LAW, MEDICINE, MEDICAL JURISPRUDENCE & RISK MANAGEMENT

LAW, MEDICINE, MEDICAL JURISPRUDENCE & RISK MANAGEMENT

1. 2. LAW AND MEDICINE 1.Medical Jurisprudence : It deals with legal aspects of medical practice of doctors. 2.Forensic Medicine : It deals with medical aspects of law and medico legal case management.
2. 3. LAWS RELATING TO MLC Sect ion 44 of IPC: Definition of Injury Any harm whatever illegally caused to any person in body, mind, reputation or property. Sect ion 319 IPC: Hurt Hurt means bodily pain, disease or infirmity caused to any person. 321 IPC: Defines “Voluntarily Causing Hurt” 322 IPC: Defines “Voluntarily Causing Grievous Hurt” 323 IPC: Describes Punishment for Voluntarily Causing Hurt . Shall be imprisonment which may extend for one year with or without fine which may be Rs 1000/ - . 324 IPC: Describes Punishment for Voluntarily Causing Hurt by dangerous weapon shall be imprisonment for up to 3 years with or without fine. 325 IPC: Describes Punishment for Voluntarily Causing Grievous Hurt . Shall be imprisonment which may extend for 7 year with or without fine.
3. 4. Sect ion 299 IPC: Defines Culpable Homicide Whoever causing death by doing an act with the intention of causing death, or with the intent ion of causing such bodily injury that likely to cause death or with the knowledge that he is likely by such act to cause death, commits the offence of culpable homicide. Murder: Sect ion 300 IPC Culpable homicide is murder: • If the act by which the death is caused is done with the intent ion of causing death or , • If it is done with the intent on of causing such bodily injury as the of fender knows to be likely to cause death or , • If it is done with the intention of causing such bodily injury which is sufficient in the ordinary course of nature to cause death or , • If the person committing the act knows that it is so imminently dangerous, that it must in all probability cause death or such bodily injury as is likely to cause death and commits such act without any excuse.
4. 5. Culpable homicide is not murder: If the offender whilst deprived of the power of self control by grave and sudden provocation causes the death of the person who gave the provocation, or causes the death of other person by mistake or accident
5. 6. DOCTOR AND MLC  Every doctor under law bound by a contract to serve its patient and can not refuse treatment.  Every doctor has to fulfill certain legal requirements in service by compulsion or voluntarily as defined under law.  Medico legal case (MLC) examination and reporting is one of the legal responsibility of all doctors working in a hospital.  
6. 7. DOCTOR AND MLC  Apart from his routine and usual “clinical” cases, a doctor will come across certain ‘Medico-legal’ problems at one time or the other during the practice of his profession.  The general belief that only the doctors working in the government hospitals would be involved with such cases has now been dispelled by the recent decisions of the Hon’ble courts, particularly the Supreme Court.  A good working knowledge of the law in this regard, coupled with a thorough understanding of the correct method of dealing with such cases helps one to build confidence over riding the fear of MLC  
7. 8. FEAR OF MLC  Every medical practitioner at any time during the practice of his profession, whether in a government setting or a private one, will encounter/ would have encountered certain cases, which at that given time or subsequently, would be labeled as “medico-legal”.  Many a practitioners are usually apprehensive in dealing with these cases as they feel, an MLC (Medico-legal Case)means  ‘ entangling’ in police cases  ‘ indefinite hours’ to be spent in the court,  facing ‘unrelenting’ defense counsels.  Because of this “fear-factor”, they either try to avoid the cases or try to manipulate them as non MLC  The best way to deal with these cases is to understand them  clearly, analyze them thoroughly, and then act accordingly.  
8. 9. MEDICO-LEGAL CASE  It can be defined as a case of injury or ailment, etc., in which investigations by the law-enforcing agencies are essential to fix the responsibility regarding the causation of the said injury or ailment.  In simple language it is a medical case with legal implications for the attending doctor where the attending doctor, after eliciting history and examining the patient, thinks that some investigation by law enforcement agencies is essential .  Or a legal case requiring medical expertise when brought by the police for examination.  
9. 10. RECEIVING A MLC  A doctor can receive a medico-legal case in any of the four situations:–  1. A case is brought by the police for examination and reporting, or order of the court for medical examination  2. The person in question was already attended to by a doctor and a medico-legal case was registered in the previous hospital, and the person is now referred for expert management/ advice.  3. When patient himself expressing his intention to register a case against the alleged accused.  4. After eliciting history and examining the patient, the attending doctor feels that some investigation by law enforcement agencies is essential to establish and fix responsibility for the case in accordance with the law of the land.  In the last situation it is the attending doctor has to utilize his medical knowledge and judgment to decide whether the case should be treated as MLC or not, specially when the history is not completely revealed, either by the patient or his relatives/ friends, due to some motive.  
10. 11. PROCEDURE OF REGISTERING A MLC  The responsibility to label any case as an MLC rests solely with the attending medical practitioner.  In the casualty, while attending to an emergency, the doctor should understand that his first priority is to save the life of the patient.  He should do everything possible to resuscitate the patient and ensure that he is out of danger.  All legal formalities to be suspended till the patient is resuscitated.  This has been clearly ordered by the Hon’ble Supreme Court of India  
11. 12.  In the judgment of case Parmananda Katara Vs Union of India:  “ Every doctor is bound to provide medical aid to the victims irrespective of the cause of injury; he cannot take any excuse of allowing law to take its course”.   The next important duty is to identify whether the said case falls under the category of an MLC or not, after carefully analyzing the injuries on the person of the patient, the history given, and the other circumstances of the case.  If it does fall in this category, then he must register the case as an MLC and/ or intimate the same to the nearest police station, either by telephone or in writing.  
12. 13.  An acknowledgement of receipt of such a message should be taken for future reference.  A medico-legal register should be maintained in the casualty of every hospital and details of all medico-legal cases should be entered in this register in duplicate/ triplicate.  This would be of immense help for future reference, when the patient through the court/ the police, requests for a copy of the medico legal report.  No fresh MLC to be made if MLC has already been made in other hospital to avoid duplication.  
13. 14. TIME LIMIT FOR REGISTERING A MLC  A medico-legal case should be registered as soon as a doctor suspects foul play or feels it necessary to inform the police at arrival,  At any time after admission.  There should not be any unnecessary delay in doing so.  A case may be registered as an MLC even if it is brought several days after the incident if suspected.  
14. 15. WHOSE DECISION  The casualty doctor (emergency physician ) attending the case has the independent authority to label the case as medico-legal or not.  Patients’ or their relatives’ request or any external pressure to label a case medico-legal, should not influence the doctor’s decision.  When the patient is admitted in the ward, indoor treating doctors can also make a case medico-legal if they think after obtaining additional information, that it should have been made MLC but it was not made at the time of admission.  
15. 16. MEDICO LEGAL CASE MANAGEMENT  The management of a MLC may be described in following heads  MLC Registration and reporting Case exam. & giving opinion Preparation of Record Identification Final opinion Investigation & treatment
16. 17. A.IDENTIFICATION OF MLC  Cases of Trauma/ Burns, the circumstances of which suggest commission of an offence by somebody.  Cases of Electrocution  Cases of Poisoning  Cases of All vehicular, factory or other unnatural accident/ calamities  Cases of sexual offences/Rape  Cases requiring age estimation  Cases of suspected or evident criminal abortion.  Unconscious patients where its cause is not natural or not clear.  Cases of hanging, strangulation, drowning and suffocation etc,.  Cases brought by police or sent by court for medical examination.  Cases brought dead with improper history creating suspicion of an offence.  Unnatural death of a lady within 7 years of marriage  All cases if alleged by the patient/ relatives of foul play  Any other case not falling under the above categories but has legal implications.  The following cases should be considered as medico-legal and as such the medical officer is “duty-bound” to intimate to the police
17. 18. DEFINITION OF INJURY AND HURT  Section - 44 of the Indian Penal Code (IPC) :  Injury : denotes any harm whatsoever illegally caused to any person in body, mind, reputation or property.  Section - 319 of the Indian Penal Code (IPC) :  Hurt : whosoever causes bodily pain, disease or infirmity to any person is said to cause hurt.  
18. 19. GRIEVOUS HURT (SECTION 320 OF IPC)  Emasculation.  Permanent privation of the sight of either eye.  Permanent privation of the sight of either ear.  Privation of any member or joint.  Destruction or permanent impairing of the powers of any member or joint.  Permanent disfiguration of the head or face  Fracture or dislocation of a bone or tooth  Any hurt which endangers life or which causes the sufferer to be during the space of twenty days in severe bodily pain or unable to follow his ordinary pursuits  
19. 20. B. REGISTRATION AND REPORTING  39 Cr.P.C ( Code of Criminal Procedure ) : The attending doctor is duty bound to inform the police about the Case  Section 176 IPC ( Indian Penal Code ) : Provides for prosecution of the doctor for the failure to inform  Police informed again when patient dies or is discharged from hospital  
20. 21. REPORTING OF MEDICO-LEGAL CASE  Reports must be prepared in duplicate on proper pro-forma giving all necessary details  Avoid abbreviations, over writings. Correction if any, should be initialed with date and time.  Reports must be submitted to the authorities promptly.  Medico-legal documents should be stored under safe custody for 10 years  Age, sex, father’s name, complete address, date and time of reporting, time of incident, brought by whom.  Identification marks and finger impressions  All MLC to be informed to the police for taking legal evidence  If the patient is dying, inform the magistrate to record ‘dying declaration’.  
21. 22. DYING DECLARATION ( Section 32 of The Indian Evidence Act)  A dying declaration or statement made by the person on the verge of death as to the cause of his death or as to any of the circumstances of the transaction which resulted in his death, such a statement, oral or in writing, made by the deceased to the witness is a relevant fact and is admissible in evidence.  Provided it has been made by the deceased while in a fit mental condition as certified by the attending doctor.  Doctor should intimate the police for calling the Magistrate to record the declaration.  If there is no time the attending doctor should record the dying declaration in presence of police.  
22. 23. C. EXAMINATION OF MLC PATIENT  Consent:  Under medical ethics all cases should be examined after obtaining a consent.  <ul> Consent to be taken for a particular purpose or procedure in writing.  </ul><ul> Consent to be taken before starting the procedure and after clearly explaining the patient/ relative what exactly to be done.  </ul><ul> If the patient is a minor or less than 18 yrs of age consent of the guardian be obtained for private part examination.  </ul><ul> Consent of relative required for unconscious patient requiring surgery  </ul><ul> If an unconscious patient brought by police from road and operation essential to save life 2 or 3 doctors to give consent by signing on consent form.  </ul><ul> A conscious adult has the right to refuse  </ul>
23. 24.  An informed consent includes information that:  the examination to be conducted would be a medico legal one and would culminate in the preparation of a medico-legal injury report,  all relevant investigations needed for the said purpose would be done,  the findings of the report may go against the patient if they do not tally with the history given. (the most important)  
24. 25.  Consent not required:  Medical Emergencies  Notifiable diseases  Immigrants  New admission to prisons  Court orders for examination & treatment  Under section 53 (1) of Cr.P.C., a person can be examined on request of the police by use of force  Members of Armed Forces on request of competent authority in writing.  <ul> Consent is not required from relative for conducting medico legal postmortems.  </ul>
25. 26.  Examination of MLC cases:  It is preferable that a lady doctor should examine a lady, or, wherever this is not possible, a female attendant (nurse, etc) should be present during the examination.   The Hon’ble High Court of Punjab and Haryana has now ruled that only a lady doctor can examine a woman who is an alleged victim of sexual offence.  If a case is referred from other hospital where medico legal case sheet has been prepared, the findings be attached to the same without making fresh MLC  If the date of incidence is delayed and patient brought late, the present findings are to be entered in MLC  
26. 27.  There should be detailed examination of patient, BP, pulse, colour, consciousness, respiration, alertness etc.  All injuries to be properly described, length, depth, breadth, margins lacerated or sharps, bleeding, dried.  Colour of the body, change in colour any part of the body to be clearly mentioned and total number of wounds, ante-mortem bruises.  Pupil reactions, conscious level, any fracture bone or fresh broken tooth.  Any injury to sensory organs like eyes, nose, ear etc.  Opinion to be given simple or grievous injury or impression of cause of death by examining doctor.  
27. 28. D.PREPARATION OF MLC RECORD An MLR comprises of three parts, namely: a) Pre-amble: includes the date, time and place of examination, name of the patient, his residential address, occupation; name of the person(s)/police official accompanying, DDR/FIR No., informed consent of the person being examined, two marks of identification, etc, wherever applicable. b) Body (Findings/Observations): includes a complete description of the injuries/any other findings present; any investigations/referrals, etc, asked for. c) Post-amble (Opinion): includes the Nature of the injury—whether simple or grievous. Weapon/Force used—whether blunt or sharp or fire-arms or burns, etc. Duration of the injuries—based on the characteristics of the external injuries. To be signed with full name of attending physician in capital letter
28. 29. D.PREPARATION OF MLC RECORD  They should be prepared in duplicate, preferably with a ball-point-pen, in a clear and legible hand.  Cutting/ overwriting, etc should be avoided as much as possible and all corrections should be properly initialed. Abbreviations of any sort should be avoided.  All the columns in MLC sheet should be filled in legible hand writing and in complete words without using shortcuts  Name and address of the person who has brought the patient  Full name, fathers name, address (complete), age, sex, time and date of accident, time and date of reporting in hospital  
29. 30.  All examination findings as detailed in examination  Investigations advised and finding to be entered  Treatment given at the site or on reporting  The opinion to be recorded in MLC sheet, if opinion cannot be given, under observation be given and signed by the doctor with name written in block letters.  Final opinion be given by same doctor making MLC in the original MLC sheet, after all investigations are completed.  
30. 31. E. DESCRIPTION OF INJURIES AND INVESTIGATION  1. Type of weapon used i.e. blunt or sharp if possible to mention  Nature of injury either simple or grievous giving size, shape, depth and margin of injury.  Probable cause of injury/ condition like suspected poisoning, traffic accident, burn, radiation etc.  The patient is admitted or discharged with advice be entered into the case sheet  The doctor examining the patient must complete the MLC sheet before leaving the hospital  All MLC X-rays be kept in department as evidence for court of law  Special samples taken to be entered into the MLC sheet.  If the patient is dead or died, handed over to police for post mortem and not to relatives.  A copy of MLC sheet be handed over to police for further investigation against his signature and belt number on the copy.  
31. 32.  II. Collection and preservation of blood/tissue samples :  If special investigation is needed like Vomits, vaginal swab DNA sample to be collected preserved, sealed, name of Pt and regd .no. written and signed by doctor to be handover to investigative officer in exchange of a receipt.  While handing over to the police official concerned, along with the medico-legal report a proper requisition letter detailing the tests to be conducted on such samples.  If the samples have been collected on the request of the police, the fact is to be mentioned in the report and no requisition is necessary.  
32. 33. F. TREATMENT OF MEDICO-LEGAL CASES  The patient should immediately be given treatment without waiting for the medico legal formalities of reporting.  Treatment to be started after examination and recording findings.  First Aid to be given immediately without waiting for completion of MLC sheet  If specialist consultation is required, patient to be referred to concern specialist for further treatment  All cases requiring constant observation and treatment to be admitted into the hospital.  
33. 34. G. TRANSFER OF MLC s  The transferring hospital provides medical treatment within its capacity that minimizes the risks to the patient  The receiving hospital (a) has available space and qualified personnel for the treatment; and (b) has agreed to accept transfer and to provide appropriate treatment  The transferring hospital sends all medical records (history, examination findings, results of diagnostic tests, provisional diagnosis, and treatment provided ) that are available at that time.  The informed written consent or certification as required by EMTALA.  The transfer is effected through qualified personnel and transportation equipment to provide life support measures during the transfer.  The Emergency Medical Treatment and Active Labor Act 1986 (EMTALA)
34. 35. H. ADMISSION AND DISCHARGE  Whenever a medico-legal case is admitted or discharged, the same should be intimated to the nearest police station at the earliest.  It is always better to inform the police through the casualty of the hospital where the medico-legal register is usually maintained and necessary entries can be made in it.  While discharging or referring the patient, care should be taken to see that he receives the Discharge Card/Referral Letter, complete with the summary of admission, the treatment given in the hospital and the instructions to the patient to be followed after discharge.  Failure to do so renders the doctor liable for “negligence” and “deficiency of service”.  
35. 36.  If the patient is not serious and can take care of himself, he may be discharged on his own request, after taking in writing from him that he has been explained the possible outcome of such a discharge and that he is going on his own against medical advice.  Police have to be informed before the said patient leaves the hospital.  Sometimes the patient, registered as a medico-legal case, may abscond from the hospital.  Police have to be immediately informed, the moment such an instance comes to the notice of the doctor/ hospital staff.  
36. 37. I. ABSCOND/DEATH OF MEDICO-LEGAL CASE  In case a person admitted as a medico-legal case expires or absconds.  Inform the police immediately.  Send the body to the hospital mortuary for preservation, till the legal formalities are completed and the police releases the body to the lawful heirs.  Request a medico-legal postmortem examination, providing a copy of death summary.  Do not issue a death certificate before postmortem even if the patient was admitted.  The dead body should never be released to the relatives; it should only be handed over to the police.  
37. 38. J. CUSTODY OF THE RECORDS  The records should be kept under lock and key, in the custody of the doctor concerned or may be kept in a Central Record Room, in hospitals where such facility is available; as per the institution’s rules.  Most hospitals have a policy of maintaining all medico-legal records for variable periods.  However, as per law, there is no specified time limit after which the MLRs can be destroyed.  Hence, they have to be preserved.  In view of the multitude of cases against the doctors under the Consumer Protection Act, it is advisable to preserve all the MLC records for a period of at least10years or till the disposal of case by the court.  
38. 39. K. FINAL OPINION  Final opinion to be given on the original MLC sheet by the same doctor preparing record depending on investigation findings or treating physician in admitted case.  Final opinion in the MLC to be given by the hospital where MLC has been made after obtaining a case summary from referred hospital.  After discharge of the patient or death the MLC record to be sent to MRD for preservation.  The doctor needs to give a witness in court as expert witness, if summoned by the honorable court.  At that time he may have to produce the case record or final opinion in front of the magistrate.  
39. 40. L.PROCEDURE OF DYING DECLARATION In a critically ill medico legal case that is not expected to survive, medical officer treating the case should inform the police to arrange for recording evidence so that the magistrate should come and record the dying declaration. In all the cases where there is immediate likelihood of death and 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 . Statement of the witness shall be recorded, preferably in the vernacular of the patient in which he/ she speaks. In all such cases medical officer should obtain either signatures or thumb impression of the patient. The original dying declaration shall be sent to the SDM concerned in a sealed cover through the Medical Record Department. Doctor should not attest the dying declaration or act as a witness in case when police or magistrate records the dying declaration.
40. 41. M. OTHER RELATED ISSUES  a. MASS CASUALTY/DISASTER  Whenever mass casualty is received in the hospital due to natural /unnatural calamities or disaster all the cases may be labeled as medico legal but injury sheets are made for only critical patients. Besides a comprehensive list of other cases may be prepared and can be handed over to the police together with the injury sheets prepared.  b. BROUGHT DEAD CASES  1. All the cases of unnatural deaths like accidents, burns, violence and sexual assault etc. depending on the history obtained from the relatives or police accompanying the case should be labeled as medico legal and all the formalities must be done with informing the police constable on duty.  In all the brought dead cases where casualty duty officer is very much satisfied after taking history and going through the records available, that the death was natural, he may not label them as medico legal purely at his discretion.  In the death certificate form against the column of cause of death one should write “ NOT KNOWN BROUGHT DEAD” .  In no case it should be mentioned that cause of death should be determined after post mortem.  
41. 42.  c. MINI M.L.C.  </ul> Cases who need minor attention as far as treatment is concerned and need not be admitted are seen on attended MLC register and a duplicate copy is taken on the register. Any treatment required is given on an OPD slip and MLC number mentioned on it.  <ul> d. EXPERT OPINION  </ul> The cases referred from legal courts/ jails for expert / specialist opinion regarding health of the individual may be entertained in the casualty/ emergency depts. of the hospital through DMS/officer in charge casualty.  
42. 43.  e. MEDICO LEGAL EVIDENCE/ARTICLES  </ul> In all medico legal cases where the medico legal evidence like patients clothes with blood stained marks, stab injury, cut mark and bullet holes mark should be encircle, sealed and must be signed by the examining doctor and must be preserved.  In case gastric lavage has been collected it should be collected in proper container and the bottle should be sealed and signed and it must be preserved.  Any foreign body recovered from the patient after operation like bullets etc. or otherwise must be sealed and preserved.  Further at the onset of examination, any document, money whether currency notes or coins or other precious material like gold ornaments must be taken in the possession, sealed and preserved.  
43. 44.  All these above evidences must be entered in the MLC sheet of the patient and must be signed by the doctor examining the case and police personnel taking possession of these articles.  In case some of the articles/ evidence are essential for the police they may be handed over to the investigating police officer as and when proper requisition is received through Medical records deptt.  Other belongings, which are not essential for the legal procedure, may be handed over to the nearest kith and kin of the patient as and when it is demanded and certified by the concerned police station and processed through medical records deptt. Records should be kept in the case file.
44.  
45. f. COPY OF MLC TO INDIVIDUALS OTHER THAN POLICE.  A medico legal report is a report given by an expert and is of confidential nature and is not a public document. As such the accused or respondent is not entitled to get a copy of the same during the investigation of the case. In such cases a no objection certificate should be obtained from the police authorities investigating the cases , before a copy is supplied.  In some cases the police ask for a medico legal report after the case has been discharged / expired.  It is irregular to issue a medico legal report on the MLC in such cases.  The police however can ask for any specific information (including the details of injury), which may be supplied to them from record of such case.  If needed a fresh MLC be made recording the present findings, after re-examining the patient on new date.  
46. 46. CONCLUSION  Medico-legal cases have to be dealt with properly, following the institution’s prevailing guidelines.  Usually, all the big hospitals and the teaching institutions have an ‘institutional medico-legal manual’ which gives, in a step-wise detail, the correct procedure of dealing with the various kinds of MLCs.  Even if such manuals are not available, these cases pose no problem if one uses proper caution and due care and attention, while dealing with them.  Proper documentation, timely information, a methodical and thorough examination including all relevant investigations and referrals, etc, are all that are necessary to see such cases completed successfully.