A claimant’s account is evidence and may provide the main history available to the expert. Medical records are important, but they are not proof that every genuine symptom was reported. The expert must decide how much confidence can safely be placed in the account, identify what is independently supported and avoid making silence prove more than it does.
Medical records are not complete biographies.
Clinical records are produced for treatment, not as comprehensive diaries of every symptom or restriction. Some people manage minor injuries with rest or over-the-counter medication. Others delay seeking help because they expect symptoms to settle, cannot obtain an appointment or do not believe treatment will assist. Psychological symptoms may also be disclosed later because anxiety, poor sleep or travel fear was initially regarded as normal.
The absence of a consultation therefore does not establish that no injury occurred. It does remove one source of contemporaneous evidence that might otherwise confirm onset, severity and progress. The expert should distinguish between a silent record and a contradiction. A GP note making no mention of neck pain is different from an entry recording that the claimant denied neck symptoms or stated that they began months later.
Start with a detailed history.
Where documentary support is limited, the quality of the clinical history becomes more important.
The expert should establish when each symptom began, how it developed, what self-treatment was used and what effect it had upon work, travel, sleep and ordinary activity. Broad statements such as “I could not do anything” require practical detail. What activities stopped? Were duties changed? Was help required at home? When did the claimant first drive, exercise or return to work?
The account should be tested for internal consistency without becoming an interrogation. A claimant may be uncertain about exact dates while remaining reliable about the sequence. Minor errors should not be treated as equal to contradictions affecting diagnosis or causation.
Look beyond GP records.
Supporting evidence is not confined to medical notes.
Employment records may show absence or reduced duties. Pharmacy receipts, treatment invoices and physiotherapy notes may provide context. Witness evidence may describe changes in activity, although it is not an independent medical diagnosis. Accident and Emergency records, ambulance documentation, imaging and earlier reports may also be relevant. The expert should ask whether the expected records have been supplied and whether an apparent absence is an incomplete bundle.
If material documents are missing, they should be requested before a firm conclusion is given. Practice Direction 35 requires experts to make clear when insufficient information prevents a definite opinion and to identify qualifications affecting their conclusions.
Consistency with the clinical picture.
An unsupported account can still be medically plausible.
A short-lived soft-tissue injury managed without formal treatment may fit ordinary clinical experience. A claim of severe neurological disability continuing for years without assessment, medication, referral or functional evidence requires more explanation.
The expert should consider whether the alleged mechanism could produce the diagnosed condition, whether the reported course is clinically credible and whether examination findings support continuing symptoms. Clinical plausibility is not proof. The phrase “consistent with” should not be used as though it establishes causation. It usually means only that the history is not medically incompatible with the proposed injury.
Severity affects the expected evidence.
The more serious and disabling the alleged condition, the more surprising a complete absence of treatment or documentation may become. A claimant may avoid attending a GP for mild neck stiffness. It is harder to explain why somebody reporting severe pain, inability to work and neurological symptoms sought no clinical help over many months.
There may be barriers involving access, anxiety, communication or competing responsibilities. The explanation should be explored and recorded.
The expert should then say what effect the absence has upon the opinion. It may reduce confidence in the alleged severity while leaving a minor injury supportable. In another case, it may prevent a reliable diagnosis or prognosis.
Do not confuse repetition with support.
A claimant’s history may appear in the letter of instruction, rehabilitation notes and later reports. If each repeats the same original account, they are not separate confirmation.
A GP entry stating “patient reports pain since accident” records the history given to the clinician. It is not necessarily an independent opinion on causation.
The GMC requires medical experts to take reasonable steps to check accuracy, include relevant evidence and distinguish facts from professional opinion. A report should therefore state when a conclusion depends upon the claimant’s account.
Use qualified or alternative opinions.
Where the history is plausible but unsupported, a conditional opinion may be appropriate.
The expert might state that, if the claimant’s account of immediate onset and continuing symptoms is accepted, the presentation is consistent with a particular injury. They should then explain that the lack of contemporaneous documentation limits confidence in the chronology or severity.
Alternative opinions may be needed where later records indicate a different onset. If the claimant’s account is accepted, causation may be supported. If the recorded later onset is preferred, another explanation may be more likely.
This allows the expert to explain the medical consequences of each version without privately resolving a factual disagreement that the available evidence cannot settle.
A claimant’s account may be enough.
There will be cases in which the claimant’s account, examination and overall circumstances provide a sufficient basis for an opinion despite limited records.
There will also be cases in which the absence of records, inconsistent history and lack of functional evidence make a reliable conclusion impossible. The expert should not adopt a rule that “it is not in the records, so it did not happen.” Nor should they accept a history uncritically because the claimant appeared sincere.
The proper approach is to state what the claimant reports, identify the available support or contradiction, examine clinical plausibility and explain the limits of the conclusion.
Medical records can strengthen or weaken an account. They do not replace professional judgement. Where the opinion depends upon recollection, the report should say so plainly and adjust its level of certainty accordingly.
