Medico-Legal Report on Scarring: What It Must Contain

Last updated: 16 October 2026

A medico-legal report on scarring is the doctor's written evidence on whether a client's scars fit the torture they describe. In the UK it is usually called an MLR. In the US, lawyers often call it a forensic medical evaluation or a physician's affidavit. Judges in both systems give a medico-legal report real weight. However, they also reject many of them, and the reasons repeat. The doctor did not see the file, graded no single scar, ignored other causes or gave no overall opinion.

This guide sets out what a medico-legal report on scarring must contain, section by section. It follows the 2022 edition of the Istanbul Protocol, the First-tier Tribunal Practice Direction of 2024 and the leading cases. It then explains how UK tribunals and US immigration judges weigh scarring evidence, and how a country expert report fits alongside the medical one. Last reviewed: 16 October 2026.

What is a medico-legal report, and why the Istanbul Protocol matters

A medico-legal report is a clinical assessment written for a court or tribunal, not for treatment. The doctor examines the client, records each injury and then states how far the findings fit the account. The standard method comes from the Istanbul Protocol, the UN manual on documenting torture. OHCHR published the revised edition as Professional Training Series No. 8/Rev.2 in 2022. It asks the clinician to give an interpretation of "the probable relationship" between the findings and possible torture.[1]

The Protocol is guidance, not law. Nevertheless, UK courts treat it as the benchmark. In SA (Somalia), the Court of Appeal commended its consistency scale to doctors who write reports in asylum cases. Later, the Supreme Court decided KV (Sri Lanka). It said an expert asked to investigate torture should treat the Protocol as "equally authoritative" with the tribunal's practice direction.[2] The Home Office takes the same line. Its guidance says a report on torture "must usually" follow the Protocol.[3]

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. The Home Office accepts their report writers "as having recognised expertise" in the effects of torture. Independent doctors also write a medico-legal report in many cases. In that case, caseworkers check registration with the General Medical Council and look at the clinician's training.[3]

What a medico-legal report on scarring must contain

The Practice Direction sets the formal frame for any expert report in the First-tier Tribunal. Paragraph 9.3 lists twelve required elements, and paragraph 9.4 adds a statement of truth.[4] The Istanbul Protocol then sets the clinical content. Together, they give the twelve sections below. A medico-legal report that misses one of them gives the Home Office an easy point at the hearing.

1. Instructions and documents seen

The report must attach the letter of instruction, and that letter must state the disputed issues. It must also confirm what material the doctor received.[4] This matters more for scars than for most evidence. In JL, the Upper Tribunal said doctors should study earlier credibility findings before forming a view. Therefore, send the interview record, the refusal letter, any earlier tribunal decision and the GP records. Each document should appear in a list, with its name and date.[5]

2. The clinician's qualifications and independence

The report must give the doctor's qualifications, and the Practice Direction requires it to be addressed to the tribunal, not to the solicitor.[4] The Protocol says a forensic certificate is not required. Instead, the most important qualification is knowing how to apply the Protocol. Clinicians should also know regional prison conditions and torture methods.[6] So the CV section should show Protocol training, the number of torture assessments done and any work in the region. It should also state the regulator and registration number.

3. The history taken

Next, the medico-legal report records the history: the claimed detention, the methods used, the injuries at the time and any treatment. It should also record the client's own past medical history, including accidents, operations, childhood injuries and work injuries. That history later lets the doctor test other causes. In addition, the report should name the interpreter, the language and the length of the interview. Medical records from the country of origin may also help, the Protocol notes, although some will leave out any mention of torture.[7]

4. The examination method

After that, the doctor should say how the examination took place. The Protocol expects a complete examination of the whole body, done in sections so the person stays covered as far as possible.[7] The report should state who was in the room, whether a chaperone attended and what equipment the doctor used. Under paragraph 9.3(g) of the Practice Direction, it must also say who carried out any measurement or test.[4]

5. Body map and photographs

Each scar should appear on a body diagram. Annex III of the 2022 Protocol contains updated anatomical drawings for this purpose. Moreover, paragraph 402 tells the clinician to take the best photographs possible, with rulers and colour scales, and to add detailed descriptions.[7] Number every scar, and use the same number on the map, in the photographs and in the text. A judge who cannot match "scar 4" to an image will give the finding less weight.

6. Description of each lesion

For each scar, the report should give its site, size, shape, colour, edges, texture and any pattern. For example, a row of parallel linear scars on the back tells a different story from one round scar on the shin. The Protocol also warns about dating. Scars made at the same time may heal at different rates, so an exact date is not usually possible.[8] Similarly, the Upper Tribunal in KV (2014) noted that medical literature does not date scarring beyond six months. In certain cases, there is some basis for dating up to two years.[9]

7. The degree of consistency for each scar

This is the core of any medico-legal report on scarring. The doctor grades each lesion against the claimed cause, using five fixed terms. In the 2004 edition the scale sat at paragraph 187, which is why SA (Somalia) and KV cite that number. In the 2022 edition it sits at paragraph 380.[1]

The doctor must give reasons for each grade. Furthermore, the opinion can go beyond the mechanism of injury. In KV, the doctor noticed that the back scars had sharp edges while the arm scars were blurred. That fitted the claim that KV was unconscious when burned on the back and awake when burned on the arm. The Supreme Court held that doctors may comment on consistency with "the circumstances in which the scarring was sustained, not limited to the mechanism".[10]

8. The overall evaluation

Grading ten scars one by one is not enough. The Protocol requires a conclusion on all the clinical evidence together. Paragraph 381 allows the overall opinion to sit higher than any single finding, because many findings can point the same way. Paragraph 384 goes further. A report that gives no opinion on the possibility of torture is "deficient".[11] In practice, this is the section of the medico-legal report that judges quote. As a result, it should name the overall grade in plain words and explain how the physical and psychological findings fit together.

9. Alternative causes, including self-infliction by proxy

A good medico-legal report names other possible causes for each scar, such as accidents, illness, ritual marking, surgery and self-harm. It then says how likely each one is, given the client's life history.[12] The Court of Appeal in SA (Somalia) expected the doctor to deal with common everyday causes. In addition, the Upper Tribunal in KV (2014) held that doctors "must consider all possible causes of scarring".[9]

Self-infliction by proxy (SIBP) means a person asks someone else to injure them to support a false claim. Under the 2014 KV guidance, where the case raises SIBP as "a more than fanciful possibility", the report must engage with it. However, the Supreme Court later adopted the view of Elias LJ that SIBP injuries are "likely to be extremely rare".[13] The 2022 Protocol takes a similar line. Clinicians have no duty to discuss self-infliction without an evidential basis. Where they do suspect it, a second clinician should assess the person.[12]

10. Psychological findings

Scars are only half the picture. A full Protocol assessment also looks for post-traumatic stress disorder, depression and anxiety, and grades them on the same scale. In psychological assessments, clinicians rarely use "typical of" and "diagnostic of".[14] The report should also say how trauma may affect memory and the ability to give evidence. Still, tribunals treat this part with care. In HE (DRC), the tribunal said a report relied on for credibility must be dealt with "as an integral part of the findings on credibility". In JL, the Upper Tribunal added that the more a diagnosis depends on believing the client, the less weight it is likely to carry.[5]

11. Limitations

The Practice Direction requires the expert to state any qualification to the opinion.[4] For scars, typical limits include the age of the lesions, poor lighting, an interpreter by phone, a single short session or missing records. The KV guidance also warns doctors not to reach conclusions on causation that go beyond their own clinical expertise.[9] Equally, the report should state that the absence of a scar does not prove the absence of torture. Paragraph 390 of the Protocol says exactly that.[11]

12. Declaration and statement of truth

Finally, the report must contain a summary of conclusions and a statement that the doctor understands their duty to the tribunal. It must also carry the date of signature and the statement of truth in the exact words of paragraph 9.4.[4] The Protocol also limits what the doctor may say about belief. Clinicians express causation as consistency, not as a legal standard of proof.[11] In KV, Lord Wilson said the conclusion about credibility "always rests with the decision-maker".[10]

How UK tribunals weigh scarring evidence

Six decisions set the framework for scarring evidence in the UK, and each one tells the doctor something about what to write.

Mibanga and HE: the report is part of the credibility assessment

In Mibanga, the adjudicator rejected the account and only then turned to the medical evidence. The Court of Appeal held that "a fact-finder must not reach his or her conclusion before surveying all the evidence relevant thereto". Wilson J relied on the earlier tribunal decision in HE (DRC), which warned against treating the report as "just an add-on".[15] Consequently, a judge who decides credibility first and then asks whether the MLR changes that view makes an error of law.

SA (Somalia), JL and KV: what the report must do

A year later, SA (Somalia) showed the other side. The doctor's letter recorded the history but gave no opinion of its own. The Court of Appeal said a report should give "a clear statement as to the consistency of old scars found with the history given".[2] Then, in JL, the Upper Tribunal asked doctors for "a critical and objective analysis" of injuries and symptoms. It also confirmed that a report which relies heavily on the account is still independent evidence, though its weight may fall.[5] Finally, the two KV decisions added the duties on alternative causes and SIBP. The Supreme Court judgment in KV also confirmed the power to comment on the circumstances of the injury.[9][10]

The Home Office guidance

The Home Office guidance 'Medical evidence in asylum claims' is still Version 2.0, published on 26 August 2022. It says a Protocol report is "expert evidence not simply a report on the credibility of a claim of torture". Caseworkers must not speculate about the cause of injuries or quote selectively from the report. In general, five months is a reasonable wait for a medico-legal report once the claim is on hold.[3] Refusal letters that break these rules often give you grounds of appeal.

Freedom from Torture reviewed 50 refused claims in which it had supplied an MLR. Where the final outcome was known, 76% of the claimants won on appeal.[16] In other words, first decisions often mishandle good medical evidence. Even so, a judge can still reject an account after properly weighing a strong report. What the judge cannot do is treat the report as an afterthought.

Rule 35 reports in detention

A Rule 35 report is different from a medico-legal report. Under rule 35(3) of the Detention Centre Rules 2001, the centre doctor must report on any detainee "who he is concerned may have been the victim of torture".[17] The report feeds into the Adults at Risk policy and can lead to release. However, it is a short screening note. A full Protocol assessment goes much further, so use the Rule 35 report as a reason to commission a proper medico-legal report.

How US immigration judges weigh forensic medical evaluations

US law reaches scarring evidence mainly through corroboration and the Convention Against Torture (CAT). Under the REAL ID Act, INA section 208(b)(1)(B)(ii) lets the judge require corroboration of otherwise credible testimony. The exception is where the applicant "does not have the evidence and cannot reasonably obtain the evidence".[18] In Matter of J-Y-C-, the Board of Immigration Appeals (BIA) confirmed that the judge looks at the totality of the circumstances on credibility. For CAT, 8 CFR 1208.16(c)(3)(i) also requires the judge to consider evidence of past torture.[18]

The circuits split on notice. In Matter of L-A-C-, the BIA held that the judge need not say in advance which corroboration is missing. By contrast, the Ninth Circuit in Ren v Holder and the Third Circuit in Saravia require notice and a chance to respond.[18] Therefore, the safe course everywhere is to file the medical evaluation early, as part of the main evidence.

On weight, Matter of J-G-T- asks the judge first whether expert evidence is relevant and reliable, and then how probative it is on the key disputed issues. Matter of M-A-M-Z- adds that expert testimony is evidence, but only the judge makes findings of fact.[19] Sanusi v Gonzales shows how an evaluation can fail. There, the judge did not credit a doctor's affidavit. The Second Circuit noted that parts of it depended on the applicant's own credibility. It also noted that "a few scars" might fit "a lifetime of normal activity", and that the doctor was an obesity specialist with no shown torture training. The court denied the petition.[20]

In the US, Physicians for Human Rights (PHR) runs a network of volunteer clinicians who carry out these evaluations, and most follow the Protocol's structure. A 2021 study of 2,584 PHR cases from 2008 to 2018 found positive outcomes in 81.6%, against a national asylum grant rate of 42.4%.[21] The cases are not a random sample, so the figure does not prove cause.

How a country expert report complements the medical report

The medico-legal report and the country expert report answer different questions. The doctor says whether the scars are consistent with the account. In contrast, the country expert says whether the account is plausible in that country at that time. For example, the expert can show which methods the security forces use, where they hold detainees and whether the client's profile fits those they target.

The two reports should meet but not overlap. The Protocol asks clinicians to correlate findings with knowledge of regional torture methods.[6] A doctor who can point to sourced country evidence on those methods therefore gives a firmer opinion. Meanwhile, the country expert should not comment on the scars at all. 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 cause than SIBP.[13]

The same format rules apply to both reports in the First-tier Tribunal. Our video on the Practice Direction walks through the paragraph 9 duties that every expert, medical or country, has to meet.

The Practice Direction Explained: What You Must Know

For more on how judges read expert evidence, see our guide on how judges assess expert witness reports. Our breakdown of what a country expert report contains, section by section shows the structure on the country side. Where the refusal turns on credibility, our guide to asylum credibility findings explains each common reason.

Common questions about medico-legal reports

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

No. Paragraph 390 of the Protocol says that the absence of physical or psychological evidence does not mean torture did not happen. Many methods leave no lasting mark. The report should explain why no scars would be expected.

Is "consistent with" a good result?

It is the weakest positive grade. It means the scar could have many other causes. Therefore, the overall evaluation and the discussion of other causes matter more.

Can the doctor say the client is credible?

No. The Protocol and the Supreme Court in KV both keep credibility for the judge. The doctor should limit the opinion to how far the clinical findings fit the account.

How long is a medico-legal report allowed to be?

In the First-tier Tribunal, an expert report must not exceed 20 pages unless the tribunal agrees to a longer one.

Is a Rule 35 report enough?

Usually not. It can support release from detention, but it is not a full Protocol assessment. Commission a full report for the asylum claim.

Must a US forensic evaluation follow the Protocol?

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

Conclusion

A medico-legal report on scarring succeeds when it does work the judge cannot do alone. It lists the documents seen, maps and photographs every scar, grades each one with the correct Protocol term and weighs other causes. Above all, it ends with one overall opinion. It fails when it repeats the client's story, skips the overall evaluation or ignores SIBP where the facts raise it. In the UK, Mibanga and HE require judges to weigh the report before deciding credibility. Meanwhile, SA (Somalia), JL and both KV decisions 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 medical report with country evidence on how the state tortures. If you need that country evidence, you can find an expert witness for the relevant country.