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Journal of Visual Communication in
Medicine
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A guide to medico-legal photography for personal injury
claims
David Bryson a
aLecturer in Medical and Technical Photography at Berkshire College of Art and
Design, Berkshire, UK
Online Publication Date: 01 January 1994
To cite this Article: Bryson, David (1994) 'A guide to medico-legal photography for
personal injury claims', Journal of Visual Communication in Medicine, 17:1, 5 - 11
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Journal of Audiovisual Media in Medicine
1994; 17: 5-11
A
guide to medico-legal photography for
personal injury
claims
DAVID
BRYSON
Clinical photographs are in essence medico-legal records but
when instructions are given to
take
photographs for litigation
the requirement
is
for
a
more specialized approach than when
producing
a
clinical record for the notes. There are special
considerations when providing
a
medico-legal photographic
service, from clients’ instructions, preparations before photo-
graphy, and the photography itself to presenting the photo-
graphs and handling the administration.
As
photographs are
taken in support of claims for compensation for personal injury
many of them can have far greater impact, financially and
psychologically, on the client than clinical photographs. Inade-
quate coverage could be construed
as
professional negligence.
Recent changes in the
UK
National
Health Service
(NHS)
have led to a
realization that medical illustration is a
valuable resource. Medico-legal photo-
graphy has a significant role to play not
just in income generation but as a vital
service to members
of
the general
public who are making claims for
compensation after personal injury’.
This article provides a guide to the
sequence in medico-legal work in which
photography is only part
of
the overall
process.
Instigation
Requests for medico-legal photography
usually come from solicitors, medical
consultants or the general public,
although occasionally instructions may
be received via other organizations such
as insurance companies or trades un-
ions. The most important document is
the letter of instruction. This provides:
(1)
permission to photograph the client
and therefore the implied consent of the
client to be photographed;
(2)
confir-
mation that the requestor will be
responsible for your ‘reasonable fees’;
David Bryson, BSc(Anatomy), CertEd,
AIMI, RMIP,
is
Lecturer in Medical and
Technical Photography at Berkshire College
of
Art and Design, Kings Road, Berkshire,
RGI
4HJ,
UK
0
1994
Butterworth-Heinemann
Ltd
0140-51 1X/94/010005-07
1.
2.
3.
4.
5.
6.
(3)
information about the client, how to
contact them and their availability.
fessionalism. Where a solicitor is work-
ing to a court date it helps keep him
aware
of
the current situation.
Further instructions may be issued for
another set
of
photographs after more
surgery or for duplicate sets, months or
are
needed.
Instructions from
a
solicitor
These will come usually by letter
or
fax years later; again written instructions
but also by telephone followed by a
letter of instruction. The following
communicating with solicitors:
Whether
you
are
a
health
authority
able to provide photographs for a
points
are
to
remember
when
employee or independent it is inadvis-
Confirm during a telephone conver-
sation that instructions will be sent,
if not follow up the telephone
instructions with a letter of confirma-
tion
of
receipt of verbal instructions.
Follow up a letter
of
instruction with
a letter confirming receipt and the
action you have taken, i.e. date of
appointment made for client.
Request a copy
of
the consultant’s
report(s) if this has not already been
sent.
Confirm in writing that medico-legal
photographic records have been
taken and will be with the solicitor at
the earliest opportunity.
Write a letter to accompany the
medico-legal photographs and in-
voice, cross-referenced to the orig-
inal instructions.
All letters should be cross-
referenced to the client’s name with
the solicitor’s reference and your job
number
or
date code reference.
medical negligence claim against a
consultant you work with, or for an
action by an employee against the
health authority or another client of
yours. If you are asked to undertake
such work your conflict
of
interest
should be declared.
Instructions from a medical
consultant
A
consultant may ask for medico-legal
photographic records
of
a patient under
his care. In this situation it is important
to ask whether they are for the consul-
tant himself and the hospital files or for
possible use by the patient’s solicitor.
It is safest to assume that the
consultant will not want to pay you
personally and would be grateful if you
dealt with the administration. This
avoids the risk of being caught between
the solicitor and the consultant, each
thinking the other ought to be Davine.
a,
Y
Good communication gives the right
impression of your efficiency and pro-
A teiephone call ‘br letter to the
solicitor asking for a letter of instruction
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before taking the photographs is prefer-
able. If the photographs are urgent it
may be necessary first to take them and
second to confirm that the solicitor will
require them. In this case it
is
best not
to have prints made until you have
received written instructions. The solici-
tor may need
to
ask for an extension
of
legal aid before he can instruct. If the
solicitor does not require the photo-
graphs straight away they can be kept as
transparencies
or
negatives with little
loss
of revenue.
A
consultant may like to provide an
all-in package including medical report
and photography. In this case it
is
still
necessary
to
obtain a letter confirming
that he will be responsible for your
fees.
Work received via a consultant is
often a golden opportunity to introduce
yourself to a solicitor, but it can also be
a financial minefield. Efficiency in
paperwork and taking the responsibility
out
of
the consultant’s hands is the
surest recipe for a smooth working
relationship.
Instructions from the general public
Receiving instructions from the general
public
is
straightforward even
if
it
is
friends, colleagues
or
acquaintances. If
they already have a solicitor they will be
able to give you the solicitor’s name and
address
to
contact in the usual way. If
they do not have a solicitor it is best to
refer them
to
the Law Society‘s Acci-
dent Legal Advice Service (ALAS)
or
to a solicitor who you know deals with
personal injury work. It may be helpful
to have copies
of
the various self-help
books”.‘
available: these are also avail-
able in public libraries.
The general public may also be
referred to
you
or
walk in
off
the street
with a form from the Criminal Injuries
Compensation Board (CICB)’. The
form acts as
your
instructions to photo-
graph.
Care must be taken
if
approached by
colleagues as
for
NHS
photographers
there
is
a conflict
of
interest
if
the injury
was sustained in the hospital
or
while
working for the health authority. Photo-
graphs
of
staff, patients. relatives
or
members
of
the general public involved
in accidents in the hospital are part
of
the health authority‘s evidence and as
such are privileged’.
Damage claims
There are three types
of
damage claim
in personal injury cases; special, general
and provisional.
Special damages
1.
Includes all losses and expenses,
hospital
fees,
fares, damage to car
and clothing.
2.
Loss
of
earnings.
General damages
1.
Pain, suffering and shock.
2.
Loss
of
amenitylhappiness, no lon-
ger able to pursue hobby.
3.
Loss
of
mobility.
4.
Loss
of
expectation
of
life.
5.
Estimated
loss
of
future earnings.
Pain, suffering and shock cannot be
photographed but early records taken in
casualty can give an impression
of
the
severity of injury.
For
example, flash
burns heal rapidly but their traumatiz-
ing effect can be inferred from photo-
graphs. Without them the patient may
have difficulty conveying the suffering
to the solicitor and end up with lower
damages.
No
accident and emergency
department should be without a medical
photographic service to record injuries
for the patient‘s benefit as well as the
hospital’s.
Table
1
Classic model for injury
assessment
lo
Functional
-
anatomical and
physiological
Cosmetic
-
surface anatomical
appearance
Social
-
effect
of
life, work,
social position
Psychological
-
effect
on
mental
state
Provisional damages
1.
Allows for a condition to deteriorate
or
for the chance that a disease will
develop, e.g. osteoarthritis.
2.
Initial payment, then should condi-
tion worsen the client can return to
court for additional damages at a
later date.
Provisional damages are not as popu-
lar with solicitors
or
insurance com-
panies due to the possibility
of
a never
ending financial commitment. The
chance
of
a poor prognosis is now dealt
with on the basis of the probability
of
a
complication occurring, usually expres-
sed in percentage terms.
For
example, a
client with a serious knee injury may
need
a
knee replacement after
10
years
so
the compensation includes a sum
for
this. Photographs to show the extent of
damage. taken during an operation, can
help demonstrate such a prognosis.
The amount
of
damages
is
often
referred to in legal texts as the
quantum
Disease or
-+
Impairment
-
disorder
~L
of damages which means in simplistic
terms ‘how much’. The monetary value
of claims’ varies considerably but
is
usually far lower than those that hit the
headlines.
Models for injury assessment
In assessing injuries it
is
useful to have a
method for determining their effect not
only in medical terms but in how they
affect activities
of
daily living (ADL).
The classic model” for injury assess-
ment
is
in terms of their functional,
cosmetic, social and psychological ef-
fects,
Table
1.
However
a
better model
is provided by the World Health Orga-
nization”,” which suggests the mea-
surement of the consequence of dis-
eases and injuries in terms
of
the
resulting impairment, disability and
handicap;
Figure
I
illustrates their
relationship:
Impairment
-
the
loss
or
abnormality of
psychological, physiological
or
anato-
mical structure
or
function.
Disability
-
any restriction
or
lack of
ability to perform an activity in the
manner
or
within the range considered
normal.
Handicap
-
a disadvantage for a given
individual, that limits
or
prevents the
fulfilment of
a
role that is normal for
that individual.
An impairment may lead to a disabil-
ity but it may
or
may not become a
handicap.
Table
2
illustrates the use
of
this model. It is surprising how many
features can be recorded:
loss
of
opposi-
tion by the client using their fingers to
Disability
-+
Handicap
$
Intrinsic
situation Exteriorized Objectified Socialized
Figure
1
World Health Organization model for consequences
of
disease”
6
Bryson
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Table
2
Use of WHO model for injury assessment and photography
Criterion Description Photography
Diseases or disorder Damage to flexor
I
m pa
i
rment
Loss
of opposition of
Disability
Loss
of pincer grip Inability to produce grip
Ha nd
i
ca p
Theatre records of torn tendon
Range of movement of thumb
tendon
thumb
a
Inability to work with Holding needle with fingers not
hand fingers and thumb
hold a needle without a normal pincer
grip; a general view
of
facial scarring
showing that the disfigurement is visible
at a distance and
so
more of a handicap
both psychologically and in obtaining
employment; and a scar that has very
thin skin which is a handicap but not
disabling,
Figure
2.
In photographic
terms it is important to record the
socialized element of the handicap, as
well as the impairment or disability.
The consultant’s report
This is usually the first and last step in a
case for compensation. At each stage in
a patient’s recovery the client’s condi-
tion is reported on, see
Figure
3.
There
are principally two types of medical
report for a patient following an acci-
dent or other personal injury, the
Figure
2
Thin skin of a scar demons-
trated by the client gently pushing
the scar tissue
Casualty/accident and emergency
In-patient notes and tests
i.e. on ward, before operation
Operating theatre
corrective surgery/treatment
Outpatient treatment
or examination
After report by consultant
1
1
1
1
1
Figure
3
Stages where photographs
of a medico-legal nature may be
taken or a patient’s condition re-
ported on by a consultant
post-accident report, or in the case
of
medical negligence the original hospital
notes, and the specialist’s report.
Post-accident report
This covers the period immediately
after an incident and is compiled by the
casualty officer or trauma consultant. It
describes the general condition
of
the
injured person on arrival, any emer-
gency treatment, and progress made in
the weeks and months following.
Specialist’s report
This is usually made a considerable time
after the original injury and is prepared
for litigation. There may be more than
one report with interim reports follow-
ing reparative operations, treatments or
periods
of
time. The definitive report is
made when there is a definable prog-
nosis which can be anything from
1-3
or
more years later. The typical content of
a report is shown in
Table
3.
There may be more than one special-
ist’s report, e.g.
a
main report by an
orthopaedic surgeon followed by re-
ports from a psychiatrist, orthodontist
or faciomaxillary surgeon.
Preparation for photography
This stage should be an integral part of
the medicolegal photographer’s prac-
tice.
Before the client arrives for
photography
Make sure you obtain a copy of the
consultant’s report.
Read the medical report carefully.
Make notes or highlight the relevant
featwes
of
the injury, including
old
injuries to avoid during photography.
Work out the standardized views
needed to cover the condition as
described in the report including
close-up views and any specialized
techniques, e.g. direct ultraviolet.
After the client arrives but before
they undress
5.
Discuss the injuries with the client
while they are relaxed to make sure
that all the matters they are con-
cerned about are covered.
6. Describe and/or demonstrate the
views you will be taking.
7.
Make sure you have an aide available
to act as a chaperone and
if
necess-
ary to help them with undressing.
Client disrobed for photography
8.
Look at the areas of scarring or
deformity, confirm that the views
worked out are appropriate and note
any others that will help show the
injuries.
Reading the report does not preclude
thinking
of
other views to take on
seeing the client but it does provide a
schema for the most pertinent records.
The schedule of views also enables an
estimate to be made of the cost of
photography which can help the solici-
tor make an early claim for disburse-
ment from the Legal Aid Fund.
Table
3
Typical contents of a
specialist’s report
Patient details and employment
History of injury
Subsequent treatment and progress
Current situation
Effect of accident on employment
Effect
of
accident on social/domestic
Past medical history
CI inical exam ination
Diagnosis
Opinion/prognosis
life
The
Journal
of
Audiovisual
Media
in
Medicine
(1
994)
Vol.
171No.
I
7
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It is also important tn we the report
to get an idea of the client's physical
capability and, as many accident victims
suffer from post-traumatic shock syn-
drome, their psychological condition.
Photographic materials
The intrinsic value
of
records is in the
originals, not in the prints. Printing is
secondary to the initial objective re-
cord.
Slide or negative?
The choice
of
materials
-
colour slides
or
negatives
-
has to be carefully
considered's's. Direct records, single-
process Kodak
Eh
or
Kodachrome,
produce a viewable image without
further printing and can be projected
in
the courtroom. Indirect records, two-
process colour negative Kodak
C41
or
monochrome negative, can produce
good prints
if
colour variations in
backgrounds are avoided, but the orig-
inal cannot be viewed directly.
Retention and filing of originals
Mounted and unmounted originals must
be kept on file. including extra copies
and overlunder-exposed film, as
it
may
be necessary
to
prove continuity of the
sequence.
Consultants' requests
-
if
medicolegal
use is the main purpose keep originals
and provide duplicates;
if
secondary
to
medical records two originals should be
taken. Obtaining a consultant's slides,
possibly
3-5
years later, can be difficult
especially if they and their 'slide collec-
tion' have moved elsewhere.
Photography
The first priority. as with all clinical
photographs
to
be used for recording or
diagnosis, is that they should be
objec-
tive.
Standardized representational
photography
Standardized views are essential to
place the clients' injuries
in
context. A
close-up of scarring is totally inadequate
without a larger scale picture
to
show
the anatomical position, extent of disfi-
gurement or overall cosmetic effect,
Figures 4a.
h
and
c.
A
series of photographs showing
scarring
of
the right hand, for example,
should
include as a minimum both
hands, palmar and/or dorsal surfaces,
right hand
on
its own and normal
close-up of the scar, not cross-lit.
Specialized views including the use of
cross-lighting or differential filtration,
or the recording
of
joint movements are
in addition to standard views.
Specialized techniques
These are useful but should be applied
carefully and judiciously in the full
knowledge that without standardized
representational views they can be
misleading or lead to misrepresent-
ation".
Lighting techniques
can be used to
compare the normal standardized light-
ing with cross-lighting or flat lighting
to
demonstrate detail in soft tissues
or
skeletal deformities. The contrast be-
tween a normal and cross-lit view can
significantly add to the information
content
of
the photographic record, but
as
Figures 5a
and
b
show, both are
needed, each demonstrating different
facets of the same lesion.
Differential filtration or panchromatism,
the use of black-and-white films with
ultraviolet, blue or green filtersl7,l8, to
demonstrate the extent of tissue dam-
age or scarring,
Figures 6a
and
b,
are
important techniques. The type of
filtration used, or lack
of
it, and type of
film, i.e. infrared must be stated as a
matter
of
routine. The
CICB
and some
solicitors ask for photographs to be
verified as unretouched not realizing to
what extent the photography itself or
omission of views can overemphasize or
distort the record.
Cosmetic appearance
is extremely signi-
ficant to a client's case. The position of
a scar in a head and shoulders view is as
important as a close-up
so
it can be seen
in relation to where a swimsuit or dress
would or would not cover up the
disfigurement. Scars can often be
camouflaged but many cannot
so
de-
monstrating this is important,
Figure
7.
The original injury
is
not the only one
that should be considered, keloid scar-
ring from a skin graft donor site can be
as obtrusive as the area it was used to
repair,
Figure 4c.
Joint movement and nerve damage
should be recorded as well as any
Figure 4
Injuries following a motor-
deformity. Abnormal joint movements
cycle accident:
a
Anteroposterior
compared with normal can be shown
view of the legs;
b
close-up of
using standard joint positions",
Figures
muscle loss;
c
close-up of keloid
8a-c,
or by actions like walking
up
and
scar, graft donor site
down stairs. Similarly nerve damage can
8
Bryson
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proved at a hearing or agreed between
the plaintiff‘s and defendant’s solicitors.
Mounting of prints
Loose prints should be avoided; they
can be lost, the order
of
viewing can be
changed, client details must be given on
the back
of
every print and turning the
prints over to see the details is awk-
ward.
Prints should be mounted
on
A4
card
of
a neutral colour, e.g. grey, which
does
not
detract from the prints. One
side only should be used
so
that all the
prints can be seen at once if spread
out.
Figure
5 Injury resulting from a pottery shard penetrating footwear:
a
normal
close-up lighting at
45”
single flash showing detail in the
soft
tissues;
b cross-lit view, as
a,
to show raised and depressed nature of the scar
be demonstrated by muscle wasting,
examination’’
or
the resultant handi-
cap. It is also useful to show the natural
state, i.e. resting position
of
the hand,
and for legs and
feet
weight and
non-weight-bearing views.
Zntraoperative
records can be advan-
tageous where a client undergoes a
reparative or exploratory operation
following an accident or negligence.
Photographs required range from ex-
amining joint movement under anaes-
thesia
(EUA)
to endoscopic and surgi-
cal photography during the operation,
Figure
9.
Medical specializations
from ophthal-
mology
to
dentistry all have their place
in medico-legal photography. However,
careful thought has to be given to their
use, e.g. with dermatological corn-
plaints it is important to photograph the
client before drug therapy as this often
produces rapid improvement
of
the
client’s condition.
Presentation
of
photographs
When photographs are presented as
evidence great care must be taken to
detail what is represented
so
they can be
Mount labels
-
common information
Information for clinical mounts only
needs to be sufficient to link them with
the patient’s notes and the department’s
records.
The information for medicolegal
work must be complete on its own. The
minimum for labelling is: surname
(including maiden name); forename(s);
International Classification of Diseases
code; date of birth; instructing organi-
zation; job number; date (and time)
photographed; name and address
of
the
photographer or department and the
photographer’s initials; name of the
solicitor and/or consultant.
Viewiprint labels and list of contents
A
cross-reference from the mounts to a
list
of
contents is essential when there is
more than
one
mount.
A
description of
each view or pair
of
views should be
placed consistently under or above the
prints, it should include an alphanum-
Figure
6
Panchromatism, depigmented area following burn from scalding water:
a
normal view;
b
llford Pan
F
film with
blue filter, Kodak Wratten
47B
The Journal
of
Audiovisual Media in Medicine
(1994)
Vol.
17INo.
1
9
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Figure
9
Effect
of
a
comminuted
fracture of the femoral trochlea on
the cartilaginous surfaces of the knee
joint
Figure
7
Scar, due to foot going
through rotten floorboards, still visi-
ble when wearing stockings
eric and brief description, e.g. la.
Dorsal view
of
the feet. A number on its
own referring to a list elsewhere is
insufficient as it is time consuming to
keep glancing back and forth.
The list
of
contents can be placed at
the beginning
of
the set
of
records, as a
fold-out index at the back
or
in the
letter to the solicitor. The information
should be the same
as
on the mounts
so
ensuring that all the prints are pre-
sented as evidence.
When a request is made for a subset
of the records the
list
of
contents should
still include
all
the records available
with a note
of
those excluded.
Collation of mounts
Collating the mounts in a brochure is
important to ensure that none are
lost
or
omitted. Semipermanent binding
which allows the prints to be spread
out
is preferable.
or
a
‘concertina’ book-
let”. The disadvantage
of
permanent
bindings,
e.p.
the spiral binding used by
the police, is that the prints cannot be
seen
all
at once
or
rearranged.
Administration
Several points have been covered above
but
the elements
of
filing, professional
fees, invoicing and payment are as
important as the photography.
Filing
A
folder for all the relevant documents.
letters. case notes and reports should be
kept; these together with the slides and
prints should be kept confidential.
Figure
8
Damage to left hand and
wrist following road traffic accident:
a
full flexion
of
hand;
b
lateral view
of
extension of the wrist;
c
radial
deviation with arms pronated
While a legal case is progressing infor-
mation is
sub-judice
’under the law‘ and
premature disclosure could be preju-
dicial.
Professional fees
County courts issue cost rate guidelines
for Legal Aid Fund work. The hourly
rate for
1993
is
f60.00.
with
10%
(f6.00)
for each lettcr out. The cost
of
prints is additional
to
these
-
I
charge
f7.00
per
7
x
5-inch print including
mounting and labelling.
The court has the power to reduce
any fees charged
to
clients receiving
Legal Aid,
if
the allowance made for
these by the court
is
less than the fees
you have charged. This
is
known as
Legal Aid Taxation.
A
solicitor may
well include a letter
to
this effect with
his instructions.
In voicing
The invoice is the legal document
requesting payment. This should in-
clude the client’s name, solicitor’s refer-
ence,
job
number, cost of professional
fees and prints. Value added tax (VAT)
is payable
on
medicolegal work at the
standard rate
(17.5%).
It
is important
to
have the letter
of
instructions and
refer to it when invoicing.
Payment
Payment is usually direct from the
solicitor. A client may pay you before
being recompensed by the solicitor after
the case is settled. Full fees should be
charged. even to friends and colleagues,
as the cost of photography is included in
the settlement figure.
Terms
of
payment should be stated
on the invoice, e.g.
30
days. Many
solicitors take longer to pay
-
2-3
months is normal and
6
months not
exceptional. The excuse is usually Legal
Aid but payment from them should
follow
2-3
weeks after payment is
requested by the solicitor depending on
the backlog at your local office.
Acknowledgements
This article is based on material from a
lecture to the Institute
of
Medical
Illustrators Conference, Bradford Uni-
versity, September
1990
and Medico-
legal Study Day at Berkshire College
of
Art and Design, Reading, June
1993.
10
Bryson
Downloaded By: [Bryson, David] At: 18:51 8 March 2008
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Law Society, Accident Legal Advice Ser-
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1993
Referees
The manuscripts we receive are seen by the Editor who sends them to two expert referees. We are most grateful to the following
people who kindly reviewed papers for the
Journal
of
Audio Visual Media in Medicine
in
1993.
Without their expertise, we would
be unable
to
maintain the
high
standards for which we strive.
Mr Simon Brown, FIMI, RMIP
Mr Colin Burgess, AIMI, RMIP
Mr Michael Creasey, FIMI, RMIP
Professor Peter Cull, HonFIMI, RMIP
Professor
J.
W.
C.
Gates, DSc, CPhys, FInstP, HonFRPS
Dr Peter Hansell, Won FIMI
Mr Roger Hickinbotham, AIMI, RMIP
Mr Colin Hood, AIMI, RMIP
Mrs Gillian Lee, Hon FIMI, RMIP
Professor Ralph Marshall, PhD
Mr Andrew McCance
Professor Richard Morton, Hon FIMI
Dr
Robin Williams, FIMI
The
Journal
of
Audiovisual Media in Medicine
(1994)
Vol.
17INo.
1
11
