Writing medico legal reports

Responsibilities

Speech and language therapists must follow the Health and Care Professions Council (HCPC) standards.

• RCSLT guidance on meeting HCPC  professional standards
• RCSLT guidance on SLTs’ duty of care

Guidance for writing medico legal reports

A medico-legal report is a written professional assessment of a given individual’s strengths, needs and situation. It will contain professional judgements, supported by evidence and expertise.

The speech and language therapist’s role is to provide impartial advice, clarification, opinion and information for the court to assist the court to reach a reasonable conclusion. It is necessary for the SLT to have expertise in the clinical area in question and have knowledge of the medico-legal process to do this.

Speech and language therapists should understand the professional obligations entailed in taking on an expert role. In particular, their duty to the court and the importance of providing objective and impartial evidence.

SLTs who are anticipating any involvement in the making of statements, medico-legal reports or appearing in court should seek help from their employing authority’s legal department.

First steps

• Gain clarity about who is asking for the report and why.
• Ensure the instructions received are clear. Seek any necessary clarification.
• Check that there is no conflict of interest. If so, this must be declared.
• If asked to be an expert witness, therapists must not take on a case if they have insufficient expertise in the area in question.
• Request further reports or information as required.
• Ensure that the time scales can be complied with.
• Confirm acceptance of instructions, or otherwise, within five working days.
• Inform the solicitor of contractual terms, (ie fees and payment method and timing). As appropriate, this will need to be discussed with any manager.
• Clarify who is to arrange the assessment appointment with the individual.
• Inform the solicitor once a date is set.

Preparation of a report and court appearance

Process related to preparation of report and preparation for court appearance:

• Read instructions/documentations carefully.
• Have all necessary documentation available at the assessment.
• Allow time for seeking out additional information, (e.g. contacting an RCSLT adviser or finding out about local availability of therapy services).
• Be prepared to attend meetings, sometimes at short notice.

Report format

The report should:

• contain a statement detailing the substance of instructions
• contain a declaration that duties have been understood and complied with
• provide a ‘range of opinion’
• be a statement of truth
• be objective
• be professionally set-out
• use numbered paragraphs with headings
• refer, on a separate page, to all the documents that have been seen
• contain a separate summary and recommendation
• be signed and dated.

Therapists may need to include an estimate of short and long-term therapy requirements.

When writing a report, the speech and language therapist must:

• give details of their qualifications
• understand the instruction provided by the solicitor
• give details of any literature or other material relied on in making the report
• contain a statement which sets out the instructions and all the relevant facts and events
• make clear which of the facts within the report are within the speech and language therapists expert knowledge
• make clear any assessment carried out and the results obtained and how these relate to the opinion formed
• set-out any recommendations and costs related to these if any
• where there is a range of opinion, summarise the range and give reasons for the expert’s own opinion
• contain a summary of the conclusions reached
• contain and sign a statement that the speech and language therapist understands their duty as an expert and has complied with that duty.

The process once the report has been prepared includes:

• checking the report carefully before submission
• submitting the report, plus any requisite copies, to the solicitor
• submitting an invoice as appropriate
• being prepared to enter the witness box, give evidence and be cross examined.

Resources

• Government practice direction on providing expert evidence

Contributors

Kathryn Cann, Sadia Hussain