Occupational health records should be requested when they are likely to contain information material to causation, functional capacity, rehabilitation or prognosis. They should not be obtained routinely simply because the claimant was employed at the time of the accident. The correct test is relevance, not availability.
First establish which records are required.
“Occupational health records” can describe several different documents.
There may be a referral from management setting out concerns about absence or performance. The occupational health clinician may hold clinical consultation notes, questionnaires and correspondence from treating practitioners. The employer may receive a shorter report dealing only with fitness for work, restrictions and suggested adjustments.
These are not interchangeable.
A personnel file may contain absence dates, return-to-work meetings, performance reviews and disciplinary correspondence. It is not an occupational health clinical record, although parts of it may be relevant to the same questions.
The expert should identify the information needed rather than ask indiscriminately for “all employment and occupational health records”. A focused request may seek occupational health assessments from a defined period, absence records or documents concerning a phased return. That is usually more proportionate and more useful than obtaining an entire employment history.
Work capacity is genuinely disputed.
Occupational health evidence may be important where the accident’s effect on employment is a material issue.
A claimant may report being unable to undertake manual work, prolonged sitting, driving or safety-critical duties. Occupational health assessments may show what restrictions were reported at the time, what duties the employer could offer and whether attempts were made to return.
This evidence can help separate medical incapacity from workplace circumstances. A claimant may have been capable of modified duties, but none were available. Alternatively, an employer may have offered adjustments that the claimant could not tolerate.
The distinction matters. Continuing absence does not necessarily establish continuing medical incapacity. Nor does a return to work prove complete recovery.
Occupational health records may also document changes over time. Recommendations for reduced hours, altered duties or home working can provide contemporaneous evidence of function that is absent from routine clinical notes.
The expert must still form an independent opinion. An occupational health recommendation is evidence to consider, not a conclusion that must be adopted.
There may have been relevant problems before the accident.
Earlier occupational health records can become important where pre-accident capacity is disputed.
The claimant may have had previous musculoskeletal symptoms, stress-related absence, restrictions on lifting or an earlier phased return. Such information may affect the baseline against which accident-related loss is assessed.
A request should not become a speculative search for anything capable of weakening the claim. The expert should be able to explain why the earlier period is relevant. If the claimant reports being fully fit for several years before the accident, records from a remote and unrelated episode may add little.
The position is different where there is evidence of recent similar symptoms, repeated absence or existing workplace adjustments. In that situation, occupational health material may assist the expert in distinguishing a new injury from an aggravation or continuation of an earlier condition.
CPR Practice Direction 35 requires experts to consider all material facts, including those that may detract from their opinions. It also requires them to state when insufficient information prevents a definite conclusion.
That obligation supports a targeted request where a genuine evidential gap affects the opinion. It does not justify routine collection of every potentially available document.
Psychological causation may require a wider history.
Occupational health records can be especially relevant in claims involving anxiety, depression or stress.
A claimant may attribute psychological symptoms entirely to an accident, while employment records indicate earlier difficulties arising from workload, conflict, disciplinary proceedings or organisational change. Equally, the records may support the claimant’s account that they worked without restriction before the event and experienced difficulty only afterwards.
The expert should not assume that a workplace referral proves an employment-related psychiatric condition. Occupational health services are often asked to assess function and adjustments rather than diagnose causation.
The wording and purpose of the assessment must be examined. A report prepared to advise whether someone can attend a meeting may contain less clinical detail than an assessment addressing long-term fitness for work.
Where several potential causes are present, occupational health material may allow the expert to provide a more balanced opinion. Without it, the conclusion may need to remain qualified.
Return-to-work recommendations need context.
A recommendation for a phased return is not proof that the claimant was medically incapable of full duties. It may have been a precautionary step intended to support a successful return after prolonged absence.
Similarly, a finding that a person was “fit for work” may have depended on specific restrictions, adjustments or management support. The phrase should not be lifted from the record without the conditions attached to it.
The expert should consider the questions put to the occupational health clinician, the information available to them and the role they were performing. Occupational health advice is often directed towards workplace management rather than the detailed diagnosis and prognosis required in litigation.
Clinical notes may also differ from the report sent to the employer. GMC guidance requires occupational health professionals to disclose only relevant, substantiated information and recognises that confidentiality applies even where the employer commissioned the assessment.
An employer-facing report may therefore be deliberately limited. Silence about a diagnosis does not necessarily mean that it was neither discussed nor considered.
Confidentiality requires a proportionate request.
Occupational health material contains special category health data. Its disclosure must be lawful, necessary and proportionate.
ICO guidance states that workers’ health information may be shared for legal claims where appropriate, but the organisation must consider the purpose, fairness and proportionality of the disclosure, as well as the applicable lawful basis and special category condition.
The ICO also advises organisations not to seek disclosure of an employee’s entire medical file unless this is necessary and warns against compromising confidential communications between the worker and occupational health professionals.
The expert should normally identify the required records to the instructing solicitor rather than approach the employer or occupational health provider directly. The parties can then deal with consent, disclosure and any legal objections.
Irrelevant third-party information, management material and sensitive history may need to be excluded or redacted. The existence of litigation does not remove the need for data minimisation.
Missing records should lead to qualification, not speculation.
An expert does not need occupational health records in every case involving absence from work.
They may add little where the injury was minor, the period of absence was short, and employment capacity is not disputed. GP records, fit notes and the claimant’s account may provide enough information for a proportionate opinion.
Where the records are likely to affect a material conclusion, however, their absence should be stated. The expert may request them before finalising the report or provide an opinion based on clearly identified assumptions.
GMC guidance requires medical experts to check whether they have received all relevant evidence and to make clear when a lack of information limits or qualifies their opinion.
The expert should not decide that the claimant is unreliable merely because occupational health evidence has not been provided. Nor should they confidently assess work capacity while ignoring records known to contain repeated functional assessments.
Occupational health records should be requested when they can answer a defined medico-legal question. That may concern previous capacity, accident-related absence, workplace adjustments, rehabilitation or competing causes of psychological symptoms.
They are not standard attachments to every employment claim. The defensible approach is narrower: identify the issue, request the records that bear upon it and explain how their presence or absence affects the opinion.
