As a student, you may be asked to provide a witness statement in relation to a clinical placement. This might be in connection with a significant incident, such as an error made during a ward round, a patient falling out of bed and sustaining an injury, or to provide an account of what happened when a patient was last reviewed.
Learning how to provide a clear and effective witness statement is a key skill for your future career as a doctor. Doctors are asked to provide statements for, amongst others, the coroner (or procurator fiscal in Scotland), serious untoward incident reviews, in response to litigation, and for child protection procedures.
The GMC requires doctors to contribute to investigations in order to keep patients safe.
Before you begin
If you are asked to provide a statement, make sure you have been given access to all the necessary information. This may include the relevant part of the clinical records, but you should not access or copy these without the trust's agreement.
It is helpful to know the purpose of the statement, and any specific questions to answer. It's important that you have the appropriate consent to provide a statement if it is requested by someone outside the trust, as you are under the same duty of confidentiality as a doctor.
In Good medical practice, the GMC explains that you must be honest and trustworthy when giving evidence and must make sure that any evidence you give or documents you write or sign are not false or misleading.
Many trusts will provide a template for your statement, and you should follow this if it is provided.
If no template is given, you should provide a clear, factual, accurate and chronological account of what happened. Avoid including any personal comments or opinions, and limit your account to matters within your own knowledge rather than providing extensive background history from the records.
Begin with an introductory paragraph providing your name, your role (eg fourth year medical student), and how long you have been attached to the particular department or team.
After this, it is helpful to provide a clear chronology of the events in question. If you saw the patient on more than one occasion, use a separate paragraph for each contact to make your statement easier to read.
Include the date, time, and the full name of any other students or clinicians present wherever possible.
If you are giving an account of what was said, make clear whether you are providing an exact quote, or whether it is your recollection of what was said. Similarly, if you are including information that is not in the clinical records, it should be clear that you are relying on your recollection alone.
Rather than using passive terms (eg 'Mr Smith was examined'), make clear who did what (eg 'Dr Amy Jones examined Mr Smith's abdomen and I documented her findings, which were as follows…').
Medical terminology and jargon are useful when doctors are communicating with each other, but a statement may be reviewed by non-clinicians, family members, coroners and many others. As such, I would advise that you avoid using medical jargon or abbreviations, and that you explain any medical terms used, so that your statement can be readily understood by the lay person.
Using the patient's name (ie. Mr Smith rather than 'the patient') can help convey a more empathetic tone. Trusts may ask you to use initials rather than names, in the interests of confidentiality.
After the chronological account, you may then address any specific questions asked. As before, if you are relying on your personal recollection, this should be made clear.
It is extremely important that you read through your statement carefully, so that you are entirely satisfied that it is accurate, factual and truthful. You should be prepared to answer any questions regarding your statement in future, and may be asked for supplementary information. The statement should be dated and signed.
Before submitting your statement, you may wish to ask an MDU medico-legal adviser to review it and provide further advice.
Dr Beth Durrell Potter
BSc(Hons) MB ChB MRCPsych PGDip(Mental Health Law)
Beth qualified from Manchester University in 2002 and completed her psychiatry training in the North West. She obtained a CCT in general adult psychiatry and worked as an inpatient consultant before leaving to join the MDU as a medico-legal adviser. She holds a postgraduate diploma in mental health law.
See more by Dr Beth Durrell Potter