Medical reports

26.1 Much of the guidance on the role of an expert and the presentation of his evidence is equally applicable to the reports discussed in this chapter. The requirements of section 6 of the Practice Direction apply equally to medical and country experts. As with country experts, the courts have emphasised the importance of medical experts' attention being drawn to these requirements and to their complying with them. But this chapter deals with issues specific to expert medical evidence. The term 'medical report' is used as a label for all expert evidence on physical or mental condition, whether or not the expert is a medical doctor (or, say, a psychologist). For convenience, two other types of expert evidence are discussed in this chapter. The first is expert evidence on medical facilities in the country of origin as this is usually submitted in conjunction with medical reports. The second is evidence from independent social workers as to the effects upon families of expulsion as this is often submitted in conjunction with psychological reports.

26.2 Medical evidence is commonly obtained to;

• corroborate past ill-treatment;

• establish scarring, injuries or other conditions which will exacerbate risk from the authorities or non-state actors;

• explain an appellant's difficulties in giving evidence or recounting events;

• demonstrate the effect of expulsion upon a person's physical or mental condition or that of a member of her family.

26.3 The courts have emphasised the care with which relevant medical evidence should be addressed - see the discussion from para 26.44 below.

Corroborating past ill-treatment

26.4 A physical examination will normally be appropriate if your client reports significant past ill-treatment and credibility is in issue. The only basis for not obtaining a physical examination would be where there is no realistic possibility that the treatment reported by your client would have left any evidence.

26.5 Do not assume that because your client has no visible marks, there is no point in a physical report. A medical expert may detect after-effects of torture which are not apparent to a lay person. (Equally, do not make assumptions about the marks you can see. Ask your client about them. It may turn out that they have an innocent explanation.)

26.6 Some have an unrealistic view of what medical evidence can do. It is virtually never the case that medical evidence can prove conclusively whether or not someone was tortured. Sometimes, judges and HOPOs will suggest that the absence of medical evidence indicates that the appellant's account of torture is false. In Junaid v SSHD (01/TH/02540), the Tribunal commented as follows:

There is a further concern in that [the adjudicator] relied upon the absence of any medical report in relation to physical evidence of torture. The appellant's account was that the wounds had healed and there was effectively nothing substantial to show for what had happened to him. In our judgement, the way the Adjudicator approached that was again wrong. She should have considered first whether the evidence established that there would have been some sort of scarring and then and only then would it have been proper for her to have drawn the conclusion that the absence of scarring in some way militated against the account given by the appellant.

26.6A Similar concern was expressed by the Court of Appeal in Reka v SSHD [2006] EWCA Civ 552 (para 35; 45) about relying on the absence of physical evidence of ill-treatment in the absence of medical evidence that such physical evidence should exist had the claimant suffered the ill-treatment she reported.

26.7 The Istanbul Protocol (guidance from which has been commended by the Court of Appeal - see para 26.44) states that:

To the extent that physical evidence of torture exists, it provides important confirmatory evidence that a person was tortured. However, the absence of such physical evidence must not be construed to suggest that torture did not occur, since such acts of violence against persons frequently leave no marks or permanent scars.

26.8 Despite this, the absence of medical evidence may raise suspicion in the judge's mind that the reason there is no report before him is that the report which was obtained was negative. That risk is not obviated if the judge does not refer to his suspicion in the determination. Where an expert indicates that the absence of positive medical evidence is not an indicator that the appellant's case is false, it may be worth serving the report.

26.9 Expert evidence on mental conditions, e.g. PTSD, may also corroborate past ill-treatment. In many countries, state agents are increasingly sophisticated in inflicting torture by means that do not leave lasting physical evidence. This has made psychiatric reports more significant in some cases. For example, in Amnesty International's report 'Turkey: Torture and Impunity' (October 2001), it stated that:

Psychiatric reports have gained importance in the documentation of torture, since the security forces increasingly use psychological and other forms of torture which do not leave visible wounds, making torture allegations more difficult to verify.

Characteristics going to present risk

26.10 Corroborating credibility may not be the only relevance of visible marks and scarring. Country evidence may indicate that visible scarring which is consistent with past torture or past combat may provoke the adverse interest of local security forces. Such scarring will be relevant regardless of whether it in fact had an innocent explanation. A medical report demonstrating scarring suggestive of past torture or combat may therefore be material, even where the scarring was actually caused in some other way. A report from a country expert may also be required in such cases as the real question is not simply what the scarring indicates to a medical practitioner but whether there is a real risk that the scarring may provoke the suspicions of the security forces. The Tribunal has also indicated that it is useful to make photographs of the scarring available where this issue arises. (Medical photography is available from medical illustration departments, often within hospitals)

26.11 Psychiatric and psychological reports may also be material to present risk. A person who is mentally ill or disordered may be less capable of withstanding intense interrogation without inadvertently incriminating herself. It may be claimed by the HOPO that your client can avoid ill-treatment by lying or concealing information when interrogated upon arrival. Such a proposition is obviously unattractive even in respect of a healthy appellant (and, following RT (Zimbabwe) v SSHD [2012] UKSC 38, legally erroneous), but expert evidence may indicate that the appellant is in any event unlikely to be able to carry off such a deception - see e.g. AN & SS (Tamils - Colombo - risk?) Sri Lanka CG [2008] UKAIT 00063.

Reports on mental condition

26.12 The Istanbul Protocol states that:

A psychological evaluation and appraisal of the alleged torture victim is always necessary and may be part of the physical examination, or where there are no physical signs, may be performed by itself. (para 103)

Even where your client does not report significant physical ill-treatment, be sensitive to the possibility that your client may be traumatised, disturbed or have other psychiatric or psychological difficulties, whether flowing from ill-treatment that she has not disclosed or some other reason. Listen to your client when you take instructions. Ask her how she is feeling, but do not unquestioningly accept her answer. Sometimes a client will have blanked out particular incidents. She may give what seem to be completely different accounts of an incident each time you speak to her. She may appear disturbed, unable to concentrate, unusually slow, unwilling to answer the questions you ask or incoherent. Such an assessment obviously requires an experienced and competent interpreter so that you get the best possible idea of how your client is expressing herself. As discussed in chapter 11, some interpreters consider their role not only to interpret but to render the language coherent and logical. If you do not recognise and prevent this, it means that you will probably miss problem signs.

26.13 The Home Office regularly alleges dishonesty on the ground that any genuine refugee should be able to give a consistent account of her ill-treatment over time. There is a large body of expert learning to the contrary, see e.g.:

• Discrepancies in autobiographical memories - implications for the assessment of asylum seekers: repeated interviews study, Jane Herlihy, Peter Scragg, Stuart Turner (British Medical Journal, Vol 324)

• Errors of Recall and Credibility: Can Omissions and Discrepancies in Successive Statements Reasonably be Said to Undermine Credibility of Testimony (Medico-Legal Journal, Dr Juliet Cohen (2001) Vol. 69 Part 1, 25-34

• Memory, Disclosure and Credibility: Implications for the Forensic Assessment of Asylum Seekers, Dr Stuart Turner and Dr Jane Herlihy, December 2004 (Available from Freedom from Torture's website)

• Just Tell Us What Happened To You : Autobiographical Memory And Seeking Asylum, Dr Jane Herlihy, Dr Laura Jobson and Dr Stuart Turner, July 2012, Appl. Cognit. Psychol. 26: 661–676 (2012)

26.14 An examination by a psychiatrist or psychologist may demonstrate that it is particularly inappropriate to expect consistency in view of your client's condition. It may go to explain past discrepancies relied upon by the Home Office and/or to explain your decision not to call oral evidence from your client. The Medical Foundation (now Freedom from Torture)'s Guidelines for the Examination of Survivors of Torture (2nd Edition) (archived in 2018 but still available online and of continuing relevance) advises that in the course of taking a medical history:

Discrepancies of fact are noted and explanations sought from the subject, allowing time for thought and ordering of the memory. Minor variations often occur in the telling even by normal subjects and are more likely by confused or forgetful subjects; they do not necessarily detract from and indeed may add to credibility.

...

Any discrepancies in the history should be discussed with the subject who should be given time to reflect and recall the correct sequence of events. It is worth stressing that precise recall of dates and places is impossible where multiple episodes of torture have occurred or where the subject has suffered severe emotionally-mediated memory disturbance. (p. 23)

26.14A The Joint Presidential Guidance Note on Child, Vulnerable Adult and Sensitive Witnesses (No. 2 of 2010) reminds judges that

...Some forms of disability cause or result in impaired memory;

The order and manner in which evidence is given may be affected by mental, psychological or emotional trauma or disability;

Comprehension of questioning may have been impaired. (10.3 Assessing evidence)

You may want to ask an expert whether any of these apply to your client.

26.15 Even when the examination is conducted by an expert, encouraging a trauma victim to recall and relive their experiences is dangerous. The Istanbul Protocol states that:

Despite all precautions, physical and psychological examinations by their very nature may re-traumatize the patient by provoking or exacerbating symptoms of post-traumatic stress by eliciting painful effects and memories... A subjective assessment has to be made by the evaluator about the extent to which pressing for details is necessary for the effectiveness of the report in court, especially if the claimant demonstrates obvious signs of distress in the interview. (para 148)

26.16 Given the risks involved even in taking a history in a supportive environment, the expert may well advise that cross-examination in the context of an adversarial court hearing will pose an unacceptable risk. In those circumstances, it will usually be inappropriate to call your client to give oral evidence at the hearing (see further chapter 30).

26.17 A fear of stigma may make your client anxious to conceal past ill-treatment from relatives and her community, particularly sexual ill-treatment. You must always take instructions in the absence of friends and relatives (see chapter 11). Your client may be worried that referral for psychiatric examination will provoke unwelcome questions from relatives. It can help to tell close relatives who are also involved in the case that your client's examination is a routine measure. If confidentiality as regards relatives is an issue, be sure that any report is not sent to your client by post without express authorisation.

Treatment

26.18 Unfortunately, many representatives consider that their job is done once they have obtained the necessary forensic evidence and give little consideration to the therapeutic requirements disclosed by the report. Left to her own devices, the prospects of your client accessing therapeutic care are little better than the prospects that she would have obtained forensic evidence on her own. A large proportion of UK citizens who suffer mental illness or disorder fail to access appropriate treatment. The obstacles are magnified for an asylum seeker.

26.19 The expert report should contain an indication of any appropriate treatment. However, the overriding duty of a medical expert, like any other expert, is to provide independent assistance to the Court. Although Freedom from Torture (formerly known as the Medical Foundation) and the Helen Bamber Foundation are a special case, an expert witness will not normally view arranging treatment for your client as consistent with his role in the litigation. You should ensure that any recommendations are taken forward in conjunction with your client's GP. Referral to Freedom from Torture or the Helen Bamber Foundation (if they did not produce the original report) may be considered, although there may be a long waiting list for treatment.

26.20 Facilitating treatment is obviously in the interests of your client. It will also avoid the HOPO attempting to discredit the forensic evidence on the ground that one would have expected her to be receiving treatment. Although he will not stand in the same shoes as an independent expert, a doctor who is responsible for your client's treatment may also be able to add valuable evidence for the appeal.

26.21 The extent of treatment in the UK may also be important in establishing the degree of private life enjoyed in the UK.

Challenging expulsion on medical grounds

26.22 The effects of expulsion upon the appellant's health may raise issues under articles 3 and/or 8. Possible issues include the following:

• The appellant or her dependants are unable to access the treatment they need in the country of origin (either because it is not available generally or will not be available to them in their particular circumstances).

• The need to access treatment precludes moving to a part of the country which would otherwise be safe.

• The form of treatment in the country of origin gives rise to a real risk of persecution, serious harm or other human rights breaches, such as being detained, isolated, chained, caged, beaten or experimented upon.

• The appellant's health prevents her working and so deprives her and any dependants of the means of survival.

• Some conditions (e.g. HIV/AIDS) provoke discrimination and stigmatisation.

• The act of forcible expulsion will trigger a relapse of a serious mental illness/disorder.

• Returning the appellant to the site of previous trauma will exacerbate her condition, or risk a substantial aggravation of physical or mental health conditions which result from past torture in circumstances where the authorities will not comply with their duty to provide appropriate after care (see 41.21A).

• Treatment which would not cross the requisite severity threshold for a healthy person will cross that threshold where the person is suffering from serious physical or mental conditions.

26.23 Medical evidence will commonly be advanced in tandem with supporting country evidence to establish the factual premise upon which the medical prognosis is based.

26.24 The Home Office sometimes seeks to discredit a medical expert's prognosis on the basis that it assumes matters about the country of origin that he is not qualified to know. It is important, therefore, that your medical expert sets out in his report the factual premise upon which he is commenting and indicates from where it is derived. If your medical expert does in fact have knowledge of country conditions (most usually, the availability of health care), then he should explain that knowledge in the same way as a country expert. If not, he should explain what information he has been given. This may be country evidence, including expert evidence, or simply your instructions. But if the latter, you will obviously have to support the statements made in the instructions by evidence. In AM (Art 3 health cases) Zimbabwe [2022] UKUT 00131 (IAC), the Tribunal observed that in cases turning on the availability of and access to treatment in the receiving state:

…such evidence is more likely to be found in reports by reputable organisations and/or clinicians and/or country experts with contemporary knowledge of or expertise in medical treatment and related country conditions in the receiving state. Clinicians directly involved in providing relevant treatment and services in the country of return and with knowledge of treatment options in the public and private sectors, are likely to be particularly helpful.

26.24A In KV (scarring - medical evidence) Sri Lanka [2014] UKUT 00230 (IAC) (which was not disturbed in this respect on appeal), the Upper Tribunal agreed that it was legitimate for medical experts to take account of country of origin information when preparing their reports but emphasised three caveats:

306. The first is that unless the COI has some specific relevance to the clinical assessment of the cause of torture (e.g. it deals with the most common methods of torture used in a particular country of origin) doctors should not go searching for such materials themselves – and indeed doctors are not and should not purport to be country experts.

307. Linked to the first, a second caveat is that even when they do draw on COI materials, doctors should make clear that they are not in a position to say what the overall state of the COI is, only to say what they have been made aware of: once again, they are not country experts who can be expected to have a comprehensive picture of COI.

308. A third caveat is that in the context of a medical report the doctor's task is to assist the asylum decision-maker by bringing to bear his or her medical expertise. He or she is not conducting a free-ranging assessment of the credibility of the claimant's story. ...

26.24B In KV (Sri Lanka) in the Supreme Court ([2019] UKSC 10), the Court also noted that country information of, as in that case, extensive torture undertaken by the authorities in the country of origin during the time at which torture was claimed to have taken place would clearly be relevant in assessing the likelihood of torture having taken place (see at [32]).

26.25 It will be apparent from the scenarios listed above that a wide range of country evidence may be required in a medical case. Particularly where health care provision in the country of origin is in issue, it is often useful for your medical expert to liaise with your country expert. The process might start with a preliminary note from the medical expert as to what treatment is required. The country expert will then produce a report upon the extent to which such treatment will be available. On the basis of that report, the medical expert will produce a prognosis.

26.26 The Home Office commonly argues that what is material is the theoretical availability of treatment. This is not necessarily determinative either way (see the discussion in chapter 41), but on one view of the law, showing that there is no treatment at all rather than no treatment accessible to your client may assist the case. It may therefore be useful for the expert to consider not only practical availability to the appellant but also whether the necessary treatment is available to anyone in the country of origin.

26.27 If the extent of health care in the country of origin is in dispute (for example, if the refusal letter or Home Office country report claimed that some health care will be available), you may wish your expert to provide an alternative prognosis on the basis of the facts claimed by the Home Office. If the prognosis is sufficiently serious to raise human rights issues even on the Home Office's case, then alternative arguments should be advanced to allow for the possibility that the Tribunal prefers the Home Office's claims about the availability of treatment.

26.28 The medical report should set out:

• your client's present condition;

• what, if any, treatment she is receiving;

• the prognosis with that treatment;

• the effects (if any) of the act of expulsion;

• the prognosis in the country of origin.

26.29 It is particularly useful in such situations to have information from the person with responsibility for your client's treatment in the UK.

26.30 In article 8 cases involving families with children, and particularly where proportionality is in issue, it will often be necessary to obtain expert evidence from a child psychologist as to the consequences for the children of their own expulsion or that of a parent. In Mindoukna v SSHD (01/TH/02635), the IAT gave guidance on the type of issues that such a report could usefully cover:

The trouble is that we do not have any reliably verified information about what the state of affairs in the family actually is, nor any expert help in predicting its future. As we hope everyone will come to realize, decisions in these cases are at least as important for the welfare of the child involved (even if that cannot be regarded as paramount), as any others. Where, as in this case, they may depend on significant recent developments, or other complications, in our view a short welfare report is required, from the local authority in whose area the child is living. Adjudicators should be asked by solicitors in such cases to make a request for one (assuming it has to come from them) in good time before the hearing. What the report should contain in this case, and how it should be dealt with, we shall discuss below.

We should not want to be accused of telling experienced court welfare officers how to do their business; but, as welfare reports have not so far been usual in this field, we shall try to give some idea of what we should expect one to contain. Naturally there would be a personal interview with both the appellant and Cathy, together with a home visit so that Leon could be seen in his normal surroundings. Some confirmation that there is regular contact between Cathy's other children and their father would be desirable; but other than that there does not seem to be any special need to go into their situation. What would be particularly appreciated is some assessment of the probable long-term stability of the appellant's relationship with Cathy, and of the contribution he is making to caring for Leon.

26.31 Court welfare officers have now been replaced by 'children's guardians'. It is not possible to obtain a report from them in their official capacity unless there are ongoing proceedings in the family courts. In RS (immigration and family court proceedings) India [2012] UKUT 00218 (IAC), the Tribunal observed that while it was bound to treat the best interests of the child as a primary consideration following the implementation of s. 55 of the Borders, Citizenship and Immigration Act 2009,

...the Tribunal does not have any means of assessing these matters for itself, in particular: there is no local authority or children's guardian, no access to the service provided by CAFCAS, and no independent means of ascertaining the wishes, concerns and interests of the child. (para 37)

26.31A However, a report from an independent social worker (many of whom also act as children's guardians) will perform the same role. Given that the best interests of any children are a primary consideration in any appeal, Baroness Hale's answer to the question "what is encompassed in the "best interests of the child"?" in ZH (Tanzania) v SSHD [2011] UKSC 4 provides some useful guidance as to the issues which such reports should address:

As the United Nations High Commission for Refugees says, it broadly means the well-being of the child. Specifically, as Lord Bingham indicated in EB (Kosovo) [2009] AC 1159 , it will involve asking whether it is reasonable to expect the child to live in another country. Relevant to this will be the level of the child's integration in this country and the length of absence from the other country; where and with whom the child is to live and the arrangements for looking after the child in the other country; and the strength of the child's relationships with parents or other family members which will be severed if the child has to move away. (para 29)

Instructing a medical expert

26.32 Freedom from Torture (formerly known as the Medical Foundation) and the Helen Bamber Foundation are the best known sources of medical reports in asylum and human rights appeals. The Home Office's guidance on medical evidence in asylum claims ('the API on medical evidence') states that:

MLRs may be provided by a specialist clinical organisation such as the Helen Bamber Foundation or Freedom from Torture. The Helen Bamber Foundation and Freedom from Torture cannot accept all cases referred to them and referrals are considered by a panel for suitability. Clinicians who write reports for these organisations receive training and supervision. Reports writers from a specialist clinical organisation such as the Helen Bamber Foundation and Freedom from Torture are accepted by the Home Office as having recognised expertise in the assessment of the physical, psychological, psychiatric and social effects of torture.

Clinicians from reputable organisations that apply a rigorous methodology to the production of reports should be objective and unbiased. Reports and other medical evidence prepared by such organisations should be accepted as having been compiled by qualified, experienced and suitably trained clinicians and health care professionals. No medical evidence should be given little weight on the grounds that the writer, whether a doctor, consultant, other clinician or healthcare professional is not sufficiently qualified to write it - including, in relation to mental health conditions, where the writer has extensive experience in the field and are regulated professionals.

26.33 The API on medical evidence states that where a caseworker is informed in writing by an asylum applicant's legal representative that the case has been accepted for an appointment by "a reputable provider or an organisation that applies a rigorous methodology to the production of reports, for the purposes of producing an MLR" normally substantive decision-making should be suspended to permit consideration of that report. The policy states: "Medical evidence in support of a claim of torture or serious harm must not be dismissed, or have little or no weight attached to it, when the overall assessment of the credibility of the claim is made."

26.34 The IAT (the predecessor of the First-tier Tribunal) has also described the Medical Foundation (now Freedom from Torture) as a 'most prestigious and reliable' body which has 'over the years accumulated a large body of expertise' (Guney v SSHD (19159)). The Helen Bamber Foundation and Freedom from Torture aim to produce a report within 5 months of a case being placed 'on hold' by the Home Office pending an initial decision (see API on medical evidence, p14). Similar timescales may be anticipated at the appeal stage and an early referral is imperative if you will need to request the Tribunal to extend the time limit for the submission of your client's appeal bundle to await a medical report.

26.35 There are a wide range of medical experts available, including many who are experienced in preparing medical reports for the purposes of litigation. The Home Office's API on medical evidence recognises that reports from other experts may be as valuable as those obtained from the Helen Bamber Foundation or Freedom from Torture, providing that they comply with the established standards for medico-legal report writing. The important thing to consider is exactly what you want and why you want it. Your expert should have the appropriate forensic expertise to analyse your client's injuries or condition and the ability to present his findings clearly and explain their relevance. The range of issues on which psychological evidence is accepted in the criminal courts is constantly expanding.

26.36 It can also pay to talk to personal injury solicitors. They are dealing on a regular basis with medical experts and will know not only where the expertise lies, but which experts are better able to produce that knowledge in a form which is useful and persuasive to a court. The Expert Witness Directory and other expert directories list vast numbers of medical experts. APIL (the Association of Personal Injury Lawyers) has a directory based on recommendations by members. As you build up relationships with the medical experts you use, use them as sources of information on other experts. Talk to other lawyers in the field. Check whether your expert's reports have been the subject of comment by the Tribunal (see para 21.29).

26.37 As with other expert reports, you should be alert to the risk, particularly when using experts new to the field, that they will be politically unsympathetic to your client. Because the production of the medical report will almost invariably involve examination and interview, it is important to ensure that your client will be as comfortable as possible with the expert. The expert's gender may be particularly significant in relation to sexual torture. Take similar care with the interpreter.

26.38 The Home Office should address in the refusal letter any medical evidence already submitted. Obviously, if a medical report was submitted to corroborate a physical injury, but the refusal letter makes allegations about discrepancies which may be explained by your client's mental condition, it will be necessary to seek a further medical report prior to the appeal. You may also need a supplementary report on the same subject where, for example, the original medical report confirmed scarring consistent with torture but the refusal letter alleges that it could have been caused by some accident (although a good report should already have considered that possibility) or even self-inflicted. Equally, your medical report might detail psychological problems yet the refusal letter nevertheless relies on discrepancies which are explicable by your client's condition. If so, you should get the expert to address directly the relevance of the alleged discrepancies

Medical experts instructed by the Home Office

26.39 The Home Office does not normally advance expert medical evidence. It has been recorded that an experiment in seeking expert evidence to rebut Medical Foundation reports was abandoned when the Home Office found that its expert tended to corroborate the Foundation's findings (see Good, Undoubtedly an Expert? Anthropologists in British asylum courts, The Journal of the Royal Anthropological Institute, Volume 10, Number 1, March 2004).

26.40 During the summer of 2002, the Home Office began routinely submitting a 'generic' expert report headed Notes for Assessing Psychiatric Injury in Asylum Seekers by a Dr Neal. It made various claims about the diagnosis and treatment of PTSD in asylum seekers - including that refugees with PTSD were best treated by returning them to the site of their trauma. None of the claims was based on research into refugees, or even experience of examining asylum seekers on the part of the expert. Judges were nevertheless invited to prefer this generic report to the report of an expert who had examined the appellant. Unsurprisingly, the IAT was unimpressed. In Harunaj v SSHD [2002] UKIAT 04042, it said that:

Dr Neal had not seen the appellant and nor had he prepared a report specific to the appellant and if the basis of [the HOPO's] submissions to us [challenging the appellant's medical report] was to be based on the general notes for reassessing psychiatric injury in asylum seekers we could see no reason why these should be preferred by the Tribunal to a specific report relative to this appellant; we felt that we lacked the qualification to make any judgment relative to psychiatric matters, and certainly could not make a judgment based on general notes as opposed to a judgment between two medical practitioners, both of whom had had the benefit of a consultation with the appellant.

26.41 In fact, the psychiatrist subsequently wrote an open letter stating that he had given no authority for his paper to be relied upon by the Home Office in appeals. The Home Office has long since abandoned this practice.

26.41A The CJEU has emphasised that any request from the decision-making authorities for an asylum seeker to undergo a medical assessment raises difficult issues about consent. The asylum seeker will know that if he refuses consent, adverse inferences may be drawn against him, but a medical examination, particularly an intimate physical examination or a psychiatric or psychological examination, necessarily entails a substantial interference in the asylum seeker's private life. The assistance which the report is likely to give in determining the asylum claim has to be such as to make that interference proportionate. In the particular case before it, the CJEU considered that in the absence of a reliable body of medical opinion supporting the reliability of any conclusions, a psychological assessment conducted to establish an asylum seeker's sexual orientation constituted a disproportionate interference in private life and showed a lack of respect for human dignity: F v Bevandorlasi es allampolgarsagi Hivatal (Directive 2011/95/EU) Case C-473/16.

26.42 Where – as usual – he has no report at all, HOPO may attack the conclusions of the most renowned psychiatrist on the basis of what appears to be no more than the HOPO's own 'medical' analysis. He commonly claims that the psychiatrist's diagnosis is defective because any psychiatrist is incapable of doing more than accepting what he is told. The High Court has in the past been provoked to point out that:

It is not appropriate for a civil servant without medical expertise to reach a conclusion contrary to that reached by a psychiatrist simply by drawing on his own native wit. (R v SSHD, ex parte Khaira [1998] INLR 731)

26.42A The Home Office's API on medical evidence reminds its caseworkers that it is not their role to dispute clinical findings or make clinical judgments that are inappropriate for a caseworker to make. It then provides a number of examples:

…Examples of clinical judgements that are inappropriate for you to make include:

• what in your opinion ought to be physically possible or survivable

• speculation about causation of physical or psychological injuries

• questioning the accuracy of a diagnosis (based on selective quoting of the diagnostic criteria)

• substitution of your own opinion on late disclosure or discrepancies in the testimony when a clinical explanation has been provided in the medical report

• speculation about the amount of detail with which a particular traumatic event ought to be remembered

It is also inappropriate for you to provide your own subjective opinion either about the claimant's behaviour, for example the reasons for not having sought or received treatment previously, or for refusing to consent to an examination. Some other examples include:

• the use of information obtained via the internet about diagnostic criteria or medication

• the use of statements made by a claimant at interview that they 'feel well' to subsequently dispute medical problems identified and documented in the medical report

• selective quoting from the medical report to challenge representations made by the claimant that the report supports when read properly and in its entirety

This is not exhaustive and if you are in doubt as to whether a finding is a clinical judgement, you must discuss the case with a senior caseworker or Second Pair of Eyes.

26.43 The HOPO's claims that the psychiatrist's diagnosis is defective because any psychiatrist is incapable of doing more than accepting what he is told can be rebutted by ensuring your expert records their consideration of their methodology (ie which includes observation of your client in addition to her self-reporting). This absurdly nihilistic approach to medical expertise is particular to the Home Office in this jurisdiction. It does not occur in those appeals where the Home Office actually submits its own psychiatric evidence. Indeed, during one appeal, R (Ahmadi) v SSHD [2002] EWHC 1897 (Admin), leading counsel for the Home Office led expert evidence from two psychiatrists aimed at supporting an adverse credibility finding - an approach that somewhat undermines the common claim by HOPOs that psychiatrists can only accept whatever the appellant tells them.

The role of the medical expert

26.44 A medical expert is just that. He is not an expert on asylum and human rights law. It is your job to ensure that the report addresses the correct issues. Doctors accustomed to litigation in other fields may be accustomed to reaching conclusions according to the balance of probabilities, and to disregarding claims which cannot be established on the balance of probabilities. In asylum and human rights appeals however, the question will often be whether there is a reasonable likelihood or serious possibility that an injury was caused in a particular way. The Istanbul Protocol gives guidance commended by the Court of Appeal. In SA (Somalia) v SSHD [2006] EWCA Civ 1302, the Court of Appeal stated (in guidance approved by the Supreme Court in KV (Sri Lanka) v SSHD [2019] UKSC 10) that

29. In cases where the account of torture is, or is likely to be, the subject of challenge, Chapter Five of the United Nations Document, known as the Istanbul Protocol, submitted to the United Nations High Commissioner for Human Rights on 9 August 1999 (Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment) is particularly instructive. At paras 186-7, under the heading "D. Examination and Evaluation following specific forms of Torture" it states:

"186.... For each lesion and for the overall pattern of lesions, the physician should indicate the degree of consistency between it and the attribution
(a) Not consistent: the lesion could not have been caused by the trauma described;
(b) Consistent with: the lesion could have been caused by the trauma described, but it is non-specific and there are many other possible causes;
(c) Highly consistent: the lesion could have been caused by the trauma described, and there are few other possible causes;
(d) Typical of: this is an appearance that is usually found with this type of trauma, but there are other possible causes;
(e) Diagnostic of: this appearance could not have been caused in anyway other than that described.

187. Ultimately, it is the overall evaluation of all lesions and not the consistency of each lesion with a particular form of torture that is important in assessing the torture story (see Chapter IV.G for a list of torture methods)."

30. Those requested to supply medical reports supporting allegations of torture by asylum claimants would be well advised to bear those passages in mind, as well as to pay close attention to the guidance concerning objectivity and impartiality set out at paragraph 161 of the Istanbul Protocol.

26.44A In RT (medical reports – causation of scarring) Sri Lanka [2008] UKAIT 00009, the Tribunal referred to this guidance, describing SA as a 'landmark case', and after citing the passage above noted that:

...SA (Somalia) emphasises the importance of a medical report whose findings on consistency express the fact that there are other possible causes (whether many, few or unusually few), specifically examining those to gauge how likely they are, bearing in mind what is known about the individual's life history and experiences. (para 42)

26.44B In JL (medical reports-credibility) China [2013] UKUT 00145 (IAC), the Upper Tribunal held that:

(3) The authors of such medical reports also need to understand that what is expected of them is a critical and objective analysis of the injuries and/or symptoms displayed. They need to be vigilant that ultimately whether an appellant's account of the underlying events is or is not credible and plausible is a question of legal appraisal and a matter for the tribunal judge, not the expert doctors (IY [47]; see also HH (Ethiopia) [2007] EWCA Civ 306 [17]-[18]).

(4) For their part, judges should be aware that, whilst the overall assessment of credibility is for them, medical reports may well involve assessments of the compatibility of the appellant's account with physical marks or symptoms, or mental condition: (SA (Somalia) [2006] EWCA Civ 1302). If the position were otherwise, the central tenets of the Istanbul Protocol would be misconceived, whenever there was a dispute about claimed causation of scars, and judges could not apply its guidance, contrary to what they are enjoined to do by SA (Somalia). Even where medical experts rely heavily on the account given by the person concerned, that does not mean their reports lack or lose their status as independent evidence, although it may reduce very considerably the weight that can be attached to them.

26.45 Refer to the general discussion in chapter 22 about the boundaries of acceptable expert comment, particularly on credibility issues. The sensitivity of the Tribunal to inappropriate comment on credibility is no less strong in relation to medical experts than country experts. In KV (Sri Lanka) [2019] UKSC 10, the Supreme Court overruled the majority of the Court of Appeal to find that decision-makers can legitimately receive assistance from medical experts who offer an opinion about the consistency of their findings with the asylum-seeker's account of the circumstances in which a particular scar or lesion was sustained, and are not limited to opining on the mechanism by which it was sustained. The Supreme Court also concluded that whereas a medical report which gives an opinion at either end of the Istanbul Protocol spectrum (ie either 'diagnostic of…' or 'not consistent with…') is tantamount to expressing a belief on the asylum-seeker's account of torture, there was no legitimate place for the expression of such a belief where any of the intermediate Istanbul categories apply. It also emphasized that the issue of the credibility of the appellant's account overall is only for the Tribunal to decide. But it is unrealistic to pretend that medical experts are not concerned with credibility. Doctors assess credibility in the ordinary course of their work. The Medical Foundation's Guidelines for the examination of survivors of torture state that:

Consistency and credibility are continuously assessed as the interview and examination proceed. In coming to a conclusion, the doctor must make a series of judgments, assessing the subject's demeanour as well as the history and physical signs. (p.22)

... All participants in the asylum process inevitably need to make some estimate of the applicant's credibility. The examining doctor is not excluded from this process of assessment and should have credibility in mind throughout the history-taking and examination and have made some personal assessment of it by the end. (p.27)

26.46 This has been recognised by the courts. In Virjon B v Special Adjudicator [2002] EWHC 1469 (Admin), Forbes J said that:

[I]t goes without saying that clinicians of the experience of [the psychiatrists whose reports were before the court] must be taken to be well used to assessing the truth or otherwise of assertions made by patients, particularly when assisted by appropriate objective forms of questionnaire and tests used for those purposes... [T]heir reports constitute a significant body of medical evidence which provides strong corroboration of the truth of the claims made by the claimant and his wife as to what had happened to them.

26.47 In MO (Algeria) v SSHD [2007] EWCA Civ 1276, Moses LJ rejected the Tribunal's comment that 'It is not within the doctor's remit to make credibility findings' as 'too prescriptive'. He observed that 'Doctors often do comment upon the consistency and credibility of the historian before them, namely of the patient's account' and 'a doctor is not to be criticised when he does so'. While the doctor's opinion was 'not dispositive', he added that if would be 'unfortunate' if the doctor could not comment because when his opinion on credibility was adverse, 'the fact-finder will be deprived of the benefit of the doctor's opinion that someone has proved to be an unreliable historian' (para 18). The Court of Appeal in MN v The Secretary of State for the Home Department [2020] EWCA Civ 1746 made similar findings, following a survey of the case law (see 26.53C).

26.47A In Y and Z (Sri Lanka) v SSHD [2009] EWCA Civ 362, Sedley LJ observed the question of whether an appellant's account of her symptoms was exaggerated was:

... in the first instance a matter for the experts themselves, a fundamental aspect of whose expertise is the evaluation of patients' accounts of their symptoms: see R. (on the application of M) v Immigration Appellate Authority [2004] EWHC 582 (Admin) per Moses J. It is only if the tribunal has good and objective reason for discounting that evaluation that it can be modified or—even more radically—disregarded. (para 12)

26.47B In KV (scarring - medical evidence) Sri Lanka [2014] UKUT 00230 (IAC), the Tribunal accepted that:

...whilst it is not the role of a medical expert to assess the credibility of a patient's asylum claim, it is part of their role to assess ... clinical plausibility. Principally the latter is (or should be) a matter of examining the physical and psychological sequelae of the claimed ill-treatment and reaching a conclusion as to causation in accordance with the [Istanbul Protocol] hierarchy.

26.47C The finding of the majority of the Court of Appeal in KV Sri Lanka (Sales LJ (with whom Patten LJ agreed)) to the contrary, namely that the expert "trespassed beyond his remit as an expert witness" by expressing an opinion as to the consistency of his medical findings with the appellant's account of how the scars were caused, was the subject of a successful appeal to the Supreme Court. In KV (Sri Lanka) [2019] UKSC 10 the Supreme Court held that Elias LJ in his dissenting judgment was right to hold at [110] that the doctor was entitled to express an opinion on consistency and that in doing so he did not overstep his remit or trespass impermissibly on the Tribunal's role in determining credibility. In the course of the hearing before the Supreme Court, the Secretary of State did not seek to defend the views of Sales LJ in the Court of Appeal which were expressed to be clearly erroneous (KV (Sri Lanka at [20]). The Court said:

20…In their supremely difficult and important task… of analysing whether scars have been established to be the result of torture, decision-makers can legitimately receive assistance, often valuable, from medical experts who feel able, within their expertise, to offer an opinion about the consistency of their findings with the asylum-seeker's account of the circumstances in which the scarring was sustained, not limited to the mechanism by which it was sustained. Had the contribution of Dr Zapata-Bravo been limited to confirming KV's account that the scarring was caused by application of a hot metal rod, it would have added little to what was already a likely conclusion. But, when he proceeded to correlate his findings of a difference in the presentation of the scars on the back and those on the arm with KV's account of how the alleged torture had proceeded, he was giving assistance to the tribunal of significant potential value; and it never suggested that he lacked the expertise with which to do so.

26.47D The Supreme Court further noted, contrary to the majority of the Court of Appeal, that its conclusion was based on the terms of the Istanbul Protocol itself:

21. … Sales LJ suggested that the references in para 187 of the Istanbul Protocol to the "trauma described" relate only to the mechanism by which the injury is said to have been caused. That is too narrow a construction of the word "trauma". It is clear that in the protocol the word also covers the wider circumstances in which the injury is said to have been sustained. Paragraph 188 of the protocol, set out in para 16 above, which Sales LJ had himself quoted in para 31 of his judgment, guides the expert towards the type of evaluation which is important in assessing "the torture story". Paragraph 105 of the protocol recommends that, in formulating a clinical impression for the purpose of reporting evidence of torture, experts should ask themselves six questions, including whether their findings are consistent with the alleged report of torture and whether the clinical picture suggests a false allegation of torture. Paragraph 122 says: "The purpose of the written or oral testimony of the physician is to provide expert opinion on the degree to which medical findings correlate with the patient's allegations of abuse …"

26.47E You should always ask your expert to expressly consider whether the appellant might be feigning or exaggerating his symptoms – the Istanbul Protocol advises in connection with psychological examinations that:

It is important to recognize that some people falsely allege torture for a range of reasons and that others may exaggerate a relatively minor experience for personal or political reasons. The investigator must always be aware of these possibilities and try to identify potential reasons for exaggeration or fabrication. The clinician should keep in mind, however, that such fabrication requires detailed knowledge about trauma-related symptoms that individuals rarely possess. Inconsistencies in testimony can occur for a number of valid reasons, such as memory impairment due to brain injury, confusion, dissociation, cultural differences in perception of time or fragmentation and repression of traumatic memories. Effective documentation of psychological evidence of torture requires clinicians to have a capacity to evaluate consistencies and inconsistencies in the report. (para 290)

26.48 Medical experts have on occasion been criticised by HOPOs for offering an opinion about how an injury was caused on the ground that such opinion is speculation. That is misconceived. It is the expert's job. What he must make clear however is that his assessment of the likelihood that the injury was caused in a particular way is based upon the application of his expertise, and not on any view he has formed as to the general credibility of the appellant's claim. The Medical Foundation Guidelines state that:

It is no part of the doctor's function to give an opinion as to overall credibility of the case, though it is quite in order to express an opinion as to whether the medical evidence supports the allegation of torture. (p.28)

26.49 The basic rule is that any conclusion that the expert reaches must be transparently justified by the expert's expertise. The report should never state 'I conclude that the appellant has been persecuted in the manner described' or 'I conclude that the history given by the appellant is correct'. But if the expert is able so to conclude, the report may state that it is unlikely that an injury was inflicted by means other than those described by the appellant. That will often be highly material. For example, in Yasotharan v SSHD (00/TH/01816) the IAT said that:

It seems to the Tribunal that where there is credible, reliable expert medical evidence that someone has been injured by a burning cigarette being applied to the skin (which to the Sivakumaran standard is the effect of the medical evidence before us) other possible causes than torture, in all but the exceptional case, can safely be excluded.

26.49A In RR (Challenging evidence) Sri Lanka [2010] UKUT 274 (IAC) (see also para 35.5A), the Upper Tribunal observed in connection with a medical report (which it described as "not particularly compelling evidence" – para 146 - but in which the expert had expressed his view that the appellant's scars could have been caused in the manner described – para 147): 'The apparent cigarette burns particularly interest us because it is hard to see how injuries of that kind could be sustained unless they were inflicted deliberately' (para 148). It noted that the respondent had "never suggested to the appellant that the scars were the result of voluntary mutilation and there is no reason to suggest such a thing except cynicism" (para 149) and continued:

...We accept that Dr Taghipour does not exclude the possibility of these scars being caused in some other way but the best explanation before us is the one given by the appellant.

154. Once it is apparent that the appellant is scarred we have to ask ourselves how he came to be scarred. He says that he was tortured. The other possibilities are that the scars were the result of some innocent but unimaginable mechanism, or that they are the result of torture in very different circumstances to those advanced by the appellant. One might speculate that they were self-inflicted, presumably to promote the appellant's case. None of these explanations is beyond belief but they do not appear to us to be likely. ...

26.49B In KV (Sri Lanka) in the Court of Appeal ([2017] EWCA Civ 119), the Court found that the Upper Tribunal had been wrong to suggest that there was an obligation on medical experts routinely to consider explanations which had neither been suggested by the parties nor appeared obvious from a clinical perspective. Sales LJ noted that:[…]

In an immigration and asylum context, if an expert medical witness is properly instructed regarding the circumstances of the individual case and thus has their attention drawn to the salient points of dispute between the parties in relation to which their assistance is being sought and also has their attention drawn to the guidance in the Practice Direction, it should be reasonably clear what evidence they can and ought to give. If the applicant for asylum has scarring and maintains that it is the result of being tortured, it should appear from the Secretary of State's decision whether she accepts their account or not. If she does not accept it, she should explain why she rejects it or is unpersuaded by it, including by saying (if this is her reason) that she considers that the injuries could have been self-inflicted or the result of [self-infliction by proxy]. The question of self-infliction or SIBP will then appear as an issue between the applicant and the Secretary of State, and the expert witness will know that that is something about which they should give any relevant evidence which they properly can, within their expertise.

… Self-infliction of wounds, or wounding by SIBP, is generally so unlikely that the Secretary of State should raise it as an issue, if it is to be part of her reasoning to reject an account of torture.

… Contrary to the UT's guidance, I do not consider that it is incumbent on medical experts in scarring cases to refer to the possibility of SIBP, where the Secretary of State has not raised it as an issue, unless there is some feature of the case which engages the duty of the medical expert to bring it to the attention of the Tribunal…. Subject to that duty, an expert witness does not have to raise and comment on issues which have not been raised by the parties to the proceedings.

…If on examining an applicant for asylum it appears to the medical expert that features of the scarring said to be corroborative of the applicant's account of torture indicate that there are medical issues which cast doubt on that account, it will be the duty of the expert witness to draw these issues to the attention of the Tribunal. For example, that might be because scarring of the kind in question is not compatible with the account given by the applicant of how it was inflicted (see [289]) or because features of the scarring indicate that it was inflicted at a time different from that stated by the applicant (see [291]). Or if the injury relied upon as corroborative of torture is also familiar to the expert as a kind which is a common sporting injury, that might be the sort of thing which should be mentioned. I do not think is it helpful to try to elaborate further in abstract terms.

26.49C The Supreme Court (KV (Sri Lanka) [2019] UKSC 10) upheld Sales LJ's criticisms of the approach of the Tribunal in these passages (but not, as noted above, his criticism of the expert's reliance on the Istanbul Protocol). It also upheld Elias LJ's dissenting opinion in the Court of Appeal to the effect that where the Tribunal had identified only torture and self-infliction by proxy as the two possible causes of the scarring on the appellant's body, it had to determine which of those was the cause of the injuries ([2017] EWCA Civ 119 at [102]). Elias LJ held that given the inherent unlikelihood of 'self-infliction by proxy', in such circumstances:

If the medical evidence is consistent with an applicant's account of how he has been tortured, I am doubtful whether even strong reservations about the veracity of an claimant's account of events could displace a finding of torture to the lower standard where the only alternative is SIBP. Plainly that would be possible where the account could be shown to be not merely inherently unlikely but actually false, such as where there is incontrovertible evidence that the applicant was not in the country when the alleged torture was said to have occurred [101]]

26.49D The Supreme Court further provided the following guidance for assessing the strength of the possibility of 'self-infliction by proxy' (at [34]):

(a) It is an extreme measure for a person to decide to cause himself to suffer deep injury and severe and protracted pain.

(b) Moreover KV needed someone to help him to do it.

(c) Wounding SIBP is, in the words of Sales LJ at para 93 of his judgment, "generally so unlikely".

(d) If KV's wounding was SIBP, the wounds on his back could have been inflicted only under anaesthetic and so he would have needed assistance from a person with medical expertise prepared to act contrary to medical ethics.

(e) If his wounding was SIBP, an explanation had to be found for the difference in both the location and in particular the presentation of the scarring as between the back and the arm.

(f) If his wounding was SIBP, an explanation had to be found for the number of the wounds, namely the three wounds on the back, albeit now represented by five scars, and the two wounds on the arm. As Elias LJ observed in para 99, "one or two strategically placed scars would equally well have supported a claim of torture".

26.50 As indicated above, while the HOPO may criticise an expert for having made some assessment of credibility, he is even more likely to advance the converse criticism, namely that the expert has simply adopted whatever the appellant told him. That is an impermissible approach to expert opinion: in R (AM (Angola)) v SSHD [2012] EWCA Civ 521, which was concerned with whether there was 'independent evidence of torture' sufficient to engage the Home Office's detention policy, Rix LJ placed considerable weight on a medical report from the Helen Bamber Foundation, which the Home Office had argued did not amount to independent evidence of torture "because the reports were based on the appellant's own information". Burnett J had agreed; Rix LJ held that he erred and in particular emphasised that:

As the judge himself rightly stated, Ms Kralj "believed the claimant". That belief, following an expert examination and assessment, also constituted independent evidence of torture. Ms Kralj's belief was her own independent belief, even if it was in part based on AM's account. However, the judge was mistaken to suggest that such belief was merely as a result of "taking everything she said at face value". A fair reading of her reports plainly went very much further than that. If an independent expert's findings, expert opinion, and honest belief (no one suggested that her belief was other than honest) are to be refused the status of independent evidence because, as must inevitably happen, to some extent the expert starts with an account from her client and patient, then practically all meaning would be taken from the clearly important policy that, in the absence of very exceptional circumstances suggesting otherwise, independent evidence of torture makes the victim unsuitable for detention. That conclusion is a fortiori where the independent expert is applying the internationally recognised Istanbul Protocol designed for the reporting on and assessment of signs of torture. A requirement of "evidence" is not the same as a requirement of proof, conclusive or otherwise. Whether evidence amounts to proof, on any particular standard (and the burden and standard of proof in asylum cases are not high), is a matter of weight and assessment. (para 30)

26.50A The Supreme Court in KV (Sri Lanka) [2019] UKSC 10 considered AM (Angola) and commented on the expression of belief or otherwise in the account given by medical expert witnesses. In short, the Court accepted that where, in Istanbul Protocol terms, an expert placed her conclusion at either extreme end of the scale (ie 'diagnostic of' or 'not consistent'), such a diagnosis was indeed tantamount to belief/disbelief in the accuracy of the description of how that scar had been caused (at [25]). In AM (Angola) the expert had placed her conclusion within the most positive category. However, where – as is more common – the expert places her conclusion within any of the intervening categories, the Court held that 'there is no room, nor sanction in the protocol, for the expression of belief or otherwise in the account given' ([25). The Court also noted:

The conclusion about credibility always rests with the decision-maker following a critical survey of all the evidence, even when the expert has placed his conclusion within category (a) or (e). Indeed, in an asylum case in which the question is only whether there is a real possibility that the account given is true, not even the decision-maker is required to arrive at an overall belief in its truth; the inquiry is into credibility only of a partial character.

26.51 Critically, however, this does not relieve the Tribunal from its duty to form an assessment of credibility holistically, rather than independently of the medical evidence and then consider the value of the medical evidence in light of the fact that the appellant lied to the expert. The Courts have emphasised that to 'put the cart before the horse' in this way is the wrong approach.

26.52 In the case of Virjon B [2002] EWHC 1469 (Admin), (para 26.46), the Administrative Court was called upon to consider the following finding by an adjudicator:

'The medical reports of [the psychiatrists] refer to the clinical depression and post traumatic stress disorder of both applicants resulting from the rape incident. However, these reports were based upon the evidence which the appellant and his wife gave the doctors. I therefore attach little weight to the reports bearing in mind that I have found both the appellant and his wife to be without credibility.'

26.52A Forbes J commented that:

It goes without saying that the Adjudicator was not bound to accept the medical evidence without question. However, if the medical evidence was to be rejected by her, it had to be rejected on a reasoned and proper basis. Moreover, in my view, it is clear from the authorities that the evidence in question should have formed part of the overall material to be taken into account by the Adjudicator when considering the credibility of the claimant and his wife, before any final conclusion was reached by the Adjudicator as to the truth of their claims.

26.53 He accepted that the adjudicator had erred in dismissing the psychiatric evidence on 'a peremptory and unreasoned basis', and concluded that:

It is clear to me that the Adjudicator used her adverse findings of credibility with regard to the claimant and his wife as the means whereby to reject the important and significant evidence of [the psychiatrists]. That was putting the cart before the horse. [Their] evidence... was strongly corroborative of the truth of the account given by the claimant and his wife about the serious rape that was suffered by the wife. It was therefore necessary for the Adjudicator to take that evidence into account as part of her consideration of all the evidence, before coming to any conclusion as to the credibility of the claimant and his wife.

26.53A In Mibanga v SSHD [2005] EWCA Civ 367, the Court of Appeal emphasised the importance of considering medical evidence relevant to credibility as part of the process of reaching a conclusion as to credibility. Buxton LJ said that

Where, as in this case, complaint is made of the reasoning of an adjudicator in respect of a question of fact (that is to say credibility), particular care is necessary to ensure that the criticism is as to the fundamental approach of the adjudicator, and does not merely reflect a feeling on the part of the appellate tribunal that it might itself have taken a different view of the matter from that that appealed to the adjudicator....

[T]his case does meet that criterion. The adjudicator's failing was that she artificially separated the medical evidence from the rest of the evidence and reached conclusions as to credibility without reference to that medical evidence; and then, no doubt inevitably on that premise, found that the medical evidence was of no assistance to her. That was a structural failing, not just an error of appreciation... (para 29-30)

See also the comments of Wilson J in relation to both country and medical evidence quoted at para 22.31A.

26.53B The Upper Tribunal has emphasised that while a judge is entitled to reject a clinical diagnosis supported by expert evidence she "must give clear reasons for doing so which engage adequately with a medical opinion representing the judgment or a professional psychiatrist on what he has seen of the appellant": BN (psychiatric evidence – discrepancies) Albania [2010] UKUT 279 (IAC).

26.53C The Court of Appeal in MN v Secretary of State for the Home Department [2020] EWCA Civ 1746 (per Underhill LJ), noted that Wilson J's judgment in Mibanga about the need to take the doctor's evidence fully into account did not exclude the 'the doctor's opinion about the applicant's veracity, based on his presentation and the way he gave his history' (at [109]). After surveying the authorities in detail, Underhill LJ gave the following general guidance on expert evidence from doctors (at [121]):

In our view the law … (so far as relevant to the issues in these appeals) can be summarised as follows:

(1) The decision whether the account given by an applicant is in the essential respects truthful has to be taken by the tribunal … (for short, the decision-maker) on the totality of the evidence, viewed holistically – Mibanga.

(2) Where a doctor's opinion, properly understood, goes no further than a finding of "mere consistency" with the applicant's account it is, necessarily, neutral on the question whether that account is truthful – see HE (DRC), but the point is in truth obvious.

(3) However, it is open to a doctor to express an opinion to the effect that his or her findings are positively supportive of the truthfulness of an applicant's account (i.e. an opinion going beyond "mere consistency"); and where they do so that opinion should in principle be taken into account – HK; MO (Algeria); and indeed, though less explicitly, Mibanga. In so far as Keene LJ said in HH (Ethiopia) that the doctor in that case should not have expressed such an opinion (see para. 117 (1) above), that cannot be read as expressing a general rule to that effect.

(4) Such an opinion may be based on physical findings (such as specially characteristic scarring). But it may also be based on an assessment of the applicant's reported symptoms, including symptoms of mental ill-health, and/or of their overall presentation and history. Such evidence is equally in principle admissible: there is no rule that doctors are disabled by their professional role from considering critically the truthfulness of what they are told – Minani; HK; MO (Algeria); SS (Sri Lanka). We would add that in the context of a decision taken by the CA on a wholly paper basis, a doctor's assessment of the truthfulness of the applicant may (subject to point (5) below) be of particular value.

(5) The weight to be given to any such expression of opinion will depend on the circumstances of the particular case. It can never be determinative, and the decision-maker will have to decide in each case to what extent its value has to be discounted for reasons of the kind given by Ouseley J at para. 18 of his judgment in HE (DRC).

(6) One factor bearing on the weight to be given to an expression of opinion by a doctor that the applicant's reported symptoms support their case that they were persecuted or trafficked (as the case may be) is whether there are other possible causes of those symptoms. For the reasons explained by Ouseley J (loc. cit.), there may very well be obvious other potential causes in cases of this kind. If the expert has not considered that question that does not justify excluding it altogether: SS (Sri Lanka). It may diminish the value that can be put on their opinion, but the extent to which that is so will depend on the likelihood of such other causes operating in the particular case and producing the symptoms in question.

26.53D The Tribunal in HA (expert evidence; mental health) Sri Lanka [2022] UKUT 00111 (IAC) gave guidance in particular in respect of reports concerning mental health of an individual. The Tribunal observed that doctors acting as witnesses in legal proceedings should adhere to relevant GMC Guidance in addition to the Tribunal's obligations for experts. In respect of mental health in particular, the Tribunal said:

(2) Although the duties of an expert giving evidence about an individual's mental health will be the same as those of an expert giving evidence about any other matter, the former must at all times be aware of the particular position they hold, in giving evidence about a condition which cannot be seen by the naked eye, X-rayed, scanned or measured in a test tube; and which therefore relies particularly heavily on the individual clinician's opinion.

(3) It is trite that a psychiatrist possesses expertise that a general practitioner may not have. A psychiatrist may well be in a position to diagnose a variety of mental illnesses, including PTSD, following face-to-face consultation with the individual concerned. In the case of human rights and protection appeals, however, it would be naïve to discount the possibility that an individual facing removal from the United Kingdom might wish to fabricate or exaggerate symptoms of mental illness, in order to defeat the respondent's attempts at removal. A meeting between a psychiatrist, who is to be an expert witness, and the individual who is appealing an adverse decision of the respondent in the immigration field will necessarily be directly concerned with the individual's attempt to remain in the United Kingdom on human rights grounds.

26.53E The Tribunal in HA (expert evidence; mental health) Sri Lanka [2022] UKUT 00111 (IAC) also highlighted the evidential relevance of GP records in cases concerning mental health and required medical experts to engage with them. Where the expert's opinion differs from the GP records, the expert will be required to say so in the report and to provide reasoned explanation for the difference. As the Tribunal observed, it 'is unlikely to be satisfied by a report which merely attempts to brush aside the GP records.'

Format and presentation of the report

26.54 This section should be read in conjunction with chapter 23. Also refer to the Medical Foundation's Guidelines for the examination of survivors of torture. Supply it to your expert if he is not already familiar with it. You should evaluate the report in light of the guidance in section 3 of that publication, and the Istanbul Protocol. In KV (Sri Lanka) v SSHD [2019] UKSC 10, the Supreme Court referred to the earlier case of SA (Somalia) v Secretary of State for the Home Department [2006] EWCA Civ 1302 in which the Court of Appeal quoted paras 186 and 187 of the Istanbul Protocol and commended them as particularly instructive for those requested to supply medical reports in relation to alleged torture. The Supreme Court in particular discredited Sales LJ's comments in KV (Sri Lanka) in the Court of Appeal to the effect that it was the Tribunal Practice Direction, not the Istanbul Protocol, which provides the relevant authoritative guidance as to the duty of medical experts. Rather, as the Supreme Court noted, there is no inconsistency between the Practice Direction and the Istanbul Protocol. Importantly, however, the Practice Direction does not address the specific area addressed by the protocol, namely the investigation of torture. The Supreme Court concluded, therefore, that '[w]hen invited to investigate an allegation of torture, the expert should therefore recognise the protocol as equally authoritative - in accordance with the Court of Appeal's decision in the SA (Somalia)' (at [24]).

26.55 The medical expert should be willing to discuss his draft with you and respond to reasonable comments, so long as it does not lead to his opinion being distorted or misrepresented (see para 23.26 for general guidance). If you have concerns in relation to a Freedom from Torture or Helen Bamber Foundation report which, for whatever reason, cannot be dealt with by the writer, then it is worth discussing them with one of the full time staff at the organisation. It is often the case that lawyers at Freedom from Torture or Helen Bamber Foundation will review medical reports before or in conjunction with your review.

26.56 The report should always start with a detailed explanation of the writer's qualifications. Do not assume that the HOPO or judge will know what the string of initials after the expert's name mean. Nor can it be assumed that everyone will be familiar with which disciplines are appropriate to different issues: a HOPO may allege at the hearing that your expert does not hold the appropriate qualifications. Do not assume that your audience will be fully conversant with the distinction between psychiatrists and psychologists and when one or other is appropriate.

26.57 As with country experts, it is vital that a medical expert demonstrates what differentiates his analysis from that of a lay person. As indicated above, the HOPO is particularly likely to attack a medical report where the appellant's mental condition is used to corroborate past ill-treatment. It is therefore important that such experts are made aware of this, and that the report pre-empts any legitimate concern. This process is particularly important if the expert will not be giving oral evidence, and so will not have that opportunity to answer criticisms. The report must also demonstrate how the examination conducted formed a sufficient basis for the opinions expressed. That is especially important for psychiatric reports. In XS (Kosovo - Adjudicator's conduct - psychiatric report) Serbia and Montenegro [2005] UKIAT 00093, the Tribunal stated that

40. Where the Adjudicator erred in relation to these reports and Dr Turner's in particular, is that he failed to realise that they were seeking to address those two concerns which commonly arise: first, to what extent was their diagnosis dependant on the Appellant's account of what had happened, and second, to what extent had they deployed their experience and expertise to reach a conclusion which was objectively supportable rather than one which simply accepted symptoms which could be described but which could not be verified. The Adjudicator dealt with the issues as if Dr Turner's report was a commonplace report which simply accepted the Claimant's evidence, concluded that what he said happened had happened and accepted as equally truthful the Appellant's own description of symptoms; it is that type of report which is of such limited value in assessing credibility or illness.

41. We are very far from saying that an Adjudicator would be bound to accept the reports' conclusions however. He could still say that those issues were not persuasively addressed. But these were reports of significantly greater authority and care than is so often found. They did seek to grapple with those difficult issues. They should have been considered on that basis. Instead, those material factors were ignored and they were dealt with as if the conclusions were simply dependant on an unqualified acceptance of whatever the Appellant told them, when the psychiatrists and Dr Turner in particular, with reason, were denying that that was so.

26.58 A medical report on a physical injury need not and should not regurgitate your client's entire account of her experiences in her country of origin. It need deal only with the matters upon which the expert is being asked to form a view. One would expect a physical report on evidence of torture to include a history of that torture. You would not expect it to include a history of the appellant's political activities. If the report does reproduce irrelevant detail of your client's case, you may ask the expert to omit it from the final report.

26.59 A report on the appellant's mental condition may involve taking a much fuller history from the patient and reproducing that history in the report. Indeed, given the sensitivity in taking a full history from a survivor of torture or sexual violence, it may sometimes contain additional details which your client only felt able to disclose in the context of a clinical interview. However, it should not consist merely of a long statement taken from the client followed by a short comment at the end. The history which is reproduced should still be limited to that which is relevant to the diagnosis, and should be closely tied to the diagnosis.

26.60 Always check any factual history in the report against your client's statement and interview. It may be that the inconsistency is symptomatic of the condition that the expert has diagnosed. But you nevertheless need to be aware of it. The HOPO may try to cross-examine on it and there is also the risk that the judge may rely upon it, even if it has not been raised during the hearing. You should provide the expert with (at least) the Home Office's decision letter, any previous reports, and any previous accounts the appellant has given of his history. In JL (medical reports-credibility) China [2013] UKUT 00145 (IAC), the Tribunal emphasised that:

Those writing medical reports for use in immigration and asylum appeals should ensure where possible that, before forming their opinions, they study any assessments that have already been made of the appellant's credibility by the immigration authorities and/or a tribunal judge (SS (Sri Lanka) [2012] EWCA Civ 155 [30]; BN (psychiatric evidence discrepancies) Albania [2010] UKUT 279 (IAC) at [49], [53])). When the materials to which they should have regard include previous determinations by a judge, they should not conduct a running commentary on the reasoning of the judge who has made such findings, but should concentrate on describing and evaluating the medical evidence (IY (Turkey) [2012] EWCA Civ 1560 [37].

It is particularly important with medical reports that it is evident that the expert has read these with care, and a failure to notice material discrepancies in the account given to the expert and that given previously to the Home Office may be seen as undermining the weight to be given to his opinion. His report will be of more assistance if he notes the discrepancy and says whether, and why or why not, it affects his opinion.

26.61 As with other expert reports, presentation is important. Ensure that the requirements of section 6 of the Practice Direction are met by the report. Check spelling, punctuation and grammar. If photographs and/or diagrams are provided, ensure that these are of good quality, clearly labelled, and consistent with the body of the report. The Tribunal has also made clear that legal representatives must check the report for accuracy and not simply act as 'a postal service via which [expert evidence] reaches the Secretary of State': R (on the application of Hoxha and Others) v Secretary of State for the Home Department (representatives: professional duties) [2019] UKUT 00124 (IAC): see further para 23.28A.

26.62 Refer to para 23.45 concerning the presentation of expert evidence during the appeal process, and the desirability that it is served in time to seek a direction that the Home Office either indicate that it is not disputed or particularise the grounds upon which it is disputed (particularly, if it is not considered at the Home Office review stage under the reform procedure). The Home Office states in its API on medical evidence:

Medical evidence submitted following refusal of asylum

In cases where medical evidence is submitted after the claim has been refused, such evidence should usually be reviewed before any appeal hearing. Medical reports must be carefully considered taking all evidence into account in accordance with the principles set out in this guidance. It is important to consider the report in the context of all the evidence to properly assess whether the report may have resulted in a different overall assessment of credibility and future risk had it been available before the initial decision. It is not enough to maintain, without clear explanation, that previous adverse credibility findings stand, and the report makes no difference to those findings. Having considered the report, it may be appropriate to withdraw the decision before any appeal hearing but only where the new evidence should lead to a grant of leave. The Withdrawing decisions guidance must be followed.

Medical evidence submitted during the appeal process

Where there is previous evidence that a claimant has notified the Home Office that a medical report is being produced and it has not been considered whether to delay the decision in accordance with this guidance, the case must be referred to the asylum casework team to consider the request. As with all claims, they must be assessed according to the appropriate standard of proof. If the Home Office is notified of the intention to provide a medical report for the first time during the appeal process, wherever possible presenting officers must contact the claimant's legal representatives to confirm whether a medical report is available and request a copy in advance of the appeal hearing to review the additional evidence. Where the representatives confirm that the claimant is still waiting for a report, then presenting officers must exercise discretion on the basis of the information already on file, together with any information given by the representative as to the likely timescale for producing a report, and evidence in the appeal bundle to decide whether to take any further action, bearing in mind the need to avoid unnecessary appeals. … (pp26-27)

26.63 If you need to apply for an extension or an adjournment to present medical evidence, you should ensure that the reasons are properly explained, for example the waiting lists of the Freedom from Torture/the Helen Bamber Foundation or experts of similar standing. In cases of long delay, be prepared to show that you have checked for other suitable experts to see whether one can provide a report sooner. The Home Office sometimes implies that such reports are available upon demand (see above para 26.33 for its own policy of agreeing postponements of decisions to await reports from Freedom from Torture/the Helen Bamber Foundation). You might also refer to the UNHCR Handbook's provision in relation to mentally disturbed asylum seekers that 'The examiner should, in such cases, whenever possible, obtain a medical report' (paragraph 208). At the appeal stage, the examiner is the Tribunal.

26.64 As with other experts, it will often be beneficial for the medical expert to be called to give oral evidence where his conclusions are disputed (see chapter 25).

Further reading

26.65 The following provide valuable guidance:

Guidelines for the examination of survivors of torture (2nd ed)
Medical Foundation for the Care of Victims of Torture (now Freedom From Torture)

Examining Asylum Seekers: A Health Professional's Guide to Medical and Psychological Evaluations of Torture (Physicians for Human Rights) (www.phrusa.org) (An abridged version appears on the website)

Medical evidence: Guidance for Doctors and Lawyers (Produced jointly by the Law Society and the British Medical Association)

The Istanbul Protocol: Manual on the Effective Investigation and Documentation of Torture and other Cruel, Inhuman or Degrading Treatment or Punishment (UN OHCHR)