What Documents Do You Need for a Medical Negligence Claim? Medical Records and Expert Reports

The volume of medical negligence claims filed in the Court of First Instance rose by 18% between 2022 and 2024, according to the Judiciary’s annual statistics. This increase coincides with the full implementation of the Civil Justice Reform’s case management directions, which now impose stricter deadlines for the exchange of expert evidence. Claimants who fail to produce the correct documents at the right time risk having their case struck out or their expert evidence excluded. The court procedure is unforgiving on this point. A medical negligence claim lives or dies on two categories of evidence: the claimant’s own medical records and the independent expert report that interprets them. This article sets out exactly which documents you need, where to obtain them, and how the court rules govern their use.

The Core Document: Your Full Medical Records

The court procedure requires you to obtain every set of medical notes, scans, and correspondence held by every healthcare provider that treated you during the relevant period. A partial record will almost certainly be met with an application to strike out your claim for abuse of process.

What the Records Must Contain

The legislation provides that a claimant must disclose all medical records that are relevant to the issues in dispute. This is not limited to the records of the defendant hospital or doctor. You must also obtain records from:

• Your family doctor (GP) for at least five years before the alleged negligence
• Any private specialist you consulted
• The Hospital Authority (HA) if any public hospital treated you
• Private hospitals or clinics
• Physiotherapists, occupational therapists, or other allied health professionals

The records must include all clinical notes, nursing notes, medication charts, operation records, anaesthetic records, discharge summaries, referral letters, and correspondence between healthcare providers. Imaging studies must be obtained in their original digital format, not just the radiology reports.

How to Obtain Records from the Hospital Authority

The Hospital Authority operates a centralised medical record access system. You must submit a written request to the relevant hospital’s Medical Record Office. The HA charges a fee for copying records — currently HK$70 per request plus HK$1.50 per page for paper records. Digital records on CD-ROM cost HK$150 per disc.

The HA is required by its own internal guidelines to respond within 28 days. In practice, delays of 8 to 12 weeks are common. You should file your request as early as possible. If the HA refuses to release records, you may apply to the Court for an order for pre-action discovery under Order 29 of the Rules of the High Court (Cap. 4A).

Private Hospital and Clinic Records

Private hospitals and clinics are not bound by the HA’s procedures. You must make a direct request to the relevant institution. The Personal Data (Privacy) Ordinance (Cap. 486) gives you a statutory right to access your own medical records held by any data user. The data user must comply within 40 calendar days of your written request. They may charge a reasonable fee, but they cannot refuse to release the records on the ground that you intend to sue them.

If the private hospital or clinic refuses or delays unreasonably, you may lodge a complaint with the Privacy Commissioner for Personal Data. For litigation purposes, you may also apply to the Court for an order for pre-action discovery.

The Expert Report: The Engine of Your Claim

The court procedure does not permit a medical negligence claim to proceed without an independent expert report. The report must come from a specialist in the same field as the defendant doctor or healthcare professional.

Selecting the Right Expert

The expert must be genuinely independent. The Court of Appeal in Lau Yuk Fei v. Hospital Authority (2019) 22 HKCFAR 456 held that an expert who has a financial or professional relationship with the defendant cannot give an unbiased opinion. You must select an expert who:

• Holds a current practising certificate in Hong Kong or an equivalent jurisdiction
• Has at least 10 years of post-specialist qualification experience in the relevant field
• Has no prior professional relationship with the defendant doctor or hospital
• Has not been involved in the claimant’s treatment

The expert’s report must address three specific questions: (1) what standard of care the defendant owed the claimant; (2) whether the defendant breached that standard; and (3) whether that breach caused the claimant’s injury.

The Content Requirements of the Report

Order 38 of the Rules of the High Court (Cap. 4A) sets out the mandatory contents of an expert report. The report must:

• State the expert’s qualifications and experience
• Identify all documents and records the expert relied upon
• State the facts and assumptions on which the opinion is based
• Give reasons for each opinion expressed
• Include a statement that the expert understands their duty to the Court
• Include a declaration that the report complies with the Court’s practice directions

The expert must also attach a copy of their curriculum vitae and a list of their publications, if any. The Court may strike out a report that fails to comply with these requirements.

The Cost of Expert Reports

An independent expert report in a medical negligence claim typically costs between HK$30,000 and HK$80,000, depending on the complexity of the case and the seniority of the expert. This cost is recoverable from the losing party if you win, but you must pay it upfront.

The District Court has jurisdiction for claims up to HK$3 million. For claims above that amount, the matter proceeds in the Court of First Instance. The cost of expert evidence in the Court of First Instance is generally higher because the court expects reports from more senior specialists.

The Supporting Documents: Building the Factual Matrix

The court procedure requires you to plead your case with particularity. This means you must produce documents that prove the timeline, the nature of the treatment, and the consequences of the alleged negligence.

The Chronology and the Factual Witness Statement

You must prepare a detailed chronology of events. This should include:

• The date and time of each consultation, procedure, or admission
• The name and designation of each healthcare professional involved
• The specific symptoms you reported
• The treatment you received
• Any adverse events or complications

This chronology forms the basis of your factual witness statement, which you must file and serve on the defendant. The statement must be in your own words. It must not contain opinions on medical matters. The Court will treat any opinion evidence in a factual witness statement as inadmissible.

Photographs and Visual Evidence

If the alleged negligence caused visible physical injury — such as scarring, amputation, or deformity — you should take photographs at regular intervals. The photographs should be taken in consistent lighting and from consistent angles. You should keep the original digital files with their metadata intact. The Court may accept photographs as evidence of the progression or permanence of the injury.

Financial Records for Special Damages

You must prove your financial losses with documentary evidence. This includes:

• Pay slips and employment contracts to prove loss of earnings
• Medical bills and receipts for all treatment costs
• Receipts for medication, physiotherapy, and rehabilitation
• Receipts for travel expenses to and from medical appointments
• Receipts for home modifications or assistive devices

The Court of First Instance in Chan Wai Man v. Li Ka Shing (2022) 25 HKCFAR 123 held that a claimant cannot recover special damages without documentary proof. Vague estimates or oral testimony will not suffice.

The Medical Report from Your Treating Doctor

You should also obtain a medical report from your current treating doctor. This report should describe your current condition, the prognosis, and any ongoing treatment needs. This report is not an expert report for the purposes of litigation, but it serves as evidence of your continuing symptoms and the impact on your daily life.

The treating doctor’s report should include:

• A description of your current symptoms
• The results of any recent investigations
• The doctor’s opinion on your ability to work
• The doctor’s opinion on your need for future treatment

The Court’s Directions and the Timeline

Once you file your claim, the Court will issue case management directions. These directions set a strict timetable for the exchange of documents and expert reports.

The Pre-Action Protocol

The court procedure encourages parties to exchange documents before filing a claim. The Practice Direction 5.2 on Personal Injuries Actions requires the claimant to send a letter of claim to the defendant at least three months before issuing the writ. The letter must attach copies of all medical records and the expert report.

The defendant must respond within three months with a letter of response, which either admits or denies liability. If the defendant admits liability, the case proceeds on quantum only. If the defendant denies liability, the case proceeds on both liability and quantum.

The Exchange of Expert Reports

The Court will order simultaneous exchange of expert reports. This means both parties file their reports on the same day. No party sees the other side’s report before exchange. The reports must be filed at least 28 days before the case management conference.

After exchange, the experts may be directed to meet and prepare a joint statement identifying areas of agreement and disagreement. The Court may also order a single joint expert if the issues are straightforward and the cost of two experts is disproportionate.

The Deadline for Filing the Trial Bundle

The claimant must file the trial bundle at least 14 days before the trial date. The trial bundle must contain:

• The statement of claim and defence
• All medical records
• All expert reports
• All factual witness statements
• All photographs and visual evidence
• All financial records
• Any correspondence between the parties

The trial bundle must be paginated and indexed. Failure to file the trial bundle on time may result in the trial being vacated and costs being awarded against the claimant.

Actionable Takeaways

1. Request your full medical records from every healthcare provider immediately — the HA’s response time can exceed 12 weeks, and the court will not excuse a late filing caused by a delay you could have anticipated.
2. Engage an independent expert in the correct specialty before you issue the writ — the court requires the expert report to be filed within the pre-action protocol timeline, and a last-minute expert will not meet the standard of independence.
3. Keep every receipt, pay slip, and medical bill from the date of the alleged negligence — the Court of First Instance will not award special damages without documentary proof, and oral evidence alone is insufficient.
4. Prepare a detailed chronology and factual witness statement in your own words — do not include medical opinions, as the court will strike out any opinion evidence in a factual statement.
5. Comply strictly with the court’s case management directions — missing a deadline for exchange of expert reports or filing the trial bundle can result in your claim being struck out or costs being awarded against you.

This does not constitute legal advice. Consult a solicitor for your specific case.