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Guidelines for Handling Medico Legal Cases


Vinay M Raj1, Vasudeva D S2, Gagan S3

edico
legal
knowledge is an essence for a medical
professional, irrespective of their
specialty. Law is common to all.
Knowledge about Medico legal issues is not optional for a treating
Doctor but a mandatory social responsibility. Proper knowledge of
the roles and responsibilities of a
health care provider is of immense importance while handling these cases to facilitate social and legal justice.
A health care provider along
with the medical records called to
the court as an expert witness is of
pivotal importance for the proceedings of the trial and any incompetence by the health care
provider can result in grave consequences for both the Institution
and self.
The health care provider must
therefore exercise vigilance and
proper documentation while
treating a Medico Legal Case. It is
advisable to follow the legal aspects to avoid embarrassment in
the court of law due to the lack of
knowledge or awareness regarding MLCs and their practices.
Hence, this effort is done to
compile a set of basic guidelines
to be practiced in a hospital when
dealing with MLCs. The following is a non-exhaustive list of

guidelines compiled to effectively


handle MLCs in a hospital.

Role of Doctor in
Casualty
Remain calm, do not panic,
and treat as a regular case.
Lives saving measures arealways FIRST in priority.
MLC workup is done
SOON after it.
Casualty services are 24x7
CMOs are supposed to register MLC by entering the following in the MLC register.
o Preliminary data:
Name Full name
should be taken with initials,
Age
Sex
Address local and
permanent.
o Identification marks:
Two reliable identification marks have to be
noted preferably from the
peripheral parts of the
body,
If not found then it
could be from private parts
Mole/scar/birth
mark/ deformity/ any other
peculiar mark can be considered.

Dept. Of Forensic Medicine, 2Principal, 3Dept. Of Community Medicine, S N


Medical College & Research Centre.
Address for Correspondence: Dr Vinay M Raj, Assistant Professor, Dept. Of Forensic Medicine, Akash Institute of Medical Sciences & Research Centre, Devanahalli 562110.
email: drvinaraj84@gmail.com

o Consent of the patient /


relative has to be taken:
Signature/
thumb
impression of the patient.
Signature of the relative / guardian.
o Brief history of the incident time/ place/nature of incident.
o Examination findings:
Injuries must be
noted in the order of
Head
to
toe
or
major to minor injuries.
o Treatment given:
Immediate treatment given
Referral to the
concerned department.
o If referred outside
Place where it is referred
should be mentioned.
o Information given to
police Name of the Police
Station.
Deciding a case as MedicoLegal or not, is based solely on the
treating Doctor
MLC can be registered at
any time after the patient has
come to the hospital arrival/
later based on the time of suspicion
Any Doctor at any point of
their treatment should inform the
CMO regarding any suspicion
about any foul play suggestive of
unnatural means in the case.
It is better to register as
MLC and later easy to convert
into non MLC than vice versa if
the Doctor is in dilemma about
the case.
Once MLC done either in
our hospital or outside is sufficient no need to repeat the same.

International Journal of Health Information and Medical Research Vol: 1, Issue: 1, Jan 2014

A copy of the same should be attached to the file.


If patient is referred from
our hospital after registering under MLC, the same has to be mentioned in the referring letter and
inform the same to the police.
History told by the patient
or the relatives has to be entered
in the same words preferably, if
any doubt regarding the history
has to be asked specifically. Avoid
guessing, assumptions about the
facts.
All the information written
should be legible, understandable
and simple in nature. Try to avoid
scientific and medical terminologies as much as possible.
To document, use ball
point pen preferably. Avoid use
of ink or gel pen.
Avoid over writing, scribbling, etc. and any corrections
made must be initialed along with
the date.
Saving the life of the patient is a priority, irrespective of
availability of attendees/ relatives
for consent. However only lives
saving procedures are allowed.
Anything other than life saving
procedures has to be with the consent.
Life saving procedures:
o Stabilizing the patient
Airway, Breathing, Circulation.
o CPR.
o Based
on
knowledge/skill/experience,
the treating Doctor will decide
the most appropriate life saving procedures needed for the
patient at that specific time.
Eg: Medical emergencies Patient with chest
pain with ECG changes
suggestive of myocardial
infarction should be treated
with aspirin & clopidogrel

Patient in Hypovolemic shock need fluid replacement.


o CMO can take the advice from the concerned department if needed any time.
o Concerned
specialist
will decide the specific treatment required and the same
can be done under their guidance during their physical absence.
Delay in payment should
never be the reason to deny the
treatment.
FIRST SAVE THE LIFE THEN
TAKE THE PAYMENT.
MLC register & Police Intimation Register has to be kept in
a locker and the Doctor at casualty
is in charge of the key. At the time
of change of duty, the concerned
doctor has to handover the key to
the reporting Doctor along with
the instructions.
If anybody found safe
guarding of the patient fromlegal
circumstances either the treating
Doctor or any other person involved is punished as per the section IPC 201.

Cases to be Registered as MLC


The following is an in-exhaustive list of cases to be registered as
MLC
1. Alleged history of assault
2. Road traffic accident Vehicle collision / pedestrian injury
3. Firearm injuries
4. Self fall injuries not consistent with the history
5. Poisoning / drug over dosage
6. Alcohol intoxication &
drunkenness
7. Anaphylaxis due to therapeutically injected drugs
8. Victims of Animal ferocity

9. Snake Bite/ scorpion sting;


however Bee sting or other insect
sting being an exception.
10. Attempted Suicide self inflicting injuries/ poisoning / any
means.
11. Attempted Homicide Hanging / strangulation / poisoning
12. Burns except for minor domestic nonfatal accidental burn
injuries
13. Electrocution/ Lightning.
14. Any patient with unconsciousness/ unexplained coma.
15. Death occurring within
24hrs of hospitalization without
establishment of a diagnosis.
16. Alleged Criminal abortion
17. Any brought dead/ Death
on arrival, without any corroborative history supports death.

Case of Assault
All cases of assault have to
be registered as MLC and MUST
be informed to the police without
fail.
Injuries have to noted
down from
o Head to toe or major to
minor
o They have to be numbered
o Description of the injury
size, site, shape, position
from bony landmark should
be noted, preferably take the
measurement using measuring tape.
o Aging of the injury has
to be mentioned.
Fresh / dark brown/
brown/ black/scar.
o Type of weapon inflicted can be assessed and correlated with the type of injury
Injury certificate has to be
issuedonly with the patients or
police request.

International Journal of Health Information and Medical Research Vol: 1, Issue: 1, Jan 2014

Case of Sexual Assault


Consent :
o Written informed Consent of the patient >18 years is
a must
o If minor, consent has to
be taken from the guardian.
Examination
o Examination of the Case
has to be done at casualty in a
private room.
o Make the patient calm
build the confidence in the victim
o Third person as a female
witness is a must in case of a
male Doctor.
o Immediate life saving
measures to be taken if required should be given as soon
as possible
o Detailed medico-legal
examination will be done by
the faculty of Forensic Medicine.
o Counseling, Treatment
and Post-Exposure Prophylaxis are part of the case management Gynecologist Opinion should be taken.
NO Doctor/ Hospital can
refuse the patient since it is a case
of sexual assault. Such Doctor/hospital will be punished under the court of law.
All cases have to be informed to the police.
In case of minor (<18 yrs)
mandatory to inform to the police
even it is a consensual sexual act.
Otherwise treating doctor is held
guilty and punished.(Prevention
of Sexual & Child Abuse Act)

Case of Poisoning
All cases should be registered as MLC

Following Samples are to


be collected no preservatives
should be added.
o stomach wash (if done)/
vomitus~ 30 ml
o Urine -10 ml
o Blood 5 ml
o Unused tablet or container brought along with the
patient has to be preserved
carefully
Labels has to be made correctly containing details of the patient, MLC no, and should be
handed over to the police.

Case of Drug Abuse


If suspicion found about
any narcotic drug abuse - opium,
ganja, charas and others must be
brought to the notice of police.
Therapeutically used drugs
(barbiturates and benzodiazepam) have to be under the guidance of a treating doctor. Any irrational use should be informed
to the police.

Case of Alcohol Intoxication (Inebriant


state)
If the patient is unconscious;
Smell of alcohol has to be
mentioned.
Fresh Blood sample has to
be collected and preserved as
soon as possible from the time of
arrival of the patient.
Blood (5 ml) has to be preserved in potassium oxalate and
sodium fluoride (2:1)
The time of blood collected
has to be noted without fail.
If a case of drunken and driving met with RTA or self fall;
MLC should be made and
police is informed.
Blood should be collected
after obtaining the consent.

If the patient refuses to give


blood for examination of alcohol
content it has to be entered in
the register.

Case of Snake
Bite/Scorpion Sting.
Case has to be registered as
MLC
Life saving treatment first
Try to locate the fang/sting
marks
o Number, size, position
from a bony landmark
o Skin color surrounding
the bite mark any signs of reactions to be noted.
Clinical signs suggestive of
type of snake bite should be
noted.

Case of Animal ferocity


Case should be registered
as MLC
Preliminary data has to be
collected
Type of injury should be
described
The history matching with
the injury found on the body has
to be correlated.

Case of Electrocution/Lightning
Life saving procedures are
first
Case should be registered
as MLC
History
o Time of incident
o Position of the victim at
the time electrocution/ lightning.
o Place of occurrence
domestic / working should be
mentioned.
Examination

International Journal of Health Information and Medical Research Vol: 1, Issue: 1, Jan 2014

o Points of entry and exit


wounds should be located and
described
o Path of electricity travelled in body has to be noted.
o Any other secondary injuries should be noted.

Case of Attempted
Hanging
Life saving procedures are
first
Case has to be registered as
MLC
History and other preliminary data should be noted.
Describe the injury
Ligature mark
o Position of the ligature
mark
o Dimension length /
Width / position from bony
land mark
o Skin color
o Is ligature material dimension comparable with the
marks found on the body
should be correlated.

Case of Alleged
criminal abortion
Doctor must be aware of
MTP act 1971 protocols and the
case should be treated as a Medico-Legal Case.
All the records must be preserved.
MLC registration & police
intimation should be made.

Case of Brought
Dead
If PROPER HISTORY available
o If the patient was suffering from any chronic ailment
has been treated in our hospi-

tal, the concerned Doctor/Department can issue the death


certificate.
o The previous illness and
other details can be taken from
the MRD of our hospital. However if the previous illness is
not supportive of the death of
the patient, then it should be
subjected to PM examination.
o If no such details are
available, it is the relatives to
decide whether they want the
Cause of Death (COD) or not.
o If the relatives want the
COD, then it is subjected for
post-mortem examination and
protocol is followed.
If PROPER HISTORY NOT
AVAILABLE
o Mandatory to make it
MLC and inform the police
body should NOT be released
from the hospital without
making the protocols.

Dying Declaration
In case the patient wishes
to make a dying declaration, the
magistrate needs to be intimated.
If magistrate is unavailable,
CMO can record by himself in the
presence of two independent witnesses whose signature are also
affixed in the document.

Police Intimation
Police has to be intimated
as soon as the MLC registration is
done.
Police intimation has to be
made in writing and countersignature should be taken from the
concerned police authority.
If the Doctor feels the need
to be kept it confidential as in certain cases, need not be informed
to the police.
Eg - A case of suicidal consumption of drug (drug over

dosage)/ poisoning, the patient


is safe from deranging complications, No need to inform the
police; however, it has to be
kept confidential. If the patient
dies, then it must be informed
to the police and protocol has
to be followed.
In a case of simple nonfatal
domestic injuries, where a young
recently married female being a
victim, it is better to inform to the
police as it might come under
dowry harassment sections.

Do Remember
There is no role of patient in
deciding whether a case is Medico-legal or not, even if the patient
refuses to get treated.
Practice of making MLC
OR NOT based on patients wish
is not entertained in the court of
law. Taking signature for the
same is again not explained in any
of the Indian laws.

Documentation in
MLC
All cases come under MLC
OPD / IPD has to be mentioned
on the case sheet. The Medico-legal registration number and the
date of registration should be entered.
MLC seal has to be entered
in all the papers of the case sheet
including lab investigations/ radiological investigations/ consent
forms/ OT & other papers/ billing
or activity charts. The seal should
not be placed over any of the values/ findings. (Ideal to place over
the corner of the page)
All the reports along with
case papers are hospitals property.

International Journal of Health Information and Medical Research Vol: 1, Issue: 1, Jan 2014

The case sheet along with


all the investigation reports enclosed should be handed over to
the MRD with acknowledgement.
Never allow the patient or
the attendees to handle the case
sheet nor the investigation reports.
At the time of discharge of
the patient, neither the reports nor
the films can be issued to the patient. If the patients request/ demands for the reports, can be
given a photocopy of the same
from MRD.
In discharge summery all
the finding should be entered and
handed over to the patient. A
copy of the same has to be kept in
the case file.
MLC case sheet should not
be taken outside the hospital under any circumstances without

the knowledge of the MRD incharge or the Medical Superintendant.


MRD guidelines for archiving the document should be followed.

Housekeeping staff
Do not discard any of the
samples collected in the hospital
without the knowledge of the
Doctor especially in MLC cases.
Purposeful disposal or destruction of the sample or evidence is a punishable offence.

Security

Only ONE responsible


guardian has to be identified as a
patient attendant
Visitor should be accompanied by a security staff at the time
of visiting the patient.
Only one visitor can visit
the patient at a time.

Acknowledgement
We sincerely thank Dr Varghese P S, Dr Manju Prakash for
valuable guidance and Dr Satish
Babu, Dr Govindraju, Dr Brijesh
for support and encouragement.

Always strict vigilance has


to be made over the visitors of the
MLC patient especially if the patient is in ICU.

~~*~~

International Journal of Health Information and Medical Research Vol: 1, Issue: 1, Jan 2014

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