Providing a report

A request for a witness to fact report caused some uncertainties for a DDU member, who called the advice line for help.

Earn CPD by reading this dilemma and the sidebar resources and then taking the quiz linked below.

The scene

A member provided routine treatment for a patient who had previously sustained a tooth fracture from an alleged assault. After the appointment, the member received a letter from an organisation acting on behalf of the patient, who wanted to pursue a claim for damages against their assailant.

The letter asked for a witness to fact report, and the member wanted to know if and how they should provide this.

DDU advice

Our adviser explained that a request to provide patient records and/or report may be received from a number of third parties. The obligation to provide information would depend on the third party requesting it, and information should only be provided with the patient's consent, preferably in writing. The practice's data controller's permission should also be obtained to release any confidential patient information or records.

Any witness to fact report (which might also be called a professional witness report) provided would need to be factual, and based purely on the patient's clinical records. It should include a chronological summary of what happened at the relevant dental appointment, what was seen, what was discussed, and what advice and treatment was provided.

It may include the patient's report of the injury, but should not contain any comment on how the injury had occurred, or any other opinion on the assault. It should be written in terms a lay person would understand, and avoid any dental jargon.

The adviser cautioned the member that they should not provide an expert witness report, which was very different.

Learning points

It's important to distinguish between a witness to fact report and an expert witness report.

A request for a witness to fact report is not that unusual, and may come from a patient, or third parties, including the police, social services, insurance companies, solicitors, etc. Members are advised to contact the DDU to discuss any request for patient information from third parties.

Providing a witness to fact report doesn't require additional indemnity cover from the DDU, and is purely factual.

On the other hand, an expert witness report is provided by an independent person and contains comments and opinions on clinical situations such as prognosis or future treatment needs. To provide one of these reports, authors should not have treated the patient, and should be formally trained as an expert witness.

Expert witnesses may be asked to present their reports in court or at a tribunal. You should let the DDU know if you're going to train to become an expert witness, as appropriate indemnity will be required.

Get verifiable CPD

If you've read this article and the advice linked in the sidebar, you'll be ready to complete our assessment and get 45 minutes of verifiable CPD.

To get your CPD certificate you'll need to score at least 80% on the assessment. You'll also need to add your name, DDU membership and GDC registration number so they're included on your certificate.

Click here to take the CPD quiz.

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This page was correct at publication on . Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.