How to deal with Medico-Legal Cases In Hospitals And Clinics: A Review

A medico-legal case is where a person is injured or harmed in any way and needs medical attention for it. Injury cases suggest some criminal offence.

Sometimes the medico-legal cases are directly brought to a hospital or clinic and then informed to the Police but sometimes some cases are brought by the Police requiring the medical expert opinion. Medico-legal cases are an integral part of medical practice that is frequently encountered by medical practitioners.

A medico-legal case applies to any case of injury or medical condition in which law enforcement agencies seek to investigate and come responsibility regarding the said injury or medical condition. It is a medical case with legal implications for the attending doctor where he after eliciting the history and examining the patient, feels that some investigation is essential.

An attending doctor in a clinic or hospital is supposed to furnish information regarding the offenses that come up to his knowledge under section 39 CrPC wherein he is duty-bound to inform the police about the offense that has come up to his notice or else he shall be liable to be punished under section 177 (giving false information) and section 201 (causing disappearance of evidence) of the Indian Penal Code.

Therefore, a medical practitioner is supposed to inform the police about the offenses which come to his knowledge while working in the hospital or clinic. He is duty-bound to examine, investigate, treat and keep a record of such cases for legal purposes.

In this article, we read about registering medico-legal cases and how a medical practitioner should deal with them.

DEFINITION

Medico-legal cases are the cases where the doctor feels the requirement of an investigation by law-enforcing agencies, essentially to fix the responsibility regarding the cause of injury.

In simple words, it can be said that it is a medical case with legal implications or a legal case requiring medical expertise.

TYPES OF MEDICOLEGAL CASES

The following types of cases are considered medico-legal cases and a medical practitioner is duty-bound to inform the police and maintain a medico-legal record regarding such cases. The list is not exhaustive and different kinds of cases can be added as medico legal cases if the attending doctor feels the need of intervention of law.

1. Cases of injury and burns, the circumstances which suggest a commission of an offence by somebody.

2. All kinds of vehicular, and industrial accidents or unnatural accidents especially when there is a likelihood of patient death.

3. Electrocution

4. Death due to snake/animal bite

5. Suspected or evidential criminal abortions

6. Unnatural unconsciousness

7. Suspected unnatural poisoning or intoxication

8. Cases referred by the court for age estimation

9. Cases brought dead with improper history creating suspicion of an offence.

10. Suicidal cases

11. Drowning

12. Unnatural death/injury in women including dowry deaths of a woman patient within 7 years of marriage.

13. Rape cases

14. Sexual offenses

15. Unclaimed newly born

16. Medical negligence cases

17. Coma without a certain cause

18. Starvation including "hunger strike"

19. Child abuse

20. Person in judicial custody or police custody

21. Drug abuse/overdose

22. Death within 24 hours of hospitalization without the establishment of diagnosis

23. Any other case not falling under the above categories but has legal implications and the medical practitioner deems it fit to inform the Police.

DUTIES OF MEDICAL PRACTITIONERS IN MEDICOLEGAL CASES

A medical practitioner working in a clinic or hospital is duty-bound to some duties which he is expected to follow when a medico-legal case comes up to him.

Duties a medical practitioner in a hospital must follow in a medico legal case-

1. Providing treatment to the patient in emergency situations

2. Informing the Police about the suspicious case

3. To decide whether or not to register a case as a medico-legal case

4. Consent of the family of patients is not required

Duties a medical practitioner in a clinic must follow in a medico legal case-

1. Providing first-aid treatment to the patient in the emergency

2. Inform the police about the emergency case

3. Take a record of the case for legal proceedings

4. Refer the patient to a hospital for proper medical care and treatment.

RECEIVING A MEDICOLEGAL CASE

A medical practitioner can receive a medico-legal case in any of the following four situations-

1. A case is brought by the police for examination and reporting, or by the order of the court for medical examination.

2. The patient in question had already been attended by a doctor and a medico-legal case has already been registered in the previous clinic/hospital, and the patient is now referred for expert management and care.

3. When a patient himself expresses his intention to register a medico-legal case against the alleged accused.

4. After the medical examination and noting down the history of the patient, the attending doctor feels that police intervention is required and a medico-legal case should be registered when a medico legal case is received.

REGISTRATION OF A CASE AS A MEDICOLEGAL CASE

The sole responsibility to label a case as a medico legal case (MLC) rests upon the attending medical practitioner. While attending to a patient in an emergency he should understand the priority to save the life of the patient and he should do everything possible to resuscitate the patient and ensure that he is out of danger.

A medico-legal case should be registered as soon as a doctor suspects foul play or feels it necessary to inform the police upon arrival, at any time after admission, there should be no unnecessary delay in registering an MLC, and can be registered as an MLC even if it is brought several days after the incident is suspected.

The medical practitioner must ensure the following points before registering a case as medicolegal –

1. Case not registered as a medico legal case (MLC) by any other hospital

2. If the family of the patient request to register a medicolegal case it must be entertained and the nearest police station should be informed.

3. If the case is already registered as a medicolegal case, no new registration shall take place to avoid duplication but only the MLC No. should be kept as a record. A separate medico-legal register should be maintained and all the details should be mentioned in duplicate/triplicate.

4. If a medicolegal case is brought by the police, the opinion should be given as per the existing medical condition at the time of medical examination.

5. If MLC has not been recorded by the first attending doctor in an emergency, it can be recorded as MLC by the treating doctor if he suspects any foul play or the need to inform the police.

6. Emergency medical care takes precedence over formalities especially when the condition of the patient is serious. As per the judgment by the Supreme Court in Parmanand Katara vs. Union Of India & ors 1989 (emergency medical care, a must).

7. All the columns in the medicolegal sheet and appropriate forms must be filled for all MLCs.

8. Informed consent should be taken by the patient unless brought by the police for medical examination or referred by a court of law. Consent is to be taken y the legal guardian if a patient is below the age of 12 years for medical examination.

STEPS TO BE FOLLOWED IN A MEDICOLEGAL CASE

There are a number of steps that must be followed by medical practitioners in a clinic or hospital when a medicolegal case has been received. The following are the steps followed in a medico legal case:-

1. If the opinion of two experts differs, the emergency doctor should adopt the opinion which considers correct citing reasons. However, both opinions of the experts should be sent to the court along with the report.

2. If any investigating officer gives requisition for any clarification regarding certain points mentioned in the report given, answers should be given in writing.

3. Whenever an investigating officer or the court demands an original document of an MLC, it should be given and acknowledgment of receipt should be obtained.

4. If a case of attempted criminal abortion is received for treatment, the doctor should ask the patient to make a statement herself.in case the patient dies, the police should be informed and be asked for a postmortem.

5. A private practitioner is legally bound to inform the police of homicidal poisoning as per section 39 CrPC. (public is duty-bound to inform the police) In government institutions, all cases of poisoning, irrespective of their manner i.e., accidental/suicidal/homicidal should be reported to the police.

6. If a medical practitioner fails to report the case of poisoning, he can be penalized under section 201 (causing disappearance of evidence or giving false information) and 202 (concealment of information of an offense) of IPC.

MEDICO-LEGAL CASE REPORT

All the Medico-Legal Cases are to be registered by the hospital or clinic. There are a number of details that are to be recorded in a medico-legal case report. The following is a comprehensive list of the kinds of details that must be recorded while making a medico-legal case report.

1. Age, sex, father's name, complete address, date and time of reporting, time of the incident, brought by whom, and type of medico legal case (MLC) should be entered in the register.

2. Case is examined and the case sheet is to be written by the duty casualty medical officer.

3. The Accident Register (AR) has two copies and Police Information (PI)has three written copies.

4. Reports must be in duplicate on proper Pro-forma giving all necessary details.

5. Avoid abbreviations, and overwriting.

6. Corrections to be made with date and time.

7. Reports must be submitted to authorities promptly. The original PI should be dispatched within 24 hours to the Police Station of the jurisdiction and be signed by the receiving police officer.

8. Medico-legal documents should be preserved under safe custody for 10 years.

9. Identification marks and finger impressions

10. All MLC is to be informed to the police for taking legal advice.

PREPARATION OF MEDICOLEGAL CASE RECORD

While preparing a medico-legal case record a medical practitioner should necessarily include all the important details of the said medico-legal case in the following manner -

1. A medico-legal report (MLR) comprises three parts namely-

i. Pre-amble- includes the date, time, and place of examination, name of the patient/ police official accompanying, FIR no.-, informed consent of the person being examined, two marks of identification

ii. Body (findings/observations) - includes a complete description of the injuries/any other findings present, any investigations/referrals, asked for.

iii. Post-amble (opinion) - includes the

a) nature of the injury – whether simple or grievous

b) Weapon/force used – whether blunt or sharp

c) Duration of injuries – based on the characteristics of the external injuries

All the medico-legal case reports are to be signed by the attending physician in capital letters with full name.

MEDICOLEGAL CASE REGISTER

The medico-legal case register is a register that has all the details of every medico-legal case that arrived at the said hospital or clinic.

The following are the points to remember as to how to maintain a medico-legal case register in a hospital or clinic -

1. The medicolegal reports must be properly numbered, and a certificate regarding the number of forms in the said register is recorded on the first page of the register.

2. Proper custody while in use in casualty, so that it is not tampered with at any stage.

3. All the medicolegal records shall be in the custody of the Chief Medical Officer on duty.

4. The medicolegal records with respect to the pending cases shall be kept under lock and key.

5. The record is to be handed over to the next Chief Medical Officer on duty.

6. The records should be kept systematically so that the retrieval of the same is easy and effortless.

7. The medicolegal register shall be returned back to the Medical Record Department after ensuring that all the reports are complete in all respect.

EXAMINATION OF MEDICO-LEGAL CASE PATIENT

When a medico-legal case has been received in a hospital or clinic, a medical practitioner must ensure that a number of criteria are required to be fulfilled while examining a patient in a medico-legal case. The following essentials are to be taken care of by the attending doctor while examining a patient in a medico-legal case -

1. CONSENT

• Under medical ethics, all cases should be examined after obtaining consent. It should be taken in writing.

• Consent is to be taken before starting the procedure and clearly explaining to the patient/relative what exactly to be done.

• If the patient is minor, consent is to be taken from the guardian.

• If an unconscious patient is brought by police from the road and an operation is essential to save a life, 2 or 3 doctors should give consent by signing the consent form.

• Under section 53(1) of CrPC, a person can be examined at the request of police by use of force without consent.

• Consent is not required from the relative for conducting medicolegal postmortems.

2. Whenever examining a female patient, a lady doctor should be appointed or if not possible as per section 53(2) of CrPC, a female attendant or nurse should be present. the hon'ble Punjab and Haryana High Court ruled that only a lady doctor can examine a woman who is an alleged victim of a sexual offense.

3. Examination can be taken place at the request of the police personnel for the purpose of evidence as per section 54 and section 174 of CrPC.

4. A doctor cannot refuse to examine a medico-legal case on the basis of being a private practitioner.

5. No delay in the examination of a medico-legal case.

6. If death is inevitable in a medico-legal case, the dying declaration should be recorded as per section 32(1) of the Indian Evidence Act 1872.

TREATMENT IN MEDICOLEGAL CASES

There are certain things that a medical practitioner should keep in mind while attending and providing treatment to a patient in a medico-legal case. The following are the steps to be followed before beginning the treatment of a medico-legal case patient -

1. Patient to be given treatment without waiting for the medicolegal formalities of reporting.

2. Treatment is to be started after examination and recording of findings.

3. First aid is to be given immediately without waiting for the completion of the MLC sheet.

4. If specialist consultation is required, the patient, is to be referred to the concerned specialist for further treatment.

5. All cases requiring constant observation and treatment to be admitted into the hospital.

TRANSFER OF MEDICOLEGAL CASES

Whenever a patient is serious and the treating medical practitioner feels that he should be referred to a higher center for proper care and management of the patient, he is transferred to the higher center after providing first aid in an emergency.

While transferring a patient from one hospital/clinic to another hospital, medical practitioners should follow certain steps-

1. Written order by the physician (referral slip)

2. Inform the patient and the family.

3. The police must be intimated in a medicolegal case.

4. Patients being referred to the higher center should be informed about the transfer.

5. Complete case summary should be provided.

6. Arrangement of transport for transfer.

7. Transport should have life-saving equipment while the transfer of the patient.

8. Give the medical records of the patient to the transfer personnel.

9. Complete medical records with the transfer summary.

ADMISSION AND DISCHARGE OF A MEDICOLEGAL CASE

There are some formalities that are taken care of when a medico-legal case is admitted or discharged.

1. Whenever a medicolegal case is admitted or discharged or referred to some higher center, the same should be intimated to the nearest police station.

2. While referring or discharging the patient, a discharge card/referral letter should be provided with a complete summary of admission, the treatment given and the instructions to be followed after the discharge.

3. Failure of which shall make the hospital liable for negligence and deficiency of service.

ABSCONDING/DEATH OF A MEDICOLEGAL CASE PATIENT

When a patient in a medicolegal case is absconded or has expired, the following steps should be taken care of -

1. Inform the police immediately

2. Send the body to the mortuary for preservation, till the legal formalities are completed.

3. Request a medico-legal postmortem examination, providing a the copy of death summary.

4. Do not issue the death certificate before post-mortemt mortem even if the patient was admitted.

5. The dead body should only be handed over to the police and not the relatives.

FINAL OPINION IN A MEDICOLEGAL CASE

A medical practitioner must follow certain rules while giving the final opinion in a medico-legal case patient. The following are certain rules -

1. Final opinion is to be given on the original medico-legal case (MLC) sheet by the same doctor preparing the record depending upon the investigation findings.

2. Final opinion is to be given by the hospital where the MLC has been made after obtaining the case summary from the referred hospital.

3. After the death or discharge of the patient, the MLC record is to be sent to the Medical Record Department for preservation.

4. The doctor needs to give a witness in court as an expert witness if summoned by the court.

5. In the court, the doctor shall be able to produce the case record or final opinion in front of the magistrate if asked for.

PROCEDURE TO RECORD DYING DECLARATION IN A MEDICOLEGAL CASE

If death is inevitable in a medico-legal case, the dying declaration should be recorded as per section 32(1) of the Indian Evidence Act,1872. The treating doctor shall inform the police to arrange for recording the evidence in front of the magistrate.

In all the cases where it is not possible to contact a magistrate, the dying declaration must be recorded by the doctor of the unit concerned in the presence of another gazetted officer or two responsible persons, either two fellow doctors or two persons from qualified nursing staff.

The statement of the witness shall be recorded, preferably in the vernacular of the patient in which he/she speaks. In all such cases, medical officers should obtain either signatures or thumb impressions of the patient.

The original dying declaration shall be sent to the SDM concerned in a sealed cover through the Medical Record Department.

Doctors should not attest to the dying declaration or act as a witness in the case when the police or magistrate records the dying declaration.

DIFFERENT MEDICOLEGAL ISSUES IN A MEDICO-LEGAL CASE

There are a number of medicolegal issues which are witnessed by a medical practitioner working in a hospital or a clinic while dealing with a medico-legal case. The following shows the kind of issues that come to a hospital or clinic and how those issues must be handled.

1. Mass Casualty/Disaster

Whenever a mass casualty is received in the hospital due to a natural/unnatural disaster the case shall be labeled as a medico-legal case but injury sheets are for critical patients.

A comprehensive list can be prepared and handed over to the police.

2. Brought Dead Cases

- All cases of unnatural deaths (accidents, burns, assault) as found out from the history, if available should be mentioned on the MLC report along with the name, age, address, relation, and other details of the person bringing the dead patient.

- All the brought dead medicolegal cases must be informed to the police.

- In the death certificate the cause of death should be mentioned as "not known brought dead".

- In no case it should be mentioned that cause of death should be determined after postmortem.

3. MINI MEDICO-LEGAL CASE

- Cases that need minor attention as far as treatment is concerned and need not be admitted are seen on the attended MLC register and a duplicate copy is taken on the register.

- Any treatment required is given on an OPD slip and the MLC number is mentioned on it.

4. Expert Opinion

- The cases referred from courts/jails/police/ specialist opinion regarding the health of the individual may be entertained in the casualty/emergency departments of the hospital through the officer in charge of the casualty.

5. Medico Legal Evidences

- In all medicolegal cases where the medicolegal evidence like the patient's clothes with blood stains, stab injury, cut marks, and bullet holes should be encircled, sealed, and be signed by the examining doctor and must be preserved.

- In case gastric lavage has been collected it should be collected in proper containers and the bottle should be sealed and signed.

- Any foreign body recovered from the patient such as bullets, etc must be sealed and preserved

- Furtherer at the onset of examination, any document, ornaments, or money must be taken in possession and preserved.

- All the evidence recovered must be mentioned in the MLC sheet of the patient and signed by the doctor examining the case and the police personnel taking possession of the articles.

- If the articles are essential for the police investigation, must be handed over to the investigating officer.

6. Copy of MLC To Individuals Other Than Police

- A medico-legal report is a confidential report and is not a public document. The accused or suspected is not entitled to get a copy of the report during the investigation of the case.

- No Objection Certificate (NOC) from the police should be obtained before supplying a copy of the report to anybody.

- In some cases the police ask for a medicolegal report after the case has been discharged/ expired.

- The police can ask for any specific information, which may be supplied from the medicolegal record.

- If needed a fresh MLC can be recorded based on the present findings, after a re-examination of the patient on the new date.

CONCLUSION

Medico-legal cases should be dealt with properly in the existing guidelines of the hospital/clinics. Whenever a medicolegal case arises, the priority of a doctor should be the treatment and providing first-aid to the patient and then inform the nearest police station about the case and then the legal formalities should be completed. Proper documentation, timely information, a methodical and thorough examination including all relevant investigations and referrals, etc must be completed.

A medico-legal case itself is a self-explanatory and an attending doctor must ensure that all the legal formalities as well a proper due care and first-aid treatment is being provided to the patient.

All the medico-legal cases must be reported to a nearest police station and the police must be informed for the intervention of law.

References:

1. Sample Policy Medico-Legal Cases

https://www.dialremedy.com/blog/sample-policy-medico-legal-cases

2. Medico-Legal Case - An Overview

https://www.iilsindia.com/blogs/medico-legal-case-overview/

3. ESCI Medico-Legal Book

https://www.esic.nic.in/Publications/ESICMedicoLegalBook.pdf