Content of a Personal Injury Report

A personal injury medical report should be presented in concise English and should have a comparable degree of intellectual rigor to a scientific paper or a thesis. Mr Porter’s reports are presented in numbered sections, each section having separately numbered paragraphs. The Civil Procedure rules require the expert’s report to separate ‘facts made known to me’ obtained by reading the medical records and consulting with the client and ‘facts within my own knowledge’, obtained by examining the client. Opinion and fact have to be kept separate.

1. In the Introduction:

• the expert’s personal details relevant to the case are given,

• the client is introduced to the Court,

• the background of the case is summarised,

• the expert’s conclusions are summarised,

• the plan of the report is explained.

2. In the second section:

• A summary of the solicitor's instructions is given, in line with the Civil Procedure Rules Part 35.10 (3).

• The purpose of the report is explained.

• The issues to be addressed in the report are tabulated.

3. The following sections are the Investigation of the Facts. 

• The Case History. This is the information given to the expert by the client about the circumstances of the accident and its immediate aftermath. 

• The Review of the Medical Records. Here the medical records are summarised. There is no need to reproduce the entire records verbatim. It is the expert’s job to make the medical records intelligible to the Court.

• An account of the client's present situation is given, as described by the client. Each symptom is described in a separate numbered paragraph. Information is given about the consequences of the index accident on the client’s work, hobbies and home life. 

• An account of the examination of the client is given. The examination of the hand is presented to a standard protocol, which is cosmetic appearance, range of movement (measured with an AO goniometer), tendon function, nerve function, ability to grasp and then other features peculiar to the individual case. At the end of this section, X-rays and medical photographs are described.

4. The opinion and prognosis is given in a standardised form, in most cases.

• The expert’s opinion is based on the facts summarised in the previous sections.

• In this section the expert will explain what the client’s situation would have been but for the accident.

• Causation is established using the but for test and the material contribution test as appropriate

• The opinion begins with a statement of the injuries.

• The cause and prognosis for each symptom are given in a separate numbered subsection.

• The cause and prognosis for each physical sign are given, in a separate numbered subsection.

• Opinions are given on discomfort and inconvenience after the accident and need for personal care and assistance. 

• Matters raised by the solicitor are answered in separate numbered subsections.

• An opinion is given on whether or not further treatment is required, with recommendations for further treatment if appropriate.

• An opinion is given on whether time taken off work (or school) was reasonable.

• An opinion is given as to whether the results of the index accident will affect the client's overall general health, in the future.

• An opinion is given as to whether the results of the index accident will affect the client's ability to obtain and retain work in the future.

• If appropriate an opinion is given as to whether the client is disabled under the definition in the Equalities Act 2010, as a result of the accident.

5. The Statement of Truth is in line with the current Civil Procedure Rules. There are statements of compliance, awareness (of Part 35), truth and conflicts.

6. In Appendix 1, the expert’s full personal details are given.

7. In Appendix 2, the written and oral sources of the report are tabulated.

8. Appendix 3 is a glossary, with key references if indicated. Every effort is made to explain technical terms, which an educated non-medical person would not understand. The aim is to produce a report, which is intelligible to an educated person. Complex reports are difficult to understand, unless the glossary is read first.

9. In a complex or difficult report Michael Porter can discuss the case over the telephone with the solicitor without extra charge.