Peer Review Audit Research Articles

Does a peer review group consensus process for MR-Linac patients affect clinical care? Evaluation of impact and feasibility

Background and purposePeer review is an important component of quality assurance in radiotherapy. To our knowledge, there are no studies reporting on the feasibility and outcomes of the peer review process for magnetic resonance (MR) guided radiotherapy (MRgRT) on the MR linear accelerator (MR-Linac) despite the planning complexity involved and its evolving clinical indications. This study aimed to quantify the rate of change in treatment plans post-peer review and the time and resources required. Materials and methodsFifty-five cases presented at weekly MR-Linac peer review meetings across two centres from 8 June to 21September 2023 were prospectively collected. Cases were analysed to determine the rate and extent of plan changes based on the Peer Review Audit Tool for radiation oncology (PRAT) developed by the Royal Australian and New Zealand College of Radiologists (RANZCR). ResultsPeer review resulted in changes to 36.4 % of treatment plans (n = 20), with 3.6 % (n = 2) having major changes requiring deferment of treatment. The most frequent changes were to organs at risk (OAR) volumes involving both delineation and increased OAR sparing (16.4 %, n = 9), total dose and fractionation (10.9 %, n = 6) and target volume dose coverage (5.5 %, n = 3). Patients with SBRT plans (39.1 % cf 22.2 %), oligometastatic/oligoprogressive sites (38.1 % cf 30.7 %) and reirradiation cases (41.2 % cf 34.2 %) had higher rates of change. Cases took a mean of 7 min (range 2–15 minutes) to discuss. ConclusionThe high rates of plan changes support the value of peer review in MRgRT. We recommend, where possible that all MRgRT cases, particularly those involving SBRT plans, oligometastatic/oligoprogressive sites, and/or reirradiation, be subject to peer review.

Exploring The Impact of Digital Technology Transformation in Islamic Education: The Islamic Education Teachers Perspective

The empowerment of digital education is one of the government’s reforms to ensuring that Malaysia’s education system remains relevant. However, some teachers still do not recognise the significance of adopting digital technology, resulting in the rejection of a few Islamic education teachers. Thus, the purpose of this study is to investigate how Islamic education teachers perceive the impact of digital technology use in the classroom. Using a case study design and a qualitative research approach, the study included five Islamic education teachers who are proficient in digital technology and were chosen by a snowball sampling process. Interviews, in-person observations, and audio-visual analysis were used to gather data. Using NVIVO 14 software, the data was subjected to a thematic analysis. Credibility, transferability, and dependability are ensured for qualitative research data by triangulation, member check and peer review, rich and thick audit trail, and inter-rater. The study’s aims, which include improved productivity in the classroom; problem-solving efficacy; quick access to information; and more systematic data management, are addressed via four main themes and eight sub-themes. It is intended that this study will offer a viewpoint that encourages Islamic education teachers to make the most of digital technology in the classroom and in day-to-day operations.

Effective peer review audit and identification of the surgeon outlier.

Surgical audit aims to identify ways to maintain and improve the quality of care for patients, in part by assessment of a surgeon's activities and outcomes. However effective data systems to facilitate audit are uncommon. We aimed to assess the effectiveness of a tool for Peer Review Audit. All General Surgeons in Darwin and the Top End were encouraged to self-record their surgical activity, including procedures and adverse events related to procedures, using the College's Morbidity Audit and Logbook Tool (MALT). A total of 6 surgeons and 3518 operative events were recorded in MALT between 2018 and 2019. De-identified reports of each surgeon's activities, compared directly to the audit group, were created by each surgeon, with correction for complexity of procedures and ASA status. Nine complications Grade 3 and greater were recorded, plus 6 deaths, 25 unplanned returns to theatre (8% failure to rescue rate), 7 unplanned admissions to ICU and 8 unplanned readmissions. One surgeon outlier was identified (>3 standard deviation over group mean) for unplanned returns to theatre. This surgeon's specific cases were reviewed at our morbidity and mortality meeting using the MALT Self Audit Report and changes were implemented as a result, with future progress monitored. The College's MALT system effectively enabled Peer Group Audit. All participating surgeons were readily able to present and validate their own results. A surgeon outlier was reliably identified. This led to effective practice change. The proportion of surgeons who participated was low. Adverse events were likely under-reported.

Improving primary care antimicrobial stewardship by implementing a peer audit and feedback intervention in Cape Town community healthcare centres.

The increasing prevalence of antibiotic resistance is a major threat to public health. Primary care, where 80% of antibiotics are consumed, is a pivotal setting to direct antimicrobial stewardship (AMS) efforts. However, the ideal model to improve antibiotic prescribing in primary care in low-resource settings is not known. To implement a multidisciplinary audit and feedback AMS intervention with the aim to improve appropriate antibiotic prescribing at primary care level. The intervention was implemented and monitored in 10 primary care centres of the Cape Town metropole between July 2017 and June 2019. The primary and secondary outcome measures were monthly adherence to a bundle of antibiotic quality process measures and monthly antibiotic consumption, respectively. Multidisciplinary audit and feedback meetings were initiated and integrated into facility clinical meetings. Two Excel tools were utilised to automatically calculate facility audit scores and consumption. Once a month, 10 antibiotic prescriptions were randomly selected for a peer review audit by the team. The prescriptions were audited for adherence to a bundle of seven antibiotic process measures using the standard treatment guidelines (STG) and Essential Medicines List (EML) as standard. Concurrently, primary care pharmacists monitored monthly antibiotic consumption by calculating defined daily doses (DDDs) per 100 prescriptions dispensed. Adherence and consumption feedback were regularly provided to the facilities. Learning collaboratives involving representative multidisciplinary teams were held twice-yearly. Pre-, baseline and post-intervention periods were defined as 6 months before, first 6 months and last 6 months of the study, respectively. The mean overall adherence increased from 19% (baseline) to 47% (post intervention) (p<0.001). Of the 2 077 prescriptions analysed, 33.7% had an antibiotic prescribed inappropriately. No diagnosis had been captured in patient notes, and the antibiotic chosen was not according to the STG and EML in 30.1% and 31.7% of cases, respectively. Seasonal variation was observed in prescribing adherence, with significantly lower adherence in winter and spring months (adjusted odds ratio 0.60). A reduction of 12.9 DDDs between the pre- and post-intervention periods (p=0.0084) was documented, which represented a 19.3% decrease in antibiotic consumption. The study demonstrated that peer reviewed audit and feedback is an effective AMS intervention to improve antibiotic prescribing in primary care in a low-resource setting. The intervention, utilising existing resources and involving multidisciplinary engagement, may be incorporated into existing quality improvement processes at facility level, to ensure sustainable change.

A Hospital's Roadmap for Improving Nursing Excellence Using AACN's Healthy Work Environment Standards.

A Hospital's Roadmap for Improving Nursing Excellence Using AACN's Healthy Work Environment Standards.

Peer review audit ( PRA ) in ultrasound practice: A paper based on established UK sonography PRA models which are generalizable to other jurisdictions

Peer review is an important and integral part of any healthcare career. This takes many formats, with a recently recognised format in ultrasound being peer review audit (PRA). PRA in sonography involves the assessment of sonographic examinations based on set criteria, in an open forum. PRA also involves sharing interesting or complicated ultrasound cases. The process is an opportunity to learn and maintain/improve patient safety. This paper outlines a suggested process for performing robust PRA, based on models used in the United Kingdom, as an introduction to sonographers unfamiliar with PRA.

The impact of radiation therapist-led structured peer review meetings on compliance to Radiation Oncology Practice Standards.

Regular tumour-specific peer review meetings (TPRMs) were established by our group during 2016. A dedicated Quality Assurance Radiation Therapist (QART) was employed in 2018 to co-ordinate the meetings and for each patient, complete the Peer Review Audit Tool (PRAT) of the Royal Australian and New Zealand College of Radiologists (RANZCR). The aim of the current quality assurance study was to investigate the impact of the TPRMs and appointment of the QART on compliance to relevant RANZCR Radiation Oncology Practice Standards (ROPS). Tumour-specific peer review meetings for eight tumour sites were assessed across our group's three hospitals from January 2017 to December 2019. Data from meetings were collected using the PRAT or from paper-based minutes and assessed against four ROPS (ROPS 3, 4, 8 and 9). Compliance with each of the four standards was measured by presence of the required documentation and presentation at TPRM, as recorded by the PRAT. There was an increase in the overall number of peer review cases audited from 173 in the 2017 calendar year to 469 in 2018 and 619 in 2019, representing 7%, 18% and 22% of all treatment courses started during these years, respectively. Staging was the most incompletely documented item across all years for audited patients. The request for radiation treatment plan modifications increased year-on-year: modifications were requested for 5% of plans in 2017 (8/172), 18% in 2018 (81/452) and 19% (119/619) in 2019. This study has shown that an increase in the number of cases for peer-review audit corresponded to the QART-facilitated TPRMs. Application of the PRAT has identified radiation treatment plan modifications that would otherwise go undetected and without opportunity to improve the quality of patients' treatment or avoid harm.

Peer review audit of non-specialist occupational physician reports.

With declining specialist occupational physician (OP) numbers, there is increasing recognition of the importance of non-specialist physicians in occupational health (OH) service delivery, yet to date, this physician group remains understudied and their competency requirements poorly understood. To evaluate the quality of a sample of non-specialist OH reports and compare these with specialist reports. A retrospective peer review audit of a convenience sample of 200 consecutive non-specialist and specialist OH reports from an Irish OH service using an assessment form based on the modified Sheffield Assessment Instrument for Letters SAIL(OH)1. Of the 200 peer reviewed OH reports, 159 (80%) were from non-specialists. For all questions, 87% and above of non-specialist reports were 'satisfactory' or 'above expected'. On the overall assessment, out of 10, the mean non-specialist report score was 6.8 (standard deviation (SD) 3-10) and the specialist score was 7.3 (SD 3-10). Comparatively, non-specialist reports highlighted legal/ethical issues marginally more and adhered slightly better to contractual/ethical/legal boundaries, while specialist reports fared better in addressing manager's questions, in their structure and clarity and in covering all significant aspects of the case, particularly if the case was complex. Our findings demonstrate a high standard of OH report quality in this sample of non-specialist OPs that is consistent across all key OH report components. Potential development areas are also identified that can inform education/training tailored to this physician group and assist in competency standard-setting.

Quality improvement in paediatric radiation oncology through peer review.

Around 300 children in Australia and New Zealand (ANZ) undergo a course of radiation treatment (RT) each year. A fortnightly videoconference for radiation oncologists managing children started in 2013. We conducted an audit of the videoconference to assess its influence on the care of children who receive RT in ANZ. De-identified data from minutes (August 2013-December 2019) were analysed retrospectively using three categories: meeting participation, case presentations and management decisions. There were 119 meetings and 334 children discussed over the six-year audit period with regular attendance from four of 11 centres treating children in ANZ. Most cases (80%) were discussed prior to RT. A change in the overall management plan was recommended for around one in eight patients (35/334, 13%). RT plan reviews were performed in 79 cases (23%). Adjustments were made to the target volume contours or treatment plan in 8% (6/79). Increasing the frequency of the meeting to weekly and compliant with the RANZCR Peer Review Audit Tool has the capacity to review all paediatric RT patients in ANZ prior to RT and initiate changes for as many as one in eight children treated by RT each year. The meeting should be considered a core component necessary to maintain expertise in paediatric RT in all centres providing RT for children in ANZ while also acting as a proton referral panel as more children are referred abroad for proton therapy before the Australian Bragg Centre for Proton Therapy opens in Adelaide in 2024.

Potentially avoidable issues in urology mortality cases in Australia: identification and improvements.

This study aimed to identify the most common potentially avoidable factors in urology deaths, focusing on the lessons that can be learnt. This study analysed data from a well-established and comprehensive peer review audit of surgical deaths in Australian hospitals (excluding New South Wales) from 2009 to 2015, focusing on urology cases with identified areas for improvement in patient management. Of all audited deaths, 11% (79/719) had serious clinical management issues with a total of 109 individual clinical management issues identified. These were categorized based on perioperative stage (preoperative, intraoperative or post-operative), followed by thematic analysis within each stage. The study found preoperative issues to be the most common (n = 48), followed by post-operative issues (n = 32) with intraoperative issues less common (n = 13). Communication issues were seen at all three stages (n = 16). Overall, the most common theme was at the preoperative stage; inadequate preoperative assessment (n = 27). More specifically, the most common preoperative assessment issues involved a failure to order necessary preoperative investigations, or to administer necessary preoperative treatment (e.g. prophylactic antibiotics). The most common communication issue was between teams and at handover, often involving failure by junior medical staff to communicate issues to the responsible surgical consultant. Urological surgical cases with potentially avoidable mortality constitute a small, but important subset of deaths. The analysis of these cases can inform various stakeholders to improve the quality and safety of urological surgical care.

Radiation Oncology Quality Assessment Tool: A proposal for a new audit tool in modern radiation oncology.

As a consequence of the development of improved treatment techniques and utilisation of digital records in radiation oncology, the RANZCR Peer Review Audit Tool has become outdated. The aim of this internal audit was to objectively evaluate the practice of our radiation oncology department to ensure that patients are being treated according to evidence-based national guidelines through the use of a new self-audit algorithm, the Radiation Oncology Quality Assessment Tool (ROQAT). Using ROQAT, a retrospective audit was conducted of patients who received definitive treatment within the first six months (June 2017-November 2017) of opening a new radiation oncology department at the Sunshine Coast University Hospital. Data were collected from MOSAIQ® and electronic medical records. Two hundred and six patients were included. The median age was 65years. Most commonly treated tumour streams included: breast (n=62), skin (n=31), colorectal (n=25), genitourinary (n=21) and head and neck (n=21). Documentation was complete for all patients. Seventy-four per cent of patients were discussed in a multidisciplinary team meeting. Fifty-five per cent of patients were treated with inverse planning techniques. Treatment with radiation therapy was indicated in 97% of patients. Dose and fractionation were concordant with protocols in 83% of cases. Thirty-nine per cent received concurrent chemotherapy, and of these, 93% were in accordance with protocols. More than 50% were treated according to published delineation protocols. The ROQAT is a proposal for a new audit tool that reflects modern radiation therapy practice, with emphasis on compliance with evidence-based guidelines.

Biobank Quality Management in the BBMRI.be Network.

From as early as 2005, different guidelines and quality standards covering biobank activities and sample handling methods have been developed to improve and guarantee the reproducibility of biomarker research. Ten years on, the BBMRI.be Quality working group wanted to gauge the current situation of these aspects in the biobanks of the BBMRI.be network. To this end, two online surveys were launched (fall 2017 and fall 2018) to the biobank quality managers in the BBMRI.be network to determine the status and setup of their current quality management system (QMS) and how their QMS and related practices have evolved over a 14 month time period. All biobanks addressed by the two surveys provided a complete response (12 and 13, respectively). A QMS was implemented in 85% of biobanks, with 4 standards emerging as primary basis. Supplementary guidelines were used, with a strong preference for the ISBER best practices for biobanks. The Standard Preanalytical Code—an indicator of the preanalytical lifecycle of a biospecimen impacting the downstream analysis results—was already implemented in 50% of the biobanks while the other half intends future implementation. To assess and maintain the quality of their QMS, 62% of biobanks used self-assessment tools and 71% participated in proficiency testing schemes. The majority of biobanks had implemented procedures for general and biobank specific activities. However, policies regarding the business and sustainability aspect of biobank were only implemented in a limited number of biobanks. A clear desire for a peer-review audit was expressed by 69% of biobanks, with over half of them intending to implement the recently published biobank standard ISO20387. Overall, the biobanks of the BBMRI.be network have actively implemented a solid quality approach in their practices. The implementation of ISO 20387 may bring further professionalization of activities. Based on the needs expressed in this survey, the Quality working group will be setting up an audit program for the BBMRI.be biobanks, to enhance, harmonize and streamline their activities. On the whole, the biobanks in the BBMRI.be network are able to substantially contribute to translational research, as a primary facilitator guaranteeing high quality standards and reproducibility.

Effect and acceptability of AKI education using peer review audit in primary care

BackgroundThis was part of the Southern Derby shire CCG AKI awareness and improved management in primary and secondary care. The programme involved educating the primary care staff (GPs nurses) about AKI, identifying and early management in at risk groups. The secondary care aspect involved protocol development for AKI risk/identification to reduce morbidity.AimAs two-thirds of AKI originates in the community we aimed to increase awareness and knowledge levels of AKI in primary care via a CCG wide education programme. This included nephrology a peer review audit of cases with an evaluation of the programme’s acceptability and impact.MethodOver a 12month period, peer review audit sessions were delivered to GPs and the primary care MDT. These sessions consisted of a short presentation by a consultant nephrologist followed by discussion of cases. Qualitative feedback was collected from all participants. Web-based, CCG-wide questionnaires incorporating factual and clinical questions were used to assess baseline and post-intervention knowledge level.Results93% of participants (94 responses) found the peer review audit sessions useful, particularly the presence of nephrologist. 45% of participants were anxious about group discussion of cases, although 36% thought they were the most useful component of the sessions. Formal presentations were ranked as the most popular format of receiving education. 996 individuals completed the questionnaires. At baseline 61% were GPs, 27% practice nurses and 8% Advanced Practitioners, with similar proportions at 1yr. Exposure to AKI teaching, self-reported awareness and confidence levels were higher in the second questionnaire and there was a significant improvement in test scores.ConclusionPrimary care education can improve knowledge and awareness of AKI. Small group teaching with involvement of a nephrologist was popular. These results suggest that there is a need to tailor education styles to individual preferences, and peer review audit may not be universally acceptable in primary care.

Potentially avoidable issues in neurosurgical mortality cases in Australia: identification and improvements.

Mortality rates are commonly used to evaluate the quality of surgical care; however, a large proportion of surgical deaths are unavoidable. Examination of the potentially avoidable issues in surgical deaths can provide a strong basis for quality improvement. Using data from a well-established and comprehensive national surgical mortality audit, we sought to identify the most common avoidable factors in neurosurgical deaths, focusing on the lessons that can be learnt. This study analysed data from a peer review audit of surgical deaths in Australian hospitals (excluding New South Wales) from 2009 to 2014, focusing on neurosurgery cases with identified areas for improvement in patient management. In the 6% of neurosurgical cases that had clinical incidents, there were 193 clinical events identified. These were first categorized based on the perioperative stage (pre-, intra- or postoperative) followed by thematic analysis within each stage. The study found preoperative issues to be the most common (n = 107) followed by postoperative issues (n = 31) and intraoperative issues (n = 29). The most common theme was inadequate assessment (n = 65) followed by poor communication (at any stage of treatment) (n = 26). Neurosurgical cases with potentially avoidable mortality constitute a small but important subset. Avoidable contributors to mortality occurred most frequently at the preoperative stage, most commonly relating to inadequate assessment and delays. These findings can inform various stakeholders to improve the quality and safety of surgical care.

Impact of peer review audit on occupational health report quality.

BackgroundIn a previous report, we described the implementation of a formal process for peer review of occupational health (OH) reports and a method of assessment of the outcomes of this process. The initial audit identified that 27% of OH reports required modifications.AimsTo assess formally, following implementation of this process, if changes in practice had occurred, i.e. whether fewer deficiencies were being identified in reports.MethodsWe repeated a prospective internal audit of all peer reviewed OH reports between September and November 2011. We used an abbreviated assessment form, based on questions 4–8 and 10–12 of the modified SAIL (Sheffield Assessment Instrument for Letters), with four possible outcomes: no action, no changes made to report following discussion with author, changes made without discussion with author and changes made following discussion with author.ResultsOne hundred seventy-three reports by 10 clinicians were audited. The audit identified a 13% reduction in OH reports requiring modifications (from 27 to 14%) compared with the previous cycle. Where modifications were required, 8% of these were related to minor typographical, spelling and grammar errors and 6% were for more complex reasons. Implementation of this process also produced a reduction in clinical complaints about OH reports from customers, from three in the preceding year to none 2 years later.ConclusionsPeer review improved the standard of OH reports and was associated with a reduction in customer complaints about reports.

Reducing urinary tract infections in catheterised patients.

Urinary tract infections in catheterised patients continue to present a challenge in reducing healthcare-associated infection. In this article, an infection prevention and control team in one NHS trust reports on using audit results to focus attention on measures to reduce bacterial infections. Educational initiatives have an important role in reducing infection, but there is no single solution to the problem. Practice can be improved using a multi-targeted approach, peer review and clinical audit to allow for shared learning and experiences. These, along with informal education in the clinical area and more formal classroom lectures, can ultimately lead to improved patient outcomes.

Use of the high dependency unit, increased consultant involvement and reduction in adverse events in patients who die after colorectal cancer surgery

We prospectively audited adverse events for surgical patients with colorectal cancer who died under surgical care to test the hypothesis that increased critical care and consultant input could be associated with a reduction in adverse events. Patients with a diagnosis of colorectal cancer who died under surgical care in Scotland from 1996 to 2005 underwent peer review audit using established methodologies through the Scottish Audit of Surgical Mortality. In the 10-year study period, 3029 patients with colorectal cancer, mean age 76 (13-105)years, died under surgical care, of whom 80% had presented as an emergency admission. Operative intervention was performed in 1557 (51%) patients of whom 1030 (34%) patients had a resection of the cancer. The annual number of patients dying after a cancer resection decreased significantly (P=0.009). Significant decreases in adverse events were noted over time with a 67% fall in adverse events relating to critical care (P=0.009), a 37% fall for surgical care (P=0.04) and a significant increase in consultant anaesthetist and consultant surgeon input, but there was a 9% increase in delay as an adverse event (P=0.006). The documented anastomotic leakage rate in patients who died increased from 8% in 1996 to 19% in 2005 (P=0.016). The number of patients dying with colorectal cancer after surgery has decreased in recent years. Adverse events in these patients have significantly reduced over a decade with increased consultant involvement although there is the potential for further improvement.

Centralization of Services and Reduction of Adverse Events in Pancreatic Cancer Surgery

The perioperative period is critical in the outcome for patients with pancreatic cancer. The aim of the present analysis was to examine adverse events in patients dying under surgical care in relation to changes in the organization of pancreatic cancer surgery. From 1996 to 2005, 1,033 patients with pancreatic cancer, mean age of 71 years (range 21-97 years) died under surgical care. The incidence, mortality, and number of operations for pancreatic cancer remained stable across the time period, but the proportion of patients undergoing surgery in the five specialist cancer centers increased from 50 to 80 % (p < 0.001). Prior to death 260 (25 %) patients underwent operation and 96 (9 %) had endoscopic retrograde cholangiopancreatography (ERCP). There was a significant rise in ERCP (p = 0.03) and a decrease in non-resectional operations (p = 0.001). Since 1996, 52 (15 %) patients in whom 90 adverse events were recorded died following surgical intervention: 28 adverse events related to the perioperative period with 15 due to direct procedure complications such as bleeding or anastomotic leak; 13 were attributed to decision making around the choice or timing of the procedure. The postoperative mortality after curative pancreatic resection reduced from 3.5 to 1.8 %. Identified adverse events fell significantly in patients who died relating to the operative period (median of 3 per annum [1994-2000] to 1 per annum [2001-2005]) (p = 0.014) and medical care (3-0) (p = 0.003). Continuous peer review audit has demonstrated a reduction in the number of adverse events in patients dying with pancreatic cancer under surgical care as increased numbers of patients treated in specialist cancer centers.

Prospective peer review of regional percutaneous interventional procedures: a tool for quality control and revalidation

Current quality measures of percutaneous coronary intervention (PCI) procedures are based on the incidence of major adverse cardiac events (MACE). This crude marker ignores the many clinical nuances that make for sound decision making in PCI. We have established a prospective peer review audit tool to determine the quality of PCI within our cardiac network, which consists of five PCI hospitals serving a population of 1.4 million people in Sussex, UK. Analysis of 10% of all PCI cases selected at random each month by a non-clinical audit manager is made by a rotating panel of two PCI operators and one cardiac surgeon. Each PCI case is assessed for anatomical suitability, lesion severity, strategic appropriateness and final outcome. Panel findings were reported back to the operator and the audit manager. A total of 326 cases were assessed by the review committee. Results were disseminated to individual operators. Coronary anatomy and lesion severity were considered appropriate for PCI in 94.2% and 96.0% of cases, respectively. Appropriateness of strategy was confirmed in 86.2% and the outcome considered satisfactory in 90.8%. A total of 242 subsequent cases were analysed to assess practice trends. This analysis demonstrated a statistically significant improvement in clinical decision making with respect to appropriateness of strategy (from 86.2% to 92.6%; p=0.004). Prospective peer review of percutaneous coronary intervention cases by a rotating regional committee is valuable in ensuring procedural quality.

Defining standards for medico-legal reports in forensic evaluation of suspicious childhood injury

Expert opinions in the form of medico-legal reports are requested by police investigators and statutory child protection officers from child protection/forensic paediatricians to help them to make child protection and prosecution decisions. These reports must be understood and able to be correctly interpreted by a range of professionals and as well as comply with the requirements of expert court reports. There is currently much variation in report construction. Having a medico-legal report framework which defines structure and standards assists report-writers to achieve objectivity, can be useful for training, peer review audits and ensures optimal standards in opinion formulation. Using legal judgements relating to child abuse proceedings, author experience and the limited existing literature, a tool is presented which defines report standards specifically in relation to the assessment of suspicious injuries.