A quick guide to reflection

  • Safety

Covering the purpose of writing reflections, when to do them, how they might be written and requirements around disclosure.

Why reflect?

We are evolutionary products of reflection in that learning from incidents and adapting behaviours can lead to a survival advantage.

High-functioning people always strive for improvement and reflection forms part of a wider strategy to improve performance. This is reflected in the sporting field, in which technology now allows detailed analysis of performance, which in turn highlights areas for improvement.

If something has gone wrong and your performance has come under scrutiny, detailed reflection (which incorporates demonstration of insight and remediation) can serve to de-escalate the matter and may make a positive difference in relation to any intervention or sanction that is imposed (or indeed avoid the imposition of intervention or sanction altogether).

When should I reflect?

In 2012 Sir David Brailsford, the then performance director at British Cycling introduced the concept of marginal gains, which was one of the strategies that led to the unprecedented success of Team GB cycling. In brief Sir David Brailsford’s theory was to look at all aspects of performance and to make improvements (even if the improvement is marginal) on the basis that the sum of all the marginal improvements would bring an overall significant improvement.

The lesson that can be learned from this is that it is important to think widely in relation to reflection and reflect on any matter (even if it did not lead to an adverse outcome) that could lead to a change in practice and/or prevent an adverse outcome.

Circumstances that should lead to reflection include (but are not limited to):

  • A complaint.
  • A matter that engages the duty of candour.
  • An adverse outcome that does not engage the duty of candour or instigate a complaint.
  • A near miss.
  • A request to provide a reflective statement by NHS England.
  • A successful outcome in which the strategies that brought about the success could be replicated by others.

Can my reflections be disclosed?

In general terms, it is unlikely that you will be called-upon to disclose your private reflections (for example; the GMC have explicitly stated that they will not seek disclosure of a doctor’s reflective notes from appraisal processes in the context of their investigation).

That said, your reflections do not attract legal protectionfrom disclosure and there may be circumstances when you are preparing reflections in the knowledge that they will be disclosed to another party (for example, if you have been asked to provide a reflective statement by NHS England).

For the above reasons, reflections should be carefully worded in the anticipation that it is possible that they may be disclosed, using the following guidance:

  • The reflections should not include any patient-identifiable information.
  • The reflections must be factually accurate.
  • The reflections must be worded in a professional away and you should avoid the use of pejorative statements directed at patients, complainants, colleagues or others.
  • If the incident led to serious patient harm or death, you are strongly advised to seek the advice of your medical defence organisation (MDO*) in relation to the wording of your reflections.

*The MDO contact details are listed below:

What should I consider when I reflect (please also refer to the appended template reflective statement)?

  • A summary of the issue – this should be a brief summary of the incident.
  • What happened? – this should be a detailed factual chronology of what happened.
  • Why did it happen? – this should be an analysis of the causative factors.
  • What has been done? – this should set out the actions that have been taken since the incident.
  • What should be done next? – this should set out any further actions that may be required, including confirming compliance with the actions that have been taking.
  • What would you do differently if confronted with the same situation again?
  • What previously unknown learning needs has this incident identified?

What other resources can I access? 

The following guidance may be of assistance:

Appendix 1 – Template reflective statement (Presentational points)

Presentational points
Please remember that if you have been asked to prepare a reflective statement with the anticipation that it will be disclosed (for example, at the request of NHS England) then it is important that it is well presented and factually accurate.

You should therefore take the following steps:

  • You must not include any patient identifiable information in reflective statements.
  • You must be comfortable with the factual accuracy of the statement before it is submitted.
  • You should correct any typographical or grammatical errors before the statement is finalised and submitted.
  • You might wish to use the headings as set out in the template below (not every heading will be relevant to every case).
  • You should use short paragraphs, with a space between each one for ease of reading.
  • You should ensure that the font and the formatting are consistent throughout the statement.
  • You should use bulleted or numbered lists if this will add to the clarity and/or facilitate the ease of reading of the statement.

Appendix 2 – Template reflective statement

Reflective statement

Prepared by insert name

At the request of insert requestor (for example NHS England)

Dated insert date


  • Provide a brief summary of the essential issues (for example – A patient with a penicillin allergy was inadvertently prescribed penicillin. The pharmacist identified the error hence no patient harm ensued).

My Background

  • Provide a brief summary as to your qualifications, current position, time in post, areas of clinical interest and any information about you, your practice or your experience that may be relevant to the issue that is the subject of concern.

What happened?
 Provide a detailed factual chronology of what happened, which should include:

  • The date of consultation, consultation type (for example, surgery consultation, home visit, telephone consultation) and who saw the patient.
  • Details of the presenting complaint and other relevant history.
  • Details of the examination findings.
  • Details of the working and/or differential diagnosis.
  • Details of the management plan, including any safety netting advice given, treatments prescribed, investigations instigated, referrals made, etc.
  • Any other relevant issues (for example; details of any complaints that were received, referrals to the coroner etc).

Why did it happen? 

  • Provide an analysis of the causative factors, with reference to any relevant dates in the chronology.
  • It would also be reasonable to include an analysis of any aspects of the care that went well.

What did I learn?

  • Provide a bulleted list of all the learning points that arose.
  • Specify any relevant CPD that you have undertaken and include your reflections.

What has been done?

  • Set out a list of the actions that have been taken subsequent to the incident (including any personal actions that you have taken, any actions that the practice have taken and any actions that involve other bodies [for example – a report to the coroner, the CQC, NHS England, the police, child or adult safeguarding etc]).
  • The actions should be specific and dated.

What should be done next?

  • Set out a list of any further actions that are indicated (as outlined above, these could include personal actions, practice actions and actions that involve other bodies).
  • Are any steps required to ensure compliance with the actions (for example, an audit) and if so, who is going to undertake this, within what timeframe and how will the results be fed back?

What would I do differently if this happened again? 

  • Are there any things that you could have done differently which would have improved the outcome?
  • Are there any system/practice changes that could be implemented which would have improved the outcome?

What further learning is required? 

  • Is any further follow-up required and if so, within what timeframe and who is going to undertake this?
  • Are there any ongoing/further actions required to meet any of the identified learning needs?
  • How could learning from this incident be utilised in other situations?
  • Is this a matter that could or should be discussed at your next appraisal?