Legal liabilities of forensic medicine practitioners: International perspectives with considerations from Saudi Arabia

Introduction and background

Forensic medicine represents the vital connection between the legal system and the medical fields, as this specialty is in constant communication with the involved legal authority to reach effective conclusions in medicolegal matters. ¹ In Saudi Arabia, the various forensic centers distributed across the country are overseen by the Ministry of Health. The role of forensic medicine is to achieve justice through the performance of crime scene investigations, postmortem examinations, clinical examinations in cases of physical and sexual assaults, and performing expert testimony in court following a formal request from the legal authorities. ¹ Having a recognized board certification and licensure from the Saudi Commission for Health Specialties (SCFHS) are the professional qualifications required to practice forensic medicine and present findings in court. ¹ Being qualified entitles them to scientific authority and permits the release of official reports to the court, thereby enabling them to serve as expert witnesses. However, by virtue of the nature of forensic medicine and its close link with the legal system, the likelihood of potential legal liability increases, making forensic medical examiners subject to subsequent malpractice allegations by the same legal system, even in the absence of a traditional therapeutic doctor-patient relationship. ²

Although forensic medicine is vastly different from other medical fields, it still adheres to the duty of care encompassing the same legal and ethical principles. ³ The duty of care refers to “the legal and ethical obligation of healthcare professionals to provide treatment that meets established standards, ensuring patient safety and well-being,” and this, even within the scope of forensic medicine, is still the most essential part of the traditional doctor-patient relationship and is the cornerstone behind any subsequent legal claims. ³ The forensic specialty is without any therapeutic aims; however, this does not necessarily protect the practitioner from accountability, as there is a special form of duty known as the “forensic duty of care.” ² This duty implies a professional and legal obligation to conduct all examinations and construct all expert judgments with the high level of ability, careful methodology, and full fairness expected of a specialist in the field. ⁴ This is understandable in clinical forensic medicine, where examinations of living subjects highly resemble the usual medical setting encountered by most other specialties. In these cases, the forensic examiner is expected to ensure that their examination will impose no harm (physical or mental) on the examinee, and to find and report any serious conditions that could endanger the examinee or the public. ⁵ Breaches of forensic duty of care are not limited to the clinical aspect but also extend to all domains of the forensic medicine environment, including post-mortem examinations. ⁵ The act of writing an expert opinion without conducting a thorough autopsy or failing to complete the task properly is regarded as malpractice. ⁶ Lack of documentation of procedures or findings, not keeping evidence at the scene of death, allowing burial before fully investigating the body, or using improper methods are all examples of a reckless practice that could leave the practitioner legally liable. ⁵

Ethical-legal violations are not less important, involving unauthorized disclosure of confidential information and improper consent procedures. ⁷ Failing to comply with the established elements of the forensic duty of care can result in legal liability and directly affect the credibility of the forensic practice. ⁸ In the context of clinical forensic medicine, the examinations involve living patients; thus, they are carried out for evidentiary purposes, and the acquisition of informed consent imposes a significant ethical obligation, in contrast to therapeutic medicine, where consent is obtained for the patient's benefit. ⁹ Therefore, fully following the ethical principles in addition to the human rights consideration is essential in the practice, as living patients could include witnesses, suspects, or victims, with each having different legal status and the ability to decline the examination after a thorough explanation of the goal, extent, and possible repercussions which involve the risk of using the findings against them in court. ⁷ As a result, inappropriate or uninformed consent may violate human rights or lead to battery accusations. ⁹ Thus, Forensic examiners need to be cautious not to enforce any pressure to gather data or evidence in a way that might be interpreted as demeaning or coercive. Furthermore, the highest standards of respect for human dignity must be an integral part of the process of examination, with the prohibition of torture and ill-treatment, with the Istanbul Protocol acting as a key safeguard against ethical violations and liability by offering an international standard for documenting such cases. ⁹

Legal liability may extend beyond the forensic medical examiner's acts to include the expert's opinion. ¹⁰ Thorough observation and evidence collection supported by the knowledge, training, and professional experience of the examiner, concludes the expert opinion, which is the final conclusive reasoning. However, a major challenge for forensic medical physicians is to objectify their opinions, as they can be influenced by a range of personal factors, including the quality of their qualifications, differences in personal backgrounds, personal views, and peer influence. ¹¹ As a result, the same case could have different opinions, and at times contradictory ones, creating a fundamental gap and serving as a basis for legal claims alleging that an opinion is erroneous or damaging. ¹⁰ The subjectivity of expert opinion is not restricted to the academic aspect of the practitioner but also includes the psychological burden of the specialty, as the nature of cases encountered by forensic professionals, such as violent deaths, child abuse, and sexual assault, affects judgment and diminishes attention to detail while simultaneously heightening the risk of errors. ¹² The resulting stress arising from the constant fear of legal consequences will diminish the objectivity of the practitioner and lead to a more protective and defensive approach. ¹³ This reality places the subjective experts’ opinion in addition to their forensic duties under the question: To what extent is a forensic medical examiner immune from liability for their professional opinions, and how do varying legal systems define and grant such protection?

In the past, the protection of physicians during court procedures was achieved through immunity for expert witnesses to certify reliable and honest testimony; however, it is now a challenging concept due to the current era having major vagueness surrounding the legal trends that highlight accountability in the realm of qualified immunity for preparatory work and absolute immunity for testimony.^10,14 In this paper, these international liability landscapes are examined, and Saudi Arabia's evolving framework is critically analyzed to identify weaknesses and suggest specific reforms that would bring its practice into compliance with international standards while protecting practitioners.

The US model

In the USA, medical examiners and coroners typically have quasi-judicial immunity when carrying out key judicial duties, such as providing testimony in court and issuing death certificates. ²⁴ Forensic physicians should be careful, as this protection has become limited, and recorded cases in which courts have established exceptions for administrative actions, bad-faith claims, and defamation are available. ²¹ Furthermore, because of the Daubert standard for the admissibility of expert testimony, which creates a front-end risk, liability exposure is not limited only to direct lawsuits. ¹⁹ And in addition to excluding evidence, a court ruling that an expert's methodology is untrustworthy may result in subsequent civil claims of professional incompetence. ¹⁹

Empirical research investigated the types and applications of different immunities and recorded the percentage of successful claims against medical practitioners, highlighting the case-specific nature of immunity and the rarity of successful litigation. ¹⁵ One groundbreaking study by Hanzlick, which collected claims regarding cause-and-manner-of-death rulings across the USA over approximately 50 years, found only sixteen cases, and twelve of these dealt with the manner of death. ¹⁵ Lower courts ruled in favor of the medical examiner in fifteen of the sixteen cases. However, as demonstrated by the fact that five of these favorable decisions were later overturned on appeal, immunity functions as a qualified defense rather than a general protection. ¹⁵ For example, a coroner accused of defamation for writing “insulin dose misadventure” on a death certificate was granted absolute privilege by an appellate court. ¹⁵ On the other hand, a different appeals court overturned a lower court's decision, concluding that a coroner had an obligation to look into the matter after listing coronary occlusion without conducting an autopsy and disregarding a previous incident. ²⁵ As a group, Hanzlick proved that, although accusations are rare and often settled in the examiner's favor, they still occur, and the results depend heavily on the circumstances. ¹⁵ Furthermore, it would be expected that the likelihood of litigation would probably be even lower in countries like Saudi Arabia, where the manner of death is not required in the medicolegal report. This structural difference should not be mistaken for granting complete immunity.

The European model

In numerous European countries, such as Germany and the UK, forensic medicine is incorporated into university departments or government-operated institutions. ²⁶ State responsibility or employer vicarious liability frequently covers liability claims, and professional disciplinary bodies may have jurisdiction over individual practitioners for violations of professional standards (the UK's General Medical Council). ²⁷ Therefore, lawsuits alleging malpractice are feasible, but they frequently go through administrative courts. To reduce individual risk through systemic quality control, the focus is on thorough internal review, standardized procedures, and accreditation. ²⁶

The Australian model

Professional insurance offered by businesses that recognize the complexity of the medico-legal sector supports forensic specialists’ duties. As a result, the insurance sector has become more focused on handling these specific risks. ²⁸ These insurance policies include various situations that are unique to forensic medicine and may lead to legal actions, either civil or criminal. Generally, these policies cover mistakes made during autopsies, errors in interpreting evidence, violations of the chain-of-custody procedures, and inaccuracies in forensic reports. ²⁹ Importantly, defamation related to professional services is also covered under Australian law. ²⁸ This is particularly important when issuing death certificates that are in dispute or when official reports challenged by the media are involved, or when cases involve suspects or families who are mourning. ³⁰ Standard insurance coverage includes public liability protection to shield professionals from risks that may occur on forensic facility premises, such as the presence of law enforcement during examinations or relatives identifying bodies. It also covers expenses related to coroner's inquests or professional standards reviews. ²⁸ Overall, this system aims to prevent financial concerns from influencing the objectivity of forensic assessments.

Landmark international cases

Since there are no reported cases of lawsuits against forensic medical examiners in Saudi Arabia, which is probably due to the “injury” dilemma and the high threshold for litigation discussed later, it is instructive to investigate how other jurisdictions have dealt with claims of forensic negligence and immunity, as the following international cases, which share several themes relevant to Saudi Arabia, demonstrate. ⁵ For example, in the UK, in the case of the General Medical Council in 2013 against Dr El-Baroudy, a forensic medical examiner who spent about a minute examining an arrested man who later died in his cell, the high court overturned the regulator findings as there was a “serious procedural irregularity” regarding the pleading of causation between clinical negligence and the legal causation of the harm. ³¹ Similar to this, the infamous case of Sally Clark and Dr Alan Williams in 2005 showed that although immunity may shield examiners from civil lawsuits, it does not protect them from professional disciplinary action. ³² This is because Dr Williams was removed from the home office's list of accredited pathologists for withholding important microbiology test results that could have cleared a woman who had been wrongfully convicted of murdering her infants. ³²

Different uses of immunity can be observed in the USA, such as when the Massachusetts Supreme Judicial Court upheld a medical examiner's office's broad quasi-judicial immunity in the case of Joseph LeBlanc, where his family unnecessarily exhumed his body due to an incorrect autopsy report. ³³ Other cases demonstrate the limits of such protection and their severe sequel, including the 2020 case of Jacobs. This involved a man who was convicted of murder and received a 17-year prison sentence. He then filed a lawsuit against the deputy medical examiner, alleging that professional negligence during the autopsy had contributed to his wrongful conviction. ³⁴ The California Court of Appeals upheld the dismissal of his claim based on statutory immunity, noting the strong protection afforded to essential judicial functions even when the alleged error results in severe sequelae. ³⁴ These examples show the importance of Saudi Arabia proactively developing a framework that safeguards genuine expert opinions while ensuring accountability through professional oversight, standardized procedures, and tailored insurance. Because experiences from other countries show that the absence of lawsuits should never be mistaken for a lack of potential liability.

The “absolute immunity” erosion

Unchecked testimonial protection has a human cost, as demonstrated by scandals involving faulty hair microscopy, discredited bite-mark analysis, and falsified or improperly handled lab reports. ⁸ Following high-profile forensic scandals, the longstanding principle of absolute witness immunity is being challenged amid calls to reform the justice system. ⁸ Due to these issues, scholars argue that immunity should serve as a safeguard within the legal system, but not permit carelessness in laboratory testing or evidence handling unrelated to testimony. ¹⁴ The shield of immunity has become increasingly perforated and is no longer a blanket of protection, requiring increased vigilance from those it once completely protected and resulting in precarious conditions in which professionals need to be as aware of their legal risk as they are of their scientific analysis. ²¹

The law of evidence

When the 2021 Law of Evidence (Royal Decree No. M/93) was issued, the legal framework governing expert testimony in Saudi Arabia underwent a significant change. ³⁶ This law formalized the expert's role as a tool of legal proof. A number of the Law's articles address the status and handling of expert opinions, providing a framework that gives the experts’ report significant weight while outlining particular judicial obligations.

Article 130: The court shall indicate in the event that it does not accept some of the report the points that were not accepted, stating the reasons for that. In all cases, the court may not address what was not accepted if the decision on it requires a technical opinion. It may return the task to the expert or assign another expert in accordance with the system's provisions. If the court does not accept the expert's report in whole or in part due to the expert's negligence or error, it must explain the reason for the negligence. ³⁶

Article 134: It is not permissible to challenge what the expert proves, or what he has done or received from the interested parties, within the limits of what he is permitted to prove, except by claiming forgery. ³⁶

A court must specify the precise points it denies and justify if it rejects an expert's report in whole or in part, according to Article 130. The court must also explain its decision if the experts’ error or negligence led to the rejection. The article's noteworthy ban on the court rendering decisions on matters requiring technical expertise without first remanding the matter to the original expert or appointing a replacement serves as further evidence of the value of expert input in technical disputes. By restricting challenges to what the expert has certified or received from interested parties, including contestation on the grounds of forgery, Article 134 further strengthens the report's evidentiary status.

Expert witnesses are granted a type of de facto qualified immunity under these conditions by limiting collateral attacks on experts’ factual certifications and requiring well-reasoned judicial justifications for rejection. ³⁶ This, in turn, leads to the law preventing experts’ judgments from being arbitrarily overturned and promoting independent and steadfast professional opinions. However, this legal protection also carries a risk. It simultaneously increases the perceived gravity of any alleged mistake by increasing the report's evidentiary value, which could result in heightened scrutiny of the expert if claims of professional negligence are made. Furthermore, unique situations, such as incomplete autopsy procedures or contaminated evidence, are governed by general principles of professional malpractice rather than by a specific guideline. Because of the silence in the above articles, there may be a regulatory gap in which the exact guidelines governing fundamental forensic tasks are not fully defined, and responsibility for laboratory-related errors must be handled under general negligence law rather than by regulations specifically formulated to address the requirements of the medicolegal framework. ⁵

The “injury” dilemma

In Saudi Arabia, the Law of Practicing Healthcare Professions and its executive regulations govern the processing of forensic malpractice claims. ³⁷ To start a formal court case, there must be evidence of a patient's injury. ³⁷ This presents a special problem for forensic medicine since it is possible for physical or psychological harm resulting from an examination in the context of clinical forensic medicine practice to be deemed illegal. However, in the context of expert and postmortem opinions, demonstrating injury from an erroneous opinion is extremely complex, as the injury is frequently a third party's alleged miscarriage of justice, such as false accusation or exoneration, which is difficult to measure in medical terms. ⁵ This high bar, as our research demonstrates, likely contributes to the lack of documented lawsuits in the Kingdom against medical examiners’ opinions, fostering a false sense of security rather than formal immunity.

Systemic vulnerabilities, unstandardized practice, and insurance deficit

By analyzing the present framework, three major weaknesses can be appreciated. ¹ The absence of a national standard of care across regions leads to inconsistent clinical privileges and increases the legal liability of forensic practitioners, who are then judged by unclear and inconsistent standards of care. Additionally, no Saudi insurance plan covers forensic medical liabilities such as defamation, evidentiary errors, or wrongful death certifications, despite their importance for licensure. ²⁸ This is another major concern, as legally driven, non-therapeutic risks remain excluded from general malpractice policies. To conclude, forensic practitioners are unprepared for the vital aspect of their work encompassed by legal risks, due to the limited information and training provided by the SCFHS, despite the rigorous and effective instruction in scientific materials. ¹ This results in a significant gap in legal literacy training.

Recommendations for a protective reform plan

Given the previously discussed weaknesses, targeted solutions are proposed to enhance the Saudi Arabian system, including improvements to functions and regulations. Initially, we recommend forming a dedicated medical committee representing the national forensic medicine authority, with members selected in accordance with transparent policies and procedures to ensure the appointment of highly qualified and experienced professionals. This committee's responsibilities will include standardizing national protocols by developing and regularly updating procedural guidelines for forensic practitioners across Saudi Arabia's forensic centers. Involving these committees will help resolve complex and sensitive cases more efficiently, providing thorough and dependable responses to courts and public prosecution inquiries. Ultimately, this will foster better decision-making and strengthen public trust in the judicial process.

One of the most important aspects of the reform plan is making use of the current academic structures. This is accomplished by formally authorizing the Saudi Board of Forensic Medicine's Scientific Committee to advise courts on standards of care and to provide the required legal liability training. The SCFHS Scientific Committee may be named as an expert consultative body in court cases involving claims of professional liability or forensic malpractice. Judges may be able to form knowledgeable opinions about the appropriateness and rationality of forensic procedures as a result. In addition to providing broad legal interpretation, which forms the basis of legal decisions, this advisory role would help validate professional standards.

The postgraduate program offered by the Saudi Board of Forensic Medicine equips professionals with broad scientific and technical education. However, it fails to address a key aspect of professional effectiveness: the capacity to comprehend, predict, and manage legal responsibilities. To address this gap, there is a need for a more holistic curriculum that fosters collaboration between medical and law institutions. ³⁸ Instead of being provided as a stand-alone lecture, a mandatory module on legal liability for the Saudi Board of Forensic Medicine should be developed by a joint committee comprising the SCFHS and pertinent university law faculties. The module should also include simulation-based training in which forensic trainees practice testifying in a mock trial setting, with law students acting as both counsel and a judge, to help them gain confidence and understand the legal system. ³⁸ The 2021 Law of Evidence should be covered in this module, along with the legal aspects of negligence and its impacts for expert witnesses. Along with the skills required to create reports that are both legally and scientifically accurate, it should also address the ethical and legal issues surrounding informed consent in forensic practice. It should also cover procedures related to insurance policies and claims, as well as courtroom testimony techniques, such as managing cross-examination. ³⁸ To maintain legal knowledge as a continuous skill rather than a one-time accomplishment, this legal liability module and continuing refresher training should be completed to renew certification through the SCFHS. Instead of merely operating as scientists who are not involved in legal matters, forensic professionals will gain the legal awareness necessary to actively engage with the legal system, identify potential challenges, and uphold the highest standards of defensible practice by concentrating on legal education. ³⁸

The recently passed law of evidence creates a formal framework for controlling the use of experts in court. ³⁶ It establishes an authorized expertise affairs unit responsible for developing regulatory guidelines and overseeing the investigation and resolution of expert work disputes. The law also requires experts to maintain a current professional insurance policy for this unit, outlining the policy's parameters and the procedures for implementing it to improve professional protection and accountability. ³⁶ The Ministry of Health in Saudi Arabia mandates that forensic medical examiners have insurance. Still, no insurance provider has yet created policies specifically for the forensic medical industry, unlike the Australian model. ²⁸ As a result, a public-private initiative should be used to create a customized insurance that covers risks unique to forensic work, including expert opinion errors, evidence spoliation, confidentiality breaches, and defamation resulting from official reports. However, it will take time for this new system to account for every possible legal issue that might arise in forensic medicine practice. The authors offer a succinct action plan that includes creating a short-term, uniform insurance policy in coordination with the Ministry of Health and current insurance providers, and offering financial incentives to reduce upfront costs and guarantee instant insurance coverage for forensic medical examiners in Saudi Arabia. To test and improve the policy, a pilot program involving a selected sample of examiners should be implemented. The creation and execution of policies should be supervised concurrently by a multidisciplinary task force that includes representatives from the Ministry of Health, insurance companies, and forensic medical examiners. To help the new insurance framework be adopted and used effectively, targeted awareness and training campaigns are also advised.

As a result of the legal consequences of negligence or misconduct, forensic medical examiners are more thorough, methodical, and careful in their investigations and conclusions. However, they may adopt defence procedures that rely heavily on established protocols, procedures, and peer-review methods to decrease potential legal risks. This may make forensic practitioners less inclined to express strong views in high-profile, complex cases where litigation is likely. Reforms must promote a culture of sound practice that goes beyond defensive medicine by training practitioners to keep meticulous records, seek peer advice when dealing with complex or obscure cases, explicitly outline the limits of their expertise in official reports, and ensure that all conclusions are based on validated evidence-based procedures. ⁵

Establishment of a permanent national forensic medicine committee, empowerment of academic institutions, developing a personalized insurance plan, and promotion of a culture of defensible practice are all key elements of a comprehensive and secure reform strategy for Saudi Arabia's forensic medicine. It is imperative to invest in the foundations of justice, thus going beyond administrative adjustment. This integrated strategy will strengthen the chain of custody from the autopsy table to the courtroom by setting common standards, improving expertise, ensuring accountability, and protecting practitioners. The result will be a forensic medical system that is characterized by unwavering scientific rigor, open professional accountability, and strong legal resilience. Because each expert opinion will be seen as a foundation of truth, the public's trust in court proceedings will grow, making the legal system fairer and more reliable for all.

Conclusion

Practitioners of forensic medicine worldwide bear heavy responsibilities and associated legal risks. Recent legislative developments in Saudi Arabia provide a solid basis for expert testimony, but also highlight structural weaknesses in standardized management and protection of professionals. It is important to understand that the lack of lawsuits does not imply immunity. Saudi Arabia can build a sustainable framework by proactively developing a reform plan that includes improved legal education, standardized privileges, institutionalized oversight, and a tailored insurance plan. This framework will hold accountability, shield skilled practitioners from needless lawsuits, and, most importantly, improve the quality and reliability of forensic science used in the country's legal system. The world is moving toward accountable expertise, and Saudi Arabia has the opportunity to set an example for a well-rounded, advanced system that guarantees justice for its forensic professionals as well as justice for everyone else.