Welcome to Journal of Case Reports and Images

Background

No greater opportunity, no greater responsibility, no greater obligation can fall to any other human being than to become a medical professional. In the care of suffering the medical professionals need scientific knowledge, technical skill, moral understanding of profession and awareness about the relevant laws of the land. Primarily doctors but also other ancillary and administrative staff of the hospital have several ethical and legal obligations in the performance of their duties. It is important therefore, that every concerned person of the hospital, related with treatment and care of the patients must understand the nature of obligations and thus fulfills these obligations to the best of his ability, to maintain nobility of medical profession. Most of doctor, irrespective of his/her specialty, would have faced certain cases, which at the time or subsequently, would be labeled as medicolegal.

Definition: A medicolegal case is a case of injury or illness where the attending doctor, after eliciting history and examining the patient, thinks 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.

Injury: is defined under section 44 IPC as “any harm whatever illegally caused to any person, in body, mind, reputation or property”. 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.

Importance: Medicolegal cases constitute a significant proportion of workload in the Accident and Emergency Medicine Departments of tertiary care hospitals. The way in which medico-legal issues are handled has a profound impact on the public image of the hospitals. 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. Medicolegal cases are an integral part of medical practice in emergency departments of major hospitals. Owing to the legal implications, these cases pose an additional workload on staff dealing with these emergencies. An apparently looking trivial trauma may have severe damage to the underlying organs and a high degree of suspicion is required to make clinically and medico-legally accurate diagnosis.

Management of Medicolegal Cases: The various steps in management of medicolegal cases are:

Case File Properly Marked as Medicolegal

The proper labeling/marking of medicolegal case files helps in their easy identification and makes the staff conscious about them. The doctor/medical officer should mark with red pen on the top of first page of the file of the patient the letters “M.L.C.” or put the stamp “Medicolegal case”. The medical officer/doctor should also see that the card of the patient is marked/stamped “Medicolegal case” by the duty staff nurse on duty.

Case Entered in Medicolegal Register

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, including the time and date of examination and the name of the doctor who is dealing with the case. This would be of immense help for future reference, when the patient through the court/ the police, requests for a copy of the medicolegal report.

Police Intimation done on Reception of the Medicolegal Case

If a case falls under medicolegal (MLC) category, the doctor must register the case as an MLC and/ or intimate the same to the nearest police station, either by telephone or in writing. An acknowledgement of receipt of such a message should be taken for future reference. If the intimation is given orally or on phone, the diary number (DD or the Daily Docket number) should be taken down as proof of intimation and should be properly documented in the patient’s records. According to the Hon’ble Supreme Court, whenever any medicolegal case comes to the hospital, the medical officer on duty should inform the Duty Constable, giving the name, age, sex of the intimation and should be properly documented in the patient’s records. According to the Hon’ble Supreme Court, whenever any medicolegal case comes to the hospital, the medical officer on duty should inform the Duty Constable, giving the name, age, sex of the patient and the place of occurrence of the incident and should start the treatment of the patient. It will be the duty of the said constable to inform the nearest concerned police station or higher police functionaries for further action.

Police Informed on Discharge of the Case

No medicolegal case shall be discharged or leave against medical advice (LAMA) without informing the police and whenever a medicolegal case dies, the police officer I/C of the police post/police station of the area should be informed immediately and a note to the effect be recorded on the file of the deceased.

Samples Properly Collected, Preserved and Sealed and Send for Toxicological Examination

Stomach wash, urine, blood etc. in poisoning cases must be collected and preserved in bottles which should be properly sealed, labeled and made into a parcel. The sealed parcel along with a letter and a copy of medicolegal report is sent through the police official concerned forensic science laboratory for detection of suspected poison. The letter should give particulars of the case, details of the bottles, sample impression of the seal put on the bottle and the poison suspected.

Toxicological Report Received by Medico-legal cell or Treating Doctor

The most important proof that poisoning has occurred depends on evidence of absorption of a toxic substance in the body. The most direct evidence of such absorption is the detection of a toxic substance followed by its quantitative estimation. So toxicological report is important for determining cause of death in suspected poisoning cases and also gives a rough estimate of likely survival time after exposure to fatal amounts of various drugs.

Autopsy done in the Mortuary of the Hospital

The objectives of a medicolegal autopsy are to determine cause of death, in unnatural deaths whether homicide, suicide or accident, to collect and document trace evidence and identify weapon, person or poison responsible for the death. In most accidental deaths, ideally an autopsy is required to rule out foul play. A medicolegal post mortem can be conducted only after a written request has been made by the police or by the order of the court. A medicolegal post mortem examination can be conducted only by a medical officer/doctor who has been authorized to do so. Autopsy or medicolegal postmortem examination has a central role in establishing cause of death and can also yield important information regarding the mechanism of injury. Various recommendations’ that can be suggested include:

• The doctors who are involved in treatment of such medico-legal cases need to be more trained in this field. Also, due to increase in accidents and violence cases, hospitals have the need for round
• the clock availability of such medico-legal experts in sufficient number to deal effectively with such cases to better serve laws of land.
• The periodical CME programmers specially by involving forensic medicine and integrated reorientation programmers should be made compulsory for all doctors in dealing with medicolegal cases.
• The medical ethics, acts related to medical practice should be emphasized in post graduate curriculum and examinations.
• There is a need to increase awareness on the role of clinicians with respect to their ethical responsibilities as providers. There is also a need to formulate standard operating procedure (SOP) in the context of doctors, nurses and police and their respective medicolegal roles.

References

1. Dogra TD, Rudra A. 2007. Lyon’s Medical Jurisprudence & Toxicology. 11th Ed. Delhi Law House. 367.

2. Justice YV, Chandrachud, Manohar VR. 20006. The Indian Penal Code. 31st Enlarged Ed.Wadhwa and Company, Nagpur. 228.

3. White, Brenda M. 2004. Duncan, Andrew (1773-1832). Oxford Dictionary of National Biography (online ed.).

4. Kumar A. 2007. Evidentiary value of medical evidence in Indian courts, J Indian Acad Forensic Med. 24: 136

5. Haryana Medicolegal Manual. 2012. 6. CK Parikh. 2010. Parikh’s Textbook of Medical Jurisprudence, Forensic Medicine and Toxicology. 6th ed. CBS Publisher &Distributor. New Delhi.

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