Of the 539 calls to our medical advice line from foundation year doctors during a recent five-year period, the most common calls related to adverse incident investigations. These usually took the form of a request for advice about writing a statement, but occasionally junior doctors had been asked to attend an investigatory meeting.
According to NHS Improvement, the number of patient safety incidents in England reported to the National Reporting and Learning System (NRLS) between October 2016 and September 2017 was 1,895,834. This was a 4.7% increase in the incidents reported for the same period the previous year.
It's not surprising, then, that the MDU receives many calls about this process, and it's entirely understandable that the clinicians involved may feel stressed at the prospect of an investigation. Anxiety levels can vary depending on how severe the outcome was for the patient, and if there is any suggestion that the doctor involved has caused the adverse outcome in some way.
The emotional effect
A 2014 survey of fellows and members of the Royal College of Physicians demonstrated that of the 1463 respondents who had been involved in an adverse event or near miss, 76% of them felt it had affected them personally and professionally.1 Previous studies have shown that doctors can have a profound emotional reaction to an adverse event. These reactions can manifest as distress, self-doubt, confusion, fear, remorse and feelings of guilt and failure.2 At the most severe end of this spectrum, one study involving 7905 surgeons highlighted that 16% of those who reported a major error experienced suicidal ideation.3
It may be reassuring to note that in our calls from foundation doctors it wasn't always the case that they were being asked for a statement due to a concern about their role in an event. Sometimes it wasn't clear what exactly had gone wrong when a patient had experienced an adverse reaction, or the concern was about another clinician; in these situations the foundation doctor's statement was required purely for context, and the concerns lay elsewhere.
When there was concern about the junior doctors' involvement, the clinical issue was usually one of the following:
- A delayed or missed diagnosis.
- A prescribing error such as the wrong drug, the wrong dose or failure to note a pre-existing drug allergy.
- A failure to recognise the severity of an unwell patient's condition and act/escalate appropriately.
- Incorrect labelling of samples or investigation requests, leading to delays or incorrect clinical decisions made on the basis of inaccurate results.
Writing a statement for an AI investigation
It's important to remember that the main purpose of most reports is to provide a clear, detailed, factual account of events based on the medical records and your own knowledge of the patient.
Reports might also be read and considered by people who do not know you, or it may be one of many statements about an incident that are collected. Therefore, you should give your full name, professional qualifications and job description in the opening paragraph. This can be followed with an explanation of who has requested the statement and for what purpose.
This last point can be important as statements written for one purpose, such as an adverse incident investigation, may find their way into other processes, such as a coroner's investigation, at a later date. As such, we would recommend you take advice at an early stage to make sure a report perhaps only intended for an 'internal' trust process is still of high quality. Making clear the purpose for which your report was written might allow a reader to understand why the style or focus may be different if it is later used in another process, or if new information has come to light since you wrote your original statement.
Next, explain which documents you have relied on in writing your statement and if any of it is based on your recollection. While your recollections can help add detail to a statement, we would always advise that you read the medical records, if possible, when compiling your statement.
Having set your statement in context, you can move on to the key part of it, namely an account of the relevant events. This should take the form of a clear, factual and chronological description that covers each relevant point during the course of the incident(s).
Doctors can have a profound emotional reaction to an adverse event. This can manifest as distress, self-doubt, confusion, fear, remorse and feelings of guilt and failure.
In addition to the basic details of the event, there are other less obvious points that are helpful to include, such as:
- Were others present as witnesses?
- Specific dates and times, if possible.
- The full name, dose, route and lay description of any drugs mentioned.
- If others were involved, you can describe your understanding of what they did – but it's important not to criticise them.
- Any negative findings.
- If you wish to include anything that isn't documented in the records then you should specify where these details come from. If you recall it, then you can explain this. Alternatively, if you think you did something but can't recall it, you can explain what your usual practice would have been in the circumstances.
- Answer any specific questions you have been asked.
As well as considering what information should be included, there are some other practical points to bear in mind when writing a statement:
- It should be typed on headed notepaper or in line with any template that you have been asked to use.
- It should be capable of standing on its own, so that the reader doesn't have to keep referring to supporting documents.
- Avoid using medical jargon/abbreviations.
- It's good style to write in the first person – for example, 'I examined the patient' rather than 'the patient was examined'.
- Make sure your report is honest, accurate and complete. Be mindful of the GMC's guidance in paragraph 71 of the GMC's Good medical practice.
- Make sure to read through your statement carefully before you submit it.
- Keep a copy of your final statement, in case you are called to give evidence at a hearing or tribunal.
1 Doctors' experiences of adverse events in secondary care: the professional and personal impact. Clin Med (Lond). 2014 Dec: 14(6):585-90. doi: 10.7861/clinmedicine.14-6-585.
2 Schwappach, DLB, Boluarte, TA. The emotional impact of emotional error involvement on physicians: a call for leadership and organisational accountability. Swiss Med Wkly 2008; 138(1-2):9-15.
3 Shanafelt, TD, Balch CM, Dyrbye L et al. Special report: suicidal ideation among American surgeons. Arch Surg 2011:146(1):54-62.
Dr Ellie Mein
Dr Ellie Mein
MB ChB MRCOphth GDL LLM
Ellie joined the MDU as a medico-legal adviser in 2013. Prior to this she worked as an ophthalmologist before completing her Graduate Diploma in Law in Birmingham.
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