write in the first person - for example, "I did this and Dr X did that" rather than "Y was done…" or "the patient was seen".
- When you are including details from memory, make this clear. For example, "My notes state that… and in addition I remember that..."
- You should also make it clear when you're describing something about your usual practice that you did not record, eg "I did not record the detail of how I did the procedure, but my usual practice is..."
- Use straightforward language, avoiding or explaining medical jargon, technical terms or abbreviations. Remember that your report may need to be read by people who are not medically trained, including the patient or their relatives.
- If you're referring to drugs, provide the generic name and include a brief description of what the drug was for as well as the dose and route of administration.
- If including test results, explain what the test is - such as 'ECG (heart tracing)'.
- For blood results, include units, reference ranges, and what the result meant to you (for example, "I checked the U and Es (urea and electrolytes) and noted a high urea level of 19mmol/L [reference range 2.5-7.8] which indicated to me that…"
- Type your report and check carefully for punctuation and errors.
- Finally, keep a copy of your report (and a note of when and to whom you submitted it) in case you need it later.
References
1 Civil Procedure Rules, rule 35.3, Criminal Procedure Rules, rule 33.2, Family Procedure Rules, rule 25.3, Children's Hearings (Scotland) Rules 1996, Act of Adjournal (Criminal Procedure Rules) 1996, Criminal Justice (Evidence) (Northern Ireland) Order 2004.
This page was correct at publication on 30/01/2024. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.