Injuries and expert evidence: reading a medical disagreement in a judgment

A problem worth reading twice

An injury case may contain an emergency record, several reports, photographs and testimony. Their number alone does not answer the court’s questions. We propose separating four issues: what harm is documented, what care was considered necessary, what causal explanation is advanced and what evidence identifies the person responsible. Each answer should be traceable to a particular basis. This article develops an editorial reading method around a historical judgment. It does not turn that judgment into a universal procedure for every case.

What the Constitutional Court decided

STC 21/2009 concerned a harsher appellate outcome based on reassessment of medical expert evidence without hearing the experts. The appeal judgment was annulled and proceedings remitted. Because documentary evidence remained, the Court did not decide whether valid evidence was sufficient for conviction. [1]

First question: what was observed, and when?

Our first reading sheet would be a chronology: the date of the reported event, the initial examination, subsequent assessments and each report. It would also identify who supplied each item: the examined person, an earlier record, direct examination or an additional test. Under this approach, “the pain began after the incident” remains a reported account if that is its only source. It is not silently converted into an observed finding. The distinction allows the value of each item to be discussed without making a sweeping judgment about the person supplying it.

Second question: where is the disagreement?

When reports differ, we suggest stating the difference precisely. It might concern a sign, the diagnostic label, a proposed mechanism, the need for an intervention or the duration of a limitation. These are separate questions. A useful editorial table would have one row per issue and one column per document. Each cell would record the conclusion, the information available and the reasoning connecting them. Leaving a cell blank when a report does not address an issue avoids assigning it a position it never expressed.

Treatment: ask the right legal question

Article 147.1 of Spain’s Criminal Code requires objectively necessary medical or surgical treatment beyond initial care; mere monitoring is excluded. [2] Our editorial questions concern the intervention in dispute, where its indication is documented and how its purpose is explained. Counting appointments or copying a prescription does not answer those questions. Nor do we suggest diagnosing someone remotely. The reading sheet identifies what the document explains and what requires professional clarification before legal consequences are drawn.

Injury and identity need identifiable support

In its particular case, STC 177/2008 distinguished proof of injury from proof of who caused it. [3] Building on that distinction, we propose recording the support for each conclusion separately. One field can contain physical findings, another the accounts of the event, and a third other identification evidence. When a report includes an account of events, ask whether it presents that account as information received or as its own conclusion. This arrangement helps reveal gaps in reasoning: establishing an injury does not automatically answer every question about how it arose.

Read the operative decision without inventing an acquittal

A commentary should distinguish a party’s request, the prosecutor’s position and the court’s decision. We propose reading the operative part first, then returning to the reasoning that supports it. The reference sheet should identify which decision is affected and what step is ordered. We should not complete the story with assumptions about later proceedings. If no later decision has been consulted, the commentary ends at the documented outcome. This discipline is especially useful for constitutional judgments: a procedural defect must not be turned into a medical conclusion the court never reached.

A 2009 judgment does not replace current legislation

Current Article 792.2 LECrim restricts appellate conviction or increased punishment through evidential reassessment on the terms of Article 790.2, allowing annulment and remittal. [4] We therefore do not transfer a historical procedural solution mechanically to a present case. Our reference sheet separates the judgment date from the date legislation was checked. Before applying its reasoning elsewhere, readers need to identify the procedure, appeal ground and precise relief sought. This article explains a problem in reading evidence; it does not resolve an individual appeal.

Turn the reading into a useful reference sheet

Our proposed worksheet ends with three fields. “Documented” contains matters that can be located in a source. “Disputed” records the competing positions examined in the decision. “Not established in the material consulted” keeps unknowns visible. We then formulate a short question for each relevant gap without filling it by intuition. This method can help both a professional preparing a review and a reader following judicial news. Its value lies in traceable statements, rather than in the number of technical expressions it contains.

Questions for discussion

What changes between the reports, and why? Can the reader separate observation, reported information and interpretation? Is the conclusion about treatment explained? What supports personal attribution? Does the operative decision annul, remit, acquit or convict, and to what extent? These questions are our proposed discussion framework. Answers should point to specific passages; unanswered questions should remain open. The linked primary sources allow readers to check the commentary and continue independently.