Istanbul Protocol Reports: Why Tribunals Accept or Reject

Last updated: 6 October 2026

An Istanbul Protocol report is a medico-legal report (MLR) in which a trained clinician examines a person who says they were tortured. The clinician then grades how far each scar, injury and symptom fits the account, using five fixed terms from the UN manual. Tribunals in the UK and the US give these reports real weight. However, judges still reject some of them, and the reasons repeat across the case law. The doctor took the account at face value, ignored other causes, never saw the GP records, or gave no overall opinion. In contrast, reports that survive scrutiny do the opposite.[1]

This guide is for immigration lawyers in the UK and the US. It explains what the 2022 Istanbul Protocol requires, how UK tribunals and US immigration judges weigh medical evidence of torture, and why some reports fail. It also sets out what to ask the doctor for and how the MLR fits with a country expert report. Last reviewed: October 2026.

What is an Istanbul Protocol report?

The Istanbul Protocol is the UN manual on the investigation and documentation of torture and other ill-treatment. A group of experts first submitted it to the UN High Commissioner for Human Rights on 9 August 1999. OHCHR then published a revised edition as Professional Training Series No. 8/Rev.2 and launched it on 29 June 2022. The 2022 edition keeps the core method but adds chapters on the role of health professionals and on state implementation.[2]

The Protocol is guidance, not law. Nevertheless, courts treat it as the standard for medical evidence of torture. In SA (Somalia) the Court of Appeal told doctors writing reports for asylum claims to bear its terms in mind. Later, in KV (Sri Lanka), the Supreme Court said an expert asked to investigate torture should treat the Protocol as "equally authoritative" with the tribunal's practice direction on expert evidence. The 2022 edition, in turn, cites KV in a footnote.[3]

In the UK, these documents are usually called medico-legal reports. In the US, practitioners often call them forensic medical or psychological evaluations, or medical affidavits. The Home Office guidance says a report documenting torture "must usually" follow the Protocol. However, it accepts that a non-Protocol report from a reputable provider may still be evidence of torture, for example a report on mental capacity.[4]

The five levels of consistency

The heart of every Istanbul Protocol report is the consistency grading. Paragraph 380 of the 2022 edition lists five terms. The clinician applies them to each finding and then to the clinical picture as a whole. The same scale appears for physical evidence at paragraph 418 and for psychological evidence at paragraph 543.[5]

Older decisions cite different paragraph numbers. For example, SA (Somalia) and the Home Office guidance quote paragraphs 186 to 188 of the earlier edition. Therefore, when you quote the scale today, cite both: the old numbers show continuity with the case law, while the new ones show the doctor used the current text.

The overall evaluation

Grading single scars is not enough. Paragraph 383 says that "it is the overall evaluation of all clinical findings" that matters, not one finding alone. Moreover, paragraph 381 allows the overall opinion to sit higher than any single finding where many findings point the same way. Paragraph 384 goes further. A report that gives no opinion on the possibility of torture is "deficient". In practice, a report that grades ten scars but never draws them together leaves the judge without the one opinion the Protocol requires.[6]

The Protocol also limits what the doctor may say. Clinicians express causation as consistency, not as a legal standard of proof. Similarly, paragraphs 388 and 389 advise them not to comment on the claimant's credibility. In KV, Lord Wilson made the same point. Only "diagnostic of" or "not consistent with" comes close to belief or disbelief, and credibility "always rests with the decision-maker".[7]

Physical and psychological evidence of torture

Physical findings

A physical examination records scars, burns, fractures and other marks on body maps and photographs. The clinician correlates them with the account and with "known torture methods" in the region. Importantly, the absence of physical findings does not mean torture did not happen. Paragraph 390 says many factors explain a lack of marks.[8]

Psychological findings

A psychological assessment looks for post-traumatic stress disorder (PTSD), depression, anxiety and related conditions. Paragraph 542 stresses that a survivor may not meet the criteria for any diagnosis. Even so, that does not mean the person was not tortured. On the other hand, tribunals scrutinise psychiatric evidence closely, because no blood test or scan can confirm it. In HA (expert evidence; mental health) Sri Lanka, the Upper Tribunal said experts must accept that a person facing removal may exaggerate or invent symptoms. It also held that GP records are "directly relevant" and that experts must engage with them.[9]

Self-infliction and fabrication

Paragraph 386 deals with self-inflicted injury. If the clinician suspects fabrication, a second clinician should examine the person. However, clinicians need not discuss self-infliction where nothing in the evidence suggests it. The Supreme Court in KV adopted the view that injuries self-inflicted by proxy are "likely to be extremely rare" and should be weighed against the evidence of torture.[10]

Who writes medico-legal reports?

In the UK, the two specialist providers are Freedom from Torture and the Helen Bamber Foundation. Freedom from Torture was formerly the Medical Foundation for the Care of Victims of Torture. In Mibanga, one of the two reports came from a doctor who worked part-time for it. Both providers accept referrals only from legal representatives, and a panel decides which cases to take. The Home Office accepts their report writers "as having recognised expertise" in the effects of torture. It also treats about five months as a reasonable time to wait for their MLR before deciding a claim.[11]

Independent doctors and psychiatrists also write MLRs. Here, the Home Office checks General Medical Council registration and expects the writer to set out training and experience. In addition, the guidance says caseworkers should not give a report little weight merely because of the type of clinician who wrote it, where that clinician is regulated and experienced. This guidance, 'Medical evidence in asylum claims', replaced the July 2015 Asylum Policy Instruction on reports from the two foundations.[11]

A Rule 35 report is different. Under Rule 35(3) of the Detention Centre Rules 2001, the detention doctor must report any detainee "who he is concerned may have been the victim of torture". The report feeds into the Adults at Risk policy, which the Immigration (Guidance on Detention of Vulnerable Persons) Regulations 2024 brought into force in revised form from 21 May 2024. A Rule 35 report can trigger release from detention. Even so, it is a short screening note, not a full Istanbul Protocol assessment.[12]

In the US, Physicians for Human Rights runs an asylum network of volunteer clinicians who carry out forensic evaluations. Other clinics, including student-run asylum clinics at medical schools, do similar work. Their affidavits usually follow the Protocol's structure and terms.[13]

How UK tribunals weigh an Istanbul Protocol report

Six decisions set the framework. Read together, they tell the judge how to approach the report and tell the doctor what to put in it.

Mibanga: consider the report before deciding credibility

In Mibanga v SSHD [2005] EWCA Civ 367, the adjudicator rejected the claimant's account and only then turned to the medical evidence. Wilson J held that "a fact-finder must not reach his or her conclusion before surveying all the evidence relevant thereto". The fact-finder who decides credibility first and then asks whether the expert evidence shifts that view acts "at his peril". Consequently, a judge who treats the MLR as an add-on makes an error of law.[14]

SA (Somalia): the doctor must give a clear opinion

A year later, SA (Somalia) [2006] EWCA Civ 1302 showed the limits of Mibanga. The doctor's letter recorded the claimant's history and his explanations for old injuries, but gave no opinion of its own. Sir Mark Potter P held that the report was "inadequate". Where a report comes long after the events, it should contain "a clear statement of the doctor's opinion as to consistency" for each relevant injury. Where scars have common everyday causes, it should say so and identify any "pointers" for or against the claimed cause.[15]

RT and JL: alternative causes and critical analysis

In RT (medical reports – causation of scarring) Sri Lanka [2008] UKAIT 00009, the tribunal added a practical rule. Where the doctor finds a degree of consistency that admits other causes, the report should examine those causes "to gauge how likely they are" in light of the person's life history. Then, in JL (medical reports – credibility) China [2013] UKUT 145 (IAC), the Upper Tribunal set out duties for report writers. They should read earlier credibility findings before forming a view. They should not run "a running commentary" on the judge's reasoning. Above all, the more a diagnosis depends on believing the account, the less weight it is likely to carry. Still, JL also confirmed that a report which relies heavily on the account remains independent evidence.[16]

KV (Sri Lanka): consistency with how the torture happened

In KV (Sri Lanka) v SSHD [2019] UKSC 10, the claimant had burn scars from a hot metal rod. The tribunal had found the wounds were probably self-inflicted by proxy. The doctor, however, noticed that the back scars had sharp edges while the arm scars were blurred. That fitted the claimant's account that he was conscious when burned on the arm and unconscious when burned on the back. The Supreme Court held that doctors may give an opinion on consistency with "the circumstances in which the scarring was sustained, not limited to the mechanism". As a result, the Court sent the appeal back for a fresh decision.[17]

HA (Sri Lanka): mental health reports and GP records

Finally, HA [2022] UKUT 111 (IAC) is now the main test for psychiatric reports. The tribunal expects strict compliance with expert duties and GMC guidance. A report that "merely attempts to brush aside the GP records" is unlikely to satisfy the tribunal. Where the expert's view differs from the records, the expert must say so and explain why.[9]

How US immigration judges weigh forensic evaluations

US law reaches medical evidence through corroboration and the Convention Against Torture (CAT). Under the REAL ID Act, INA s 208(b)(1)(B)(ii) lets the judge require corroboration of otherwise credible testimony, unless the applicant "does not have the evidence and cannot reasonably obtain the evidence". For CAT protection, 8 CFR 1208.16(c)(3)(i) requires the judge to consider "evidence of past torture inflicted upon the applicant". Meanwhile, 8 CFR 1208.18(a) defines torture as severe physical or mental pain or suffering inflicted by, or with the acquiescence of, a public official.[19]

Two circuit cases show both sides. In Fiadjoe v Attorney General, 411 F.3d 135 (3d Cir. 2005), the Third Circuit granted the petition and sent the case to a different judge. Among other failings, the Board had not considered the treating psychologist's further evidence on the claimant's trauma. By contrast, in Sanusi v Gonzales, 445 F.3d 193 (2d Cir. 2006), the doctor's affidavit arrived after the decision. The judge discounted it because parts relied on the claimant's own report and his "few scars" could be "consistent with a lifetime of normal activity". Furthermore, the doctor specialised in obesity medicine and gave no evidence of torture training. The Second Circuit denied the petition.[20]

The data on outcomes is striking, but it needs care. Lustig and colleagues studied Physicians for Human Rights cases from 2000 to 2004. Of 746 cases with known outcomes, 89% won asylum, against a national average of 37.5%. A 2021 follow-up by Atkinson and colleagues covered 2,584 cases from 2008 to 2018 and found positive outcomes in 81.6%, against a national grant rate of 42.4%. Neither study proves that the evaluation caused the result, because PHR cases are not a random sample. Nevertheless, both figures help explain why US practitioners treat a forensic evaluation as standard in torture claims.[21]

Why tribunals reject an Istanbul Protocol report, and why they accept one

Freedom from Torture reviewed 50 refused claims in which it had supplied an MLR. Where the final outcome was known, 76% of claimants won asylum on appeal, compared with an average appeal success rate of 30% at the time. In other words, the first decision often mishandles good medical evidence. Still, tribunals also reject weak reports. The table below sets out the recurring reasons from the authorities above.[22]

One more point matters for appeals. A judge can still reject an account after properly weighing a strong MLR. What the judge cannot do is decide credibility first and treat the report as an afterthought. That is the Mibanga error, and a decision that makes it is open to challenge on appeal.

What lawyers should ask the doctor for

Most weaknesses in an MLR start with the letter of instruction. In the First-tier Tribunal, the 2024 Practice Direction requires the expert to attach that letter, list the material seen, and keep the report under 20 pages unless the tribunal agrees otherwise. Accordingly, a good instruction covers the following points.[23]

1. Send the full file: interview records, the refusal letter, witness statements and any earlier tribunal decision, so the doctor can address credibility points already raised.
2. Include the GP records and any hospital, detention or Rule 35 records, and ask the doctor to deal with them expressly.
3. Request a grading of each relevant lesion or symptom using the five Protocol terms, with reasons.
4. Ask the doctor to name other possible causes for each finding and say how likely they are.
5. Seek an opinion on consistency with how the torture happened, not only the mechanism, as in KV.
6. Require an overall evaluation of all physical and psychological findings together.
7. Where relevant, ask how trauma may affect memory, disclosure and the ability to give evidence.
8. Insist on qualifications, regulator number, the expert's declaration of duty to the tribunal and a statement of truth.

Do not ask the doctor whether the client is telling the truth. The Protocol and the courts both reserve that question for the judge. Instead, ask how far the clinical evidence supports the specific account.

How the MLR and the country expert report fit together

The doctor and the country expert answer different questions. On one side, the doctor assesses whether the findings are consistent with the account. By contrast, the country expert explains whether that account is plausible in the country concerned. For example, the expert can show which methods the security forces use, where detainees are held, and whether the claimant's profile fits those targeted. The Protocol itself asks clinicians to consider "known torture methods" in the region. Therefore, a doctor who can cite sourced country evidence on those methods gives a stronger opinion.[8]

The two reports also support each other at the hearing. In KV, Lord Wilson noted that extensive torture by state forces in Sri Lanka in 2009 was well established in the evidence. That context made torture a far more likely explanation than self-infliction by proxy. Our guide on how country expert reports strengthen your case explains how to instruct the expert. For a country example, see our report on IRGC torture in Iran. Both reports should stay within their fields. Credibility and the well-founded fear test remain matters for the judge.[17]

Watch it on our YouTube channel: our video on credibility versus plausibility explains where the expert's role ends and the judge's begins.

YouTube video player

If you need country evidence on torture methods, detention practices or risk on return, you can find an expert witness for the relevant country.

Common questions about Istanbul Protocol reports

Does the absence of scars mean my client was not tortured?

No. Paragraph 390 of the Protocol says the absence of physical or psychological evidence does not mean torture did not happen. The Home Office guidance repeats this. The report should explain why no marks would be expected.

Can the doctor say the client is credible?

No. The Protocol advises clinicians not to comment on credibility. They should limit their opinion to how far the clinical evidence fits the account. The decision on credibility belongs to the judge.

Is "consistent with" a good result?

It is the weakest positive grade. It means the finding could have many other causes. On its own it adds little, so the overall evaluation and the explanation of other causes matter more.

Is a Rule 35 report enough?

Usually not for the asylum claim itself. A Rule 35 report is a short note from the detention doctor. It can support release from detention, but it is not a full Istanbul Protocol assessment.

How long does an MLR take?

The Home Office treats about five months as a reasonable wait for a specialist MLR once the claim is on hold. Make the referral early and tell the Home Office in writing.

Must a US forensic evaluation follow the Protocol?

No US rule requires it. Still, most evaluators use its structure and terms, because judges and trial attorneys recognise them.

Conclusion

An Istanbul Protocol report succeeds when it does the work the judge cannot do. It grades each finding with the correct term, weighs other causes, engages with the medical records and reaches an overall opinion. It fails when it simply repeats the client's story. In the UK, Mibanga requires the judge to weigh the report before deciding credibility, while SA (Somalia), RT, JL, KV and HA set the standard for the report itself. US judges reach similar questions through corroboration and CAT. In both systems, the strongest files pair a careful MLR with country evidence on how the state tortures. Above all, lawyers control the quality of the instruction, and that is where most rejected reports go wrong.