PREPARATION OF MLC REPORTS

							         PREPARATION OF MLC REPORTS




                Department of A&E
                GTB Hospital
                Dilshad Garden,Delhi




MEDICOLEGAL TRAINING PROGRAMME for TRAINEE JUDICIAL OFFICERS
 GURU TEG BAHADUR HOSPITAL AND UCMS DELHI 25 NOVEMBER 2009
      DISCLAIMER/CAUTION
THIS PRESENTATION BRIEFLY OUTLINES THE PROTOCOL
FOR PREPARATION OF MEDICOLEGAL REPORTS.THESE
GUIDELINES ARE NOT THE FINAL AND COMPLETE
DOCUMENT OF THE MEDICOLEGAL SYSTEM. THE
GUIDELINES ARE SUBJECT TO REVISION FROM TIME TO
TIME AS PER CENTRAL GOVT/STATE GOVT OR COURT
DIRECTIVE AS THE CASE MAY BE. THE GUIDELINES ARE
BEST UTILIZED IF THE MEDICAL PROFESSIONAL USES
KNOWLEDGE AND SKILL TO THE BEST OF HIS/HER
CAPABILITIES FOR PATIENT CARE AND MEDICOLEGAL
DOCUMENTATION AS PER PROVISIONS OF THE LAW OF
THE STATE. THE HEALTH CARE PROFESSIONALS ARE
ALSO ADVISED TO CONSULT STANDARD REFERENCES IN
SUCH MATTERS WHENEVER NECCESSARY.
                Why to manage MLC

   ML Cases are just as Non MLC sick/injured
    patients and doctor is duty bound to treat
    as well as document the details.

   Crucial piece of evidence

    Communication to law enforcing agencies is required under section
    39 of CrPC and failure to do so will attract legal penalty
    Liable to be prosecuted under section 201 of IPC
            DUTIES OF REGISTERED MEDICAL
           PRACTITIONER TOWARDS PATIENT
1.    Duty to exercise reasonable degree of skill and knowledge.
2.    Duties in regard to attendance and examination.
3.    Duty to furnish proper and suitable medicines.
4.    Duty to give instructions.
5.    Duties towards children and adults.
6.    Consultation with a specialist.
7.    Duties in regard to psychiatric patients.
8.    Duties in regard to poisoning.
9.    Duty to notify certain diseases.
10.   Duties in regard to operative procedures.
11.   Duties under Geneva convention.
12.   Duties in convention with X-rays.
13.   Professional Secrecy.
         DUTIES OF REGISTERED MEDICAL
         PRACTITIONER TOWARDS STATE

1.   Consent
2.   Confidentiality
3.   Maintenance Of Records
4.   Collection And Preservation Of Samples
5.   Dying Declaration
          OVERVIEW
 WHAT
 WHO
 WHERE
 WHEN
 HOW


          RELATED LAWS
WHAT IS A MEDICOLEGAL CASE?
                 No legal definition
 Pre-labeled case: It is a case of injury or ailment
 where an attending doctor after taking history
 and clinical examination of the patient thinks
 that some investigation by law enforcing
 agencies is essential, so as to fix the
 responsibility regarding the case in accordance
 with the law (BPRD).
                     Receiving an MLC

A doctor can receive a medico-legal case–
   Brought by the police for examination and reporting.

   Already registered MLC referred from other health care system for

    expert management/advice


   After history taking and thorough examination, if the doctor suspects

    that the circumstances/ findings of the case are such that registration

    of the case as an MLC is warranted

   Directive of court.
                      Who?
Any doctor who

     Possess permanent registration with MCI/SMC
     Some experience (preferable)

The doctor who has -First contact with patient should
prepare an ML case report

    In rape victims by the examination and preparation
    of MLC is done by female doctors.
               Where?
No specified area is defined for ML case

 Emergency Department is the area where
   majority of ML reports are prepared
                  but
sometimes may be in wards after detection
             of new findings
                      When?
    Some of the Pre-labeled MLC (as per BPRD)
           [This list is not comprehensive]
   RTA’s, Rail accidents, factory accidents or any other
    unnatural mishap
   Suspected or evident homicides or suicides
   Suspected or evident poisoning
   Burn injuries due to any cause
   Injury cases where foul play is suspected
   Injury cases where there is likelihood of death in near
    future
   Sexual assault cases
   Suspected or evident criminal abortions
   Unconscious cases where cause of it is not clear
   Brought in dead cases where suspicion of foul play
   Cases referred from court
  Consent in Medico legal cases
CONSENT FOR MEDICOLEGAL EXAMINATION
TO BE TAKEN IN WRITTEN IN ALL CASES

Exception : Cases brought by police being
arrested on charge of committing an offence

Person below 12 years/unsound mind- consent
of guardian is to be taken.
              REMEMBER

     saving is the foremost duty of a doctor
 Life
 and a hospital, in accident or medico-legal
 cases (MLC). Patient treatment is priority

 Doctor has to do is to COMPLETE the
 injury sheet, which is a part of the
 assessment of the patient.

  NO DELAY FOR PROVIDING FIRST AID
 TREATMENT is PRIORITY

    THE PRIME RESPONSIBILITY
               OF
  DOCTOR IS THE INSTITUTION OF
PROPER TREATMENT TO THE PATIENT
            PROMPTLY
    MLC should be registered as early
               as possible

   There is no time limit for preparing an MLR or registering a
    case as MLC

    A case which otherwise qualifies to be an MLC was not
    registered earlier is to be registered as MLC by the concerned
    doctor

    A case due to unraveling of new findings –history/clinical
    examination etc. later on qualifies to be an MLC to be
    registered by the concerned doctor
    DOCUMENTATION OF A MEDICOLEGAL CASE

 Documentation is done in duplicate in a set Performa as
per hospital policy

 Separate performas may be available for medical
examination, examination of drunkenness etc.

All columns are filled up carefully and by the same
doctor who had examined the patient

Each MLC is given a fresh MLC number sequentially or
parallel series as per hospital policy
DOCUMENTATION OF A MEDICOLEGAL CASE contd..

The details are completed then and there only, leaving
no provisions as to be completed later on.

After completion doctors sign and mention his/her
name in full below it with designation

Police constable on duty informed in each case.

After registration of a case as MLC , thereafter all
documents and requisition forms bear the same MLC
number including the discharge slip.
 GENERAL DEATAILS

1. REGISTRATION NUMBER
2. MLC NO
3. NAME
4. S/D/W OF
5. AGE
6. SEX
7. RELIGION
8. OCCUPATION
9. RESIDENTIAL ADDRESS
10.BROUGHT BY …….
11.DATE AND TIME OF EXAMINATION
12.NAME OF POLCE STATION
          DETAILS OF EXAMINATION
• ALLEGED HISTORY
• TO BE PRECICISE AND TO THE POINT
• LEGIBALY/CLEARLY WRITTEN
• DESCRIPTION OF INJURIES
• ABBREVIATIONS AVOIDED
• WHEN IN DOUBT CONSULTATION OBTAINED
•MINOR INJURIES ALSO NOTED IN CASE OF
 POLYTRAUMA/MULTIPLE INJURIES


MARKS OF IDENTIFICATION ARE NOTED AND DOCUMENTED
CERTIFY FITNESS
     and
  OPINION
        CERTIFYING FITNESS


As a part of documentation of ML Case report or
whenever the I.O requests the doctor for
certifying fitness of the patient to make a
statement the examining doctor will certify the
same on the original MLC sheet. He/she will
mention date and time clearly with signature,
name in full with designation       below the
certification.
          OPINION REGARDING INJURIES

•SIMPLE

•UNDEROBSERVATION AND REFERENCE FOR
 A SPECIALIST OPINION

•GREVIOUS (AFTER CONSIDERATION OF
 ALL FINDINGS/X-Ray etc)

•CAUSED BY SHARP/BLUNT OBJECTS
 Time limit for registering a Medico legal case



A medico-legal case is registered as soon as a
doctor suspects foul play or feels it necessary to
inform the police, at any time after admission.

A case is registered as an MLC even if it is
brought several days after the incident.
  Can a doctor refuse to attend MLC
                 NO
GOVT SERVICE DOCTORS -DUTY BOUND

   ROLE OF PRIVATE PRACTITIONERS?
A doctor cannot refuse to examine medico
 legal case on the basis of being a private
     practitioner or citing a jurisdiction
                  problem.
 ML CASE

 Discharged after initial treatment
 Admitted as in patient
 Referred to other hospital after
 providing First Aid / stabilization for
 expert management after completion
 of all necessary documentation
 If the case brought is a referred case
                 and is
already registered as medico legal case
            FRESH REPORT
                   is
            NOT REQUIRED
   A case that is admitted and on treatment, later on found
    out be MLC, is made MLC by the concerned doctor.

   If death is inevitable, arrangement to take the dying
    declaration is made.

   All the materials such as vomit, gastric lavage sample,
    blood urine, etc. in poisoning cases, vaginal swab and
    pubic hair in sexual offences, foreign bodies found in the
    wounds, etc are collected .
    Samples are properly preserved, packed and sealed
    then handed over to the police.
                       How?
           First aim is to preserve life
•      Registration at designated area
1.     Specified Register

2.     Cases already registered and referred
i.     Duty of referring doctor
ii.    Duty of receiving doctor

      Entertaining requests of patient/relative
 Whenever there is doubt, doctors take second
          opinion/consult specialists




All reports and documents of a medico legal case
are labeled as MLC with the number assigned
Information is given only to I.O. or any
      person designated by I.O.

  If the I.O. gives requisition for any
 clarification regarding certain points
mentioned in the report given, answer is
             given in writing.

DOCTORS MAINTAIN CONFIDENTIALITY
         IN ALL MLC CSES
   the I.O. demands an original document/
 If
 photocopy of the same, of a MLC, it is
 given and a receipt obtained.

   the court demands X-Ray films, P.M.
 If
 report etc. they are deposited in the court
 and a receipt obtained.
        COLLECTION AND PRESERVATION OF SAMPLES


•   Gastric lavage/ vomitus in poisoning cases
•   Blood in alcoholic/poisoning cases/drug abuse or for DNA
    test
•   Clothes in assault/injury/fire-arm/burn cases
•   Nail clippings in assault/rape cases
•   Pellets/bullet etc. if recovered
•   Vaginal swabs/public hair in rape cases
•   Swabs in un-natural sexual offence cases
•   Swabs from fire-arm entry wounds
•   Washing from hands in fire-arm suicide cases
        COLLECTION AND PRESERVATION OF SAMPLES

•   Urine for pregnancy test in rape cases
•   Undergarments
•   Swabs from glans penis in rape/unnatural sexual
    offences
•   Swab from bite marks for blood/DNA test
•   Nails and hair in chronic poisoning of heavy metals
•   Any other material which may be useful in investigation
•   Any other exhibit e.g. bottle of poison or tablet or
    weapon if recovered should be properly labeled and
    sealed. It is essential to give sample of seal on separate
    cloth/paper putting initials. The endorsement of sample
    of seal should also be made in MLR.
                    AGE DETERMINATION


                                                         Generally
                    1. GENERAL PHYSICAL
                       EXAMINATION                       X-ray of
                    2. DEV. OF SECONDARY                 •Wrist
• VICTIM
                       SEXUAL CHARACTERS                 •Elbow
                    3. DEVELOPMENT AND                   •Shoulder
•ACCUSED
                       ERUPTION OF TEETH
                    4. OSSIFICATION OF                   is advised for age
                       BONES                             determination- juvenile
                                                         or not




  It is necessary that to estimate age all precautions to be taken so that
  range of estimation should not be more than ± 6 months up to 16 years
  of age and ± 1 year up to 21 years.
         RELEVANCE OF AGE DETERMINATION



1. CRIMINAL CULPABILITY Section 82 IPC child < 7 years
                        Section 83 IPC child 7 years -12 years

2. CONSENT FOR MEDICAL EXAMINATION

3. CONSENT for any harm not intended to cause death or grievous
   hurt can be given by a person> 18 years age Section 87 IPC

4. IMPRISONMENT –Juvenile < 18 years not to be kept in prison

5. CASES OF SEXUAL ASSAULT/RAPE
Issues regarding MLC

     Dying declaration
     Dying deposition



   Custody of ML Records

   Attending court of Law
       Admission and Discharge of MLC
    Whenever a medico-legal case is admitted the
    same is documented in admission papers and
    hospital records

    When discharged, the same should be intimated
    to the police authorities of the hospital
 Police is informed if a MLC is taking discharge against
  medical advice
 At the time of discharge, detailed instructions to the
  patient regarding treatment, follow up general care, diet,
  exercise etc are given in writing.
  Death of a person admitted as a medico-legal case


The following are the do's and don'ts in case a person
  admitted as a medico-legal case expires.
 Police Informed immediately.
 Body sent to the hospital mortuary for preservation, till
  the legal formalities are completed and the police
  releases the body to the lawful heirs.
 Death certificate not issued – even if the patient was
  admitted.
 Dead body never released to the relatives directly
       BROUGHT IN DEAD PATIENTS


•   POLICE TO BE INFORMED IF NOT ALREADY DONE

• NO INJURIES NOTED IN MLC RECORD

• ARTICLES IN POSSESSION DOCUMENTED AND HANDED
  OVER TO RELATIVES/POLICE

• DEAD BODY TO BE SENT TO HOSPITAL MORTUARY
        MEDICAL EXAMINATION OF VICTIMS
             OF SEXUAL ASSAULT
                   Section 164A of CrPC

•Examination only by female registered medical practitioner
•Without delay
•Consent -documented
•Note down particulars
•Complete history
•Examination – Genital examination and injuries:
 Standard protocols and guidelines
•Preserve samples-DNA profiling
•Emergency Contraception if required
•Treatment /prophylaxis as required
•Opinion
     EXAMINATION OF PERSON ACCUSED OF SEXUAL
                     ASSAULT
                      Section 53A CrPC

•Brought by police written and signed request

•Details of examination findings


•Sample preservation –Clothing/Blood/Semen sample/Pubic hairs
 for DNA profiling

•Opinion

•Age determination

                 Consent not required
CHILD ABUSE/ SUSPECTED VICTIMS OF SEXUAL
      ASSAULT/ABANDONED CHILDREN
                 Guidelines laid down by hon’ble court
   A detailed description of assault/abuse history be mentioned
   In case of girl victim medical examination preferably by a female
    doctor
   As far as practical –psychiatrist help be made available to victim
   Report to be prepared as early as possible
   Parents/ guardian whom child should trust should be allowed to be
    present
   In case of results of examination are likely to be delayed the same
    should be mentioned
   Emergency medical treatment/prophylaxis against STD to be
    provided when necessary
   After examination child permitted to wash up and provide fresh
    clothing if clothing is taken as evidence
   Preserve samples according to guidelines –SAFE [Sexual abuse
    Forensic Evidence] Kit provided in Govt. hospitals
           LEGAL PROVISIONS
 Section 191 IPC (Giving false evidence)
 Section 192 IPC (Fabricating false evidence)
 Section 193 IPC (Punishment for false
  evidence)-Imprisonment up-to 7 years+ fine

   Section 201 IPC (Causing disappearance of
    evidence of offence, or giving false information
    to screen offender)
    LEGAL PROVISIONS (cont.)
 Section 202 IPC (Intentional omission to give
  information of offence by person bound to
  inform)
 Section 203 IPC (Giving false information
  respecting an offence committed)-Under
  Sections 201 and 202 and in this section the
  word “offence”, includes any act committed
  underSection302,304,382,393,394,395,396,397,
  398,402,435,436,449,450,457,458,459 and 460
    LEGAL PROVISIONS (cont.)
 Section 204 IPC (Destruction of document or
  electronic record to prevent its production as
  evidence) Imprisonment up-to 2 years or fine or
  both
 Section 88 IPC (Act not intended to cause
  death, done by consent in good faith for
  person’s benefit)
 Section 89 IPC (Act done in good faith for the
  benefit of child or insane person, by or by
  consent of guardian)
     LEGAL PROVISIONS (cont.)
 Section 92 IPC (Act done in good faith for
  benefit of a person with out consent)
 Section 93 IPC (Communication made in
  good faith)
 Section 39 CrPC (Public to give information
  of certain offences-Section 302-304)
    LEGAL PROVISIONS (cont.)
 Section 53 CrPC (Examination of accused by
  medical practitioner at the request of police
  officer)
 Section 53A CrPC (Examination of person
  accused of rape by medical practitioner)
 Section 54 CrPC (Examination of arrested
  person by medical practitioner at the request of
  the arrested person)
                      SUMMARY
 MLC REPORTS FILLED LEGIBALY

 AVOID SUPERLATIVES,ABBREVATIONS, TECHNICAL JARGON

 ALL RELEVANT DETAILS NOTED

 SIGNATURE / NAME IN FULL CAPITAL LETTERS BELOW

 ALL RELATED FORMS ARE LEGAL DOCUMENTS FILLED IN DUPLICATE
  WITH MLC NUMBER AND DETAILS

 ALL COULUMS COMPLETED

 CONFIDENTIALITY MAINTAINED

NONJUDGEMENTAL ABOUT ANY CASE –DUTY IS TO EXAMINE THE
    PATIENT AND DOCUMENT THE FINDINGS AND PATIENT
                     MANAGEMENT.
THE ONUS OF FIXING RESPOSIBILITY OF GUILTY IS FOR THE
                        COURT