Writing a statement 

A statement is a factual narrative account of your involvement in a specific event, either as a care giver or as a witness to the event. It should complement not simply duplicate the medical records, allowing for greater understanding of your involvement and decision making.

No statement regarding a clinical incident should be written from memory without access to the maternity records. It is important to reference the records and make clear any information which is additional and from memory.

It may be required as part of an internal investigation, or in response to a complaint or from an external agency. Once submitted it is disclosable to third parties including, but not limited to, the patient, their legal representative, the Coroner or the NMC.

You may be required by your employer to use an agreed template.  The RCM would recommend using a template. It is also recommended that each page and paragraph is numbered for ease of reference.

Seek advice from your local RCM steward before submitting your statement. You can call RCM Connect to help find help if you are not sure where to start.

Where to start?

Make sure to include the following:

• Your full name
• PIN number
• qualifications (with dates)
• role and pay banding
• your employer details
• length of employment
• where you normally work within the workplace
• purpose of statement
• date of incident
• period of duty
• any exceptional points e.g., staffing levels, unit activity, whether you were in your usual area of work
• If you are writing the statement a long time after the event, make that clear.

Main body of statement

Document the purpose of the statement and the person requesting the statement, for example:

‘This statement is prepared at the request of (insert name) who is undertaking an investigation under the Trust’s Serious Untoward Incident, /Complaints/Disciplinary Policy (delete as appropriate). I write this statement having reviewed the maternity records of (insert name). I have personal recollection/have no recollection (delete as appropriate) of my involvement in this client’s care.

• Your specific involvement in the event, for example whether you were the lead carer, and the specific timeframe during which you were involved. This is particularly important if your involvement was transient, for example if you were relieving a colleague or you were involved in a co-ordinating capacity
• Identify other staff involved in the client’s care using their full name and status i.e., Mr John Smith (Consultant Obstetrician) and the care they gave but avoid statements of opinion on their care.
• Full medical terminology (no abbreviations) as your statement may be disclosed to non-medical personnel and abbreviations used locally may not be universally applied
• An explanation of decision making in relation to the care given if not obvious from the records
• Reference to midwifery practice/ clinical guidelines in existence at the time if the incident occurred sometime previous and practices have changed
• If recollection is difficult, it is acceptable to document what your usual practise would be.

Don't forget to always: 

• Be completely honest and state clearly what you can/cannot recall
• State facts
• Be as specific as possible avoiding ambiguous statements
• Avoid making comments expressing your personal opinion or speculation
• Always use first person ‘I witnessed, I did, I went
• Spell check
• Re-read, re-read, re-read
• Write ‘end’ at the end with your signature
• Sign and date each page of the statement
• Keep a copy