Preparation of Reports

Doctors are frequently asked to prepare reports for medicolegal reasons. It is important to understand the nature of the request and what is required—a simple report of fact, a report on present condition and prognosis after a medi-

cal examination, an expert opinion, or a combination of these. Because a doctor possesses expertise does not necessarily make him or her an expert witness every time a report is requested.

A report may be required for a variety of reasons, and its nature and content must be directed to the purpose for which it is sought. Is it a report of the history and findings on previous examination because there is now a criminal prosecution or civil claim? Is an expert opinion being requested based on the clinical notes made by others? Is it a request to examine the patient and to prepare a report on present condition and prognosis? Is it a request for an expert opinion on the management of another practitioner for the purposes of a medical negligence claim?

The request should be studied carefully to ascertain what is required and clarification sought where necessary in the case of any ambiguity. The fee or at least the basis on which it is to be set should also be agreed in advance of the preparation of the report. If necessary, the appropriate consents should be obtained and issues of confidentiality addressed.

Care must be taken in the preparation of any report. A medicolegal report may affect an individual's liberty in a criminal case or compensation in a personal injury or negligence action. A condemnatory report about a professional colleague may cause great distress and a loss of reputation; prosecuting authorities may even rely on it to decide whether to bring homicide charges for murder ("euthanasia") or manslaughter (by gross negligence). Reports must be fair and balanced; the doctor is not an advocate for a cause but should see his or her role as providing assistance to the lawyers and to the court in their attempt to do justice to the parties. It must always be conisdered that a report may be disclosed in the course of legal proceedings and that the author may be cross-examined about its content, on oath, in court, and in public.

A negligently prepared report may lead to proceedings against the author and perhaps even criminal proceedings in exceptional cases. Certainly a civil claim can be brought if a plaintiff's action is settled on disadvantageous terms as a result of a poorly prepared opinion. There is also the attendant risk of adverse judicial comment and press publicity.

The form and content of the report will vary according to circumstances, but it should always be well presented on professional notepaper with relevant dates and details carefully documented in objective terms. Care should be taken to address the questions posed in the letter of instructions from those who commissioned it. If necessary, the report may be submitted in draft before it is finalized, but the doctor must always ensure that the final text represents his or her own professional views and must avoid being persuaded by counsel or solicitors to make amendments with which he or she is not content: it is the doctor who will have to answer questions in the witness box, and this may be a most harrowing experience if he or she makes claims outside the area of expertise or in any way fails to "come up to proof" (i.e., departs from the original statement).

In civil proceedings in England and Wales, matters are now governed by the Civil Procedure Rules and by a Code of Practice approved by the head of civil justice. Any practitioner who provides a report in civil proceedings must make a declaration of truth and ensure that his or her report complies with the rules.

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