Evaluation of the Forensic Medical Report Reform

In 2006, the “forensic medical report reform” was implemented. The primary purpose of the reform was to raise the quality of the forensic medical report and to strengthen the rule of law and legal certainty in the judicial process. This would occur via inter alia a forensic medical report, which is usually issued by forensic doctors at Rättsmedicinalverket, the Swedish National Board of Forensic Medicine or other doctors with whom the authority has an agreement.

Statskontoret, the Swedish Agency for Public Management, has evaluated the Forensic Medical Report Reform. Our primary task has been to investigate why the number of forensic medical reports issued by the National Board of Forensic Medicine has decreased in recent years.

Most forensic medical reports are issued by the National Board of Forensic Medicine

Statskontoret’s conclusion is that the majority of forensic medical reports in the period 2007-2016 have been issued by the National Board of Forensic Medicine. The goal of the forensic medical report reform, that forensic medical reports are most often issued by a person with specialist expertise at the Swedish National Board of Forensic Medicine, has been met to a large extent.

A forensic medical report can be based on a physical examination of the individual, however also on documents, especially patient records. Forensic medical reports are issued primarily in connection with investigations of violence and sexual offences. Investigations related to suspected assault and battery (both simple and aggravated assault and battery) were the source for more than one-half of all forensic medical reports issued by the National Board of Forensic Medicine during the period investigated. However, the forensic medical reports for simple assault and battery have decreased by nearly 50 percent since 2008.

The total number of forensic medical reports issued has decreased over time

The number of forensic medical reports from the Swedish National Board of Forensic Medicine increased during the first years after the reform. However since 2008, the number of forensic medical reports from the Board has decreased by approximately one-third. This reduction has not been compensated for by other parties issuing more forensic medical reports, i.e. public or private medical clinics. Instead, the number of certificates from these parties has decreased in recent years. This means that the total number of forensic medical reports issued in Sweden has decreased over time.

There are a combination of explanations behind the decrease

There are several explanations as to why the number of forensic medical reports has decreased. One is that it has become more common for preliminary investigation authorities to rely only on patient records (medical charts) as documentation for injury in the criminal investigation, and not forensic medical reports. An additional explanation is that since 2017 the National Board of Forensic Medicine no longer makes use of specially contracted doctors who could also issue a forensic medical report in the name of the Board. The contracted doctors have been replaced by the new unit: forensic documentation doctors (“FD -doctor”). So far, these FD doctors deal with very few cases.

Circumstances in the criminal investigation and geographical accessibility are the issues that mainly affects the requests for a forensic medical report

It is Statskontoret’s assessment that it is primarily above all the particular circumstances of the individual criminal investigation and the availability of the National Board of Forensic Medicine’s services which determines whether the police and/or public prosecutor decides that they need a forensic medical report, and if so, where they turn to to obtain one. For example, this may relate to the degree of seriousness of the crime, the situation in general concerning the available evidence, or if the suspected perpetrator has been identified or not.

The availability of forensic expertise is of particular importance for forensic medical reports that are built upon physical examinations of a person. It is our assessment that significant geographic distances to some form of forensic skills affects the preliminary investigation authority’s decision to request physical examinations of an individual or not. This may be due to the distance to the National Board of Forensic Medicine’s forensic units, however also to other doctors with whom the Board has an agreement. The situation in the Stockholm region is that it is in close proximity to a forensic unit, however the wide range of medical clinics means that the police often turn to issuers other than the National Board of Forensic Medicine to obtain a forensic medical report.

The cost of forensic medical reports may have some bearing on whether the police and/or public prosecutor requests a certificate in the case of a non-aggravated offence or when it is not self-evident that a forensic medical report would be of assistance in the investigation. In situations of aggravated criminal offences, the cost is rarely a factor of any significance.

The National Board of Forensic Medicine forensic medical report is more common in the case of aggravated criminal offences

The Police and public prosecutors generally regard National Board of Forensic Medicine’s forensic medical reports as being of good quality. It is therefore more common for them to turn to the National Board of Forensic Medicine when investigating aggravated criminal offences involving injuries to persons, as there may be more circumstances for which evidence needs to be produced. In these cases, the distance to a forensic unit is of less importance, as the police and public prosecutors attach greater importance to obtaining a forensic medical report issued by a forensic doctor.

The National Board of Forensic Medicine could work more efficiently and in a more coordinated manner

Statskontoret’s conclusion is that the National Board of Forensic Medicine has implemented several changes in recent years for the purpose of improving the coordination of its forensic operations. The Board has also recruited more forensic doctors over a longer period of time. It is important that the Board continues to work strategically, in order to ensure that the forensic doctors’ services are sufficiently manned.

Our assessment is that the National Board of Forensic Medicine should continue to make its operations more efficient and effective, for example the forensic units systematically working to learn from each other, and thus further develop best available methods and practices. For example, some units have had consistently shorter processing times than average for the Board as a whole. Improved coordination is also important for quality assurance and for strengthening the rule of law and legal certainty. 

Stronger joint efforts with the client ordering authorities, primarily the Police Authority, can also lead to a more efficient use of the forensic skills. Presently there are deficiencies in the documentation upon which the police make requests for a forensic medical report, resulting in that the work of the forensic doctors is more time-consuming. It is also our assessment that it is necessary to clarify which types of matters have the greatest need for the specialist expertise of the forensic doctors, in other words, where this expertise has the greatest significance for the judicial process.

Statskontoret’s proposal for more high-quality forensic medical reports throughout the country

In the report, Statskontoret presents a number of proposals to facilitate that a greater number of high-quality forensic medical reports are issued throughout the country. The proposals focus on improving the collaboration between the National Board of Forensic Medicine and the client ordering authorities, increasing access to forensic expertise, reviewing how the pricing of forensic medical reports can become more appropriate, and ensuring the quality of the certificates. Our proposals are primarily addressed to the National Board of Forensic Medicine, the public agency responsible for forensic medical reports.

Statskontoret proposes that the National Board of Forensic Medicine should:

• Develop a guidance document concerning how the client ordering authorities request a forensic medical report. This guidance should, inter alia, make it clear when a client ordering authority should request a forensic medical report and when forensic expertise would contribute to added value. The National Board of Forensic Medicine should do this in cooperation with the Police Authority and the Swedish Prosecution Agency.
• Intensify its work of systematically informing the police and public prosecutors about its activities, including the new unit: FD doctors.
• Intensify the recruitment for the new unit “FD doctor,” especially in those parts of the country located at a far distance from a forensic unit or where these doctors are not available at the present time.
• Ensure that the recruitment of “FD doctors” also covers the necessary specialist skills, especially dentists.
• Review the pricing model for forensic medical reports. The focus of the review may, for example, be to analyse whether hourly rates or differentiated pricing would be most appropriate.
• Develop regular quality follow-ups of forensic medical reports.
• Perform regular follow-up of FD doctors’ documentation of injuries to persons, in order to ensure the quality of the Board’s forensic medical report.
• Carry out regular follow-ups on how police and public prosecutors perceive the issuance of forensic medical report activities and what needs they have.
• Decide on regulations that clarify what should be included at a minimum in a forensic medical report, irrespective of who issues the report/certificate. The National Board of Forensic Medicine should make this decision concerning regulations in consultation with the Police Authority, the public prosecutor’s office and the National Board of Health and Welfare.

Statskontoret proposes that the Swedish Police Authority should:

• Designate a contact person or unit who has a designated responsibility for certification within the Authority.

The Swedish Agency for Public Management proposes that the Government should:

• Authorise the Swedish National Board of Forensic Medicine to issue regulations for what a forensic medical report should contain.