QSGUI01 Guidance on Writing a Witness Statement by Provide Community

Version: V2

Ratified by: Quality & Safety Committee

Date ratified: 25/03/2021

Job Title of author: Clinical & Project Leads, Essex Sexual Health Service

Head of Infection Prevention Serious Incident Investigator

Reviewed by Sub Group or Expert Group Clinical Reference Group

1. Introduction

The aim of this guidance is to provide staff with a framework for writing witness statements when asked to do so as part of either a Human Resources (HR), Serious Incident (SI) investigation or a safeguarding incident to police. Responding appropriately when things go wrong is a key part of the way in which Provide CIC Group can continually improve the quality and safety of services delivered to all service users. Healthcare systems are complex and can have weaknesses that lead to errors, some of which can have serious consequences for service users and staff, as well as to the reputation of Provide CIC Group

This guidance can be used as a reference guide so that all staff fulfil their statutory duties in safeguarding and protecting service users which supports the thorough investigation of an incident. For further clarification please refer to Incident Reporting and Management Policy.

A witness statement is a written account of events that have taken place. The purpose of a witness statement is to provide a supporting account of the event as part of a detailed investigation. It is a legal document and therefore can be used as evidence. When a statement is submitted as part of a formal HR investigation, this may subsequently be used within internal hearing and appeal hearing meetings but may also be used at an Employment Tribunal. If the statement is part of an SI investigation, it may be used to inform the investigation, and may mean that the person who wrote the statement could be asked for more information A witness statement must always be a truthful and accurate account of the event.

This guidance applies to all staff and workers employed by Provide CIC Group, temporary, voluntary, contracted and self-employed staff working on behalf of Provide Group

2. Purpose

The purpose of the guidance includes: -

• To support all staff with writing witness statements for a HR, SI investigation or police to support a criminal prosecution. It should be noted that if an investigation moves forward to prosecution YOUR witness statement may be heard in court, or that you may be requiredto presentto court for examination and cross examination. This can be supported in a number of ways. Contact the Safeguarding team on 03003032642 or provide.safeguarding@nhs.net if this is the case, to discuss support required

• To support staff with the legislation around writing a witness statement for a HR or SI investigation. To supply witness testimony to police to safeguard vulnerable children young people and Adults at risk, (Working together to Safeguard Children DH 2018,The Care Act DH 2014)

• To signpost staff to get help and support when required

3. Scope

This guidance applies to all staff and workers employed by Provide CIC Group, temporary, voluntary, contracted and self-employed staff working on behalf of Provide Group.

This guidance relates to all Provide CIC Group employees and workers who are required to write a witness statement as part of a HR or SI investigation

It should be noted however, that only certain HR polices apply to both employee and workers via Workforce Solutions.

4. Duty of Candour

Providers of healthcare have a duty to be honest and open with service users and their families, to give them information about any incidents that have taken place in relation to the care delivered by Provide CIC Group.

HR incidents and serious incidents require an in-depth investigation, as do police investigations. Often if police are working toward criminal prosecution this must take precedence. CRIMINAL CASES ARE PRIORITY.

Provide CIC Group’s Chief Executive Office and Board are responsible for ensuring that the organisation supports the Statutory Duty of Candour, and is open in its reporting of incidents. Safety incidents, particularly those causing significant harm can have severe and long-lasting consequences for service users, their families and carers. This can often be distressing for the professionals involved. Being open with people about what has happened and discussing incidents promptly, fully and compassionately can help service users and professionals to cope better with the after effects.

Being open following an SI involves: -

• Acknowledging, apologising and explaining when things go wrong;

• Conducting a thorough investigation and reassuring service users, their families and carers that lessons learned will help prevent the incident happening again;

• Providing support for those involved to cope with what has happened.

Reporting of incidents requires an open and just culture so that healthcare professionals feel able to report. This is one of the key foundations for being open. A just culture recognises that competent people make mistakes but has no tolerance for reckless, dangerous or negligent behaviour.

5. What is a Witness Statement

A witness statement is: -

• A formal written document for an HR or a serious incident investigation

• A factual account to police personnel to safeguard vulnerable service users

• A set of facts relating to a certain event, or events

• A legal document

• A statement with factual information (what you observed, what you heard, what you are certain took place)

• A statement must be signed and dated by the person who makes it, to confirm that the contents are a truthful record of the incident as recorded by the person.

If you witness an incident, it is very important that you write a statement whilst it is fresh in your memory. It is the responsibility of the manager on shift where the incident occurred to remind all staff present to write an incident statement.

Following a reported serious incident, an Investigating Officer will be allocated to undertake a full investigation on behalf of the Assistant Director of the Business Unit where the incident occurred. For further information please read QSPOL01: Incident Reporting & Management Policy.

A witness statement is a written account of events that have taken place; you may be asked to write a witness statement as part of a serious incident investigation or police related incident , if for example, a service user hurt themselves or been harmed, if their condition has seriously deteriorated or if something unpredicted has occurred. This will be supported by a member of the Safeguarding team who should be notified a witness statement is required by police. Contact the Safeguarding team on 03003032642 or provide.safeguarding@nhs.net if this is the case, to discuss support required.

Within a formal HR investigation, a witness statement may be one of two things but both may be required, depending upon the circumstances of the case:

1. An individual witness an incident and writes their own statement of what occurred and submits this to the investigating officer, who then may or may not need to ask further questions;

2. An individual is asked to attend an investigatory meeting and the notes of the meeting are deemed to be their statement;

3. An individual may write a statement and may also need to be interviewed so potentially there are two statements.

As previously stated, a statement that is signed and submitted as part of an HR process may also be used at an Employment Tribunal.

6. Help and Support

Writing a statement can be a daunting thought and sometimes staff may feel anxious. A witness statement must be legible and easy for anyone to read. If you have to write a statement about a service user in your care, you can always ask to see the records or documents to remind you of any involvement you had.

When writing a witness statement, you must differentiate between the facts written in the clinical records/documents and your own recollection. A witness statement is a legal document, regardless of the circumstances it must be legible and easy to read.

As a Provide CIC Group employee, you have a duty to comply with any internal or external investigations.

Staff requested to write a witness statement must be given enough time by their line manager to write the statement. Staff should take time when writing a witness statement and should make sure they are happy with the content and accuracy.

It is important to note that nobody should change your witness statement without your permission. A witness statement must always be written by the witness themselves.

Staff writing a witness statement should keep copies and store in a safe place.

Advice can be sought from the organisation’s Human Resources Department.

Staff writing a witness statement have the right to seek advice from a professional colleague, a member of the safeguarding team, a union representative, an external legal team commissioned by Provide CIC Group and/or may also ask their nominated representative to read through the statement before it is submitted.

An example of witness statement is included in Appendix 1.

7. Writing your Statement

All staff involved in the care of the service user when the incident occurred may be asked to write a statement by the Investigation Officer.

The Investigating Officer will speak to the manager of the department to arrange a suitable appointment time to meet with all the staff involved. Your line manager may request that you meet with the Investigating Officer and you will be given a specific allocated time. The Investigating Officer will ask you to go through the timeline of events up to and including the incident.

If you are asked to write a witness statement and you have agreed to do so, the witness statement template (Appendix 2) must be used. Before you start to write the statement, carefully think about the events and follow the principles of record keeping and clear written communication. Witness statements are designed to relate to factual information, they should be about what you saw and what you know took place. Remember to take your time to write the statement and make sure you are happy with the content and accuracy.

The Investigating Officer will read the statement and may ask you questions about it.

All witness statements should include the following: -

• Job Title

• Place of Work

• Date

• Signature

• Main responsibilities of the witness’ role

• A chronological narrative of events, approximate timings, names and places.

The witness should remember to write clearly

• The time they were on or off duty on the day/s in question

• Give brief details of the work environment at the time including responsibilities and number of service users under their care

• Use the first person (e.g. ‘I’). For example, ‘I gave Patient A 500mg of Paracetamol’ rather than ‘500mg of Paracetamol was given’

• Be clear about what was seen and heard. Include professional involvement, as appropriate, based on clinical records

• Relate the facts from the beginning and keep them in chronological order, giving precise dates and time. Be consistent in using ‘am’ or ‘pm’ or the 24-hour clock

• Avoid jargon or official language. Be as brief as possible while covering all the essential points needed to address the allegations, complaint of request

• Explain clinical or healthcare procedures and avoid general statements such as ‘routine observations were made’. If normal procedures were not following, explain what is normal and why there was a departure from the accepted procedure

• State what is personal recollection and what can be corroborated as fact with reference to, for example, healthcare records, reports, clinical guidelines or standards

• Where known, use full name and job titles of colleagues

• Always write the subject of an abbreviation or acronym in full at the first mention

• Always keep a copy of the statement for future reference. If any oral evidence you are asked to give, at a later date, is significantly difference from the written statement, this might affect credibility

• The witness statement could be used as a script in the witness box, in forums outside of the organisation, such as Employment Tribunal, Coroner’s Court, Serious Case Review, Domestic Homicide Review, Health and Safety Investigation.

• Having good records ensures a good defence

Remember, it must be Relevant: -

• Do not speculate, elaborate or exaggerate, or use emotional language. You may be called as a witness to give oral evidence based on the written statement

• If you cannot remember something, say so

• It is acceptable to form a view based on your professional judgement. Document the facts or evidence on which you based your conclusion . Relate how this would impact on service user care or service levels

• Do not assume that the reader knows anything of the facts of the case. Write your statement in such a way that an intelligent lay person should be able to understand the content

• Avoid giving opinions or making judgements that you cannot support by factual evidence or corroboration. Reflect on what has been observed to be usual practice or experience

• Hearsay is second hand, rather than first hand evidence. For example, ‘I heard Susan say that she had seen Jill give the injection’. It can be admissible in certain legal proceedings, but it must be clear that it is hearsay evidence. Only relate what

you were told by another/others. You will have no way of verifying the accuracy of others’ accounts

• In any summary, recap the main points and avoid adding new information or comments

• The Investigating Officer will decide who needs to be interviewed and who to meet with. Not everyone will need to be interviewed. If your witness statement is clear and concise it may be acceptable not to interview you as a witness

8. Meeting with the Investigating Officer

If you have been called to attend an interview with the Investigating Officer regarding a Serious Incident, your line manager should be flexible in supporting you to attend. Within an HR process, staff members may be accompanied by a work place colleague or trade union rep if they wish

When meeting with the Investigating Officer, witnesses should answer questions factually, accurately and objectively. Where possible, supporting evidence should be given i.e. times and dates, witnesses or records.

If a witness cannot remember the event or incident they should stipulate this to the Investigating Officer. The witness should not be rushed into speaking.

Witnesses should think carefully about their responses and should ask for a break if needed. If a further meeting is necessary to provide supporting evidence or information the witness can request a postponement.

If a witness is asked to discuss issues that they were not informed about or they feel uncomfortable to talk about they should request that the meeting be adjourned until further advice can be sought. Any agreement will be made at the Investigating Officer’s discretion.

The Investigating Officer will arrange for notes to be taken at the meeting as part of the investigation process. A member of staff from the Clinical Quality Team may be present at the meeting to record the minutes.

9. Draft Statement

In some cases, a witness statement will be prepared by the Investigating Officer for the witness to sign. This may have been prepared as a result of the witness meeting with the Investigating Officer.

If the witness disagrees with any of the content contained within the statement, the witness must not sign or submit the statement. The witness must return the statement indicating the areas that require amendment.

All statements written by the Investigating Officer on behalf of the witness must contain the following paragraph: -

‘This statement was drafted on my behalf by (name of Investigating Officer) and I have confirmed its accuracy having seen it in draft and having been given an opportunity to make corrections or additions. This statement is true to the best of my knowledge’.

The witness must sign and date the witness statement.

Appendix 1: Example of a Witness Statement

Witness Statement

Private & Confidential

Datix Web Reference: WEB12345

Commissioner Reference: STEIS12345

Date & Time: 17/03/2021 00:00

Witness Name: Gladys Emmanuel

Job Title: Staff Nurse

Work Place: St Elsewhere

Hours of Work: Monday to Friday 09:00 to 17:00

I am employed by Provide and my role is Staff Nurse. My qualifications and experiences are Registered Nurse

I have worked in my current job role for 2 years

I have been involved in the care of Patient X since 10/03/2021

I am responding to a request for a written statement from Mildred Ratched

Statement

On 10/03/2021 at 14:00, I witnessed the patient lying on the floor of Bay 5, bed 2.

I noted that the patient was lying on her right side on the floor, with her right side twisted. The bed was on the right side of the bay and a chair was positioned to the left side of the patient. There was fluid on the floor.

I saw that the patient was in a lot of pain and had been incontinent of urine. I followed the organisation’s Adult Falls Prevention and Management Police and undertook the following:

• Did not move the patient

• Recorded pain score and administered 10mg or Oramorph at 14:15

• Recorded the NEWS score and followed guidelines

• Contacted a senior member of staff

• Commenced neurological observations

• Contacted the patient’s relatives to inform them that the incident had occurred

At the time of the incident I was at the Nurses’ Station within Braintree Community Hospital Ward with my colleague Lisa Duffin, a HealthCare assistant who also works on the ward. We were reviewing staff rotas.

The patient was showing signs of distress as she was groaning, crying and holding the right side of her pelvis. I ensured the patient was warm and comfortable and then called for an ambulance at 14:20, as I had assessed that the patient needed to be seen at the Accident and Emergency Department.

While waiting for the ambulance to arrive I completed the following observations:

14:25

BP 95/60, NEWS score 8. Eyes opening to pain. Motor response, abnormal flexion. Verbal response, incomprehensible. Left pupil size 8mm. Right pupil size 8mm. Pupil reaction, sluggish.

The ambulance arrived at 14:30 and the patient was taken to the acute hospital.

I submitted a Datix incident report at 14:35.

This statement is true to the best of my knowledge and belief. This statement sets out the evidence that I am prepared to give in a court as a witness.

Name: Gladys Emmanuel

Signature: Gladys Emmanuel

Signature Date & Time: 10/03/2021 15:00

Appendix 2: Witness Statement Template

Witness Statement

Private & Confidential

Datix Web Reference: Insert Datix Web Reference

Commissioner Reference: Insert Commissioner Reference

Date & Time: Insert the date and time

Witness Name: Insert Full Name

Job Title: Insert Job Title

Work Place: Insert Work Place

Hours of Work: Insert Days of the Week and Hours Worked

I am employed by Provide Group and my role is Insert Job Title. My qualifications and experiences are Click here to enter text.

I have worked in my current job role for Click here to enter text.

I have been involved in the care of Patient X since Click here to enter a date.

I am responding to a request for a written statement from Click here to enter text.

This statement is true to the best of my knowledge and belief. This statement sets out the evidence that I am prepared to give in a court as a witness.

Name: Insert Full Name

Signature: Click here to enter text.

Signature Date & Time: Click here to enter a date.