Writing mlc

How to write medicolegal cases for health care professionals

1. Moderator: Dr. Sanjay Jain (MS) Professor Department of surgery, Gandhi medical college & Hamidia Hosp., Bhopal Presented By: Dr. Rajat Maheshwari RSO Surgery, Gandhi medical college& Hamidia Hosp., Bhopal WRITING MLC

2. A MLC is defined as “ any case of injury or ailment where, the attending doctor after history taking and clinical examination, considers that investigations by law enforcement agencies are warranted to ascertain circumstances and fix responsibility regarding the said injury or ailment according to law. DEFINITION

3. RSO/ Casualty medical officer/ Duty Medical Officer(DMO), who is attending the case may label a case as MLC. Medicolegal cases have not been defined anywhere in law. It depends more or less upon the judgement of doctors. In doubtful cases, it is better to inform the police than not informing. This will save the doctors from unnecessary and needless allegations later on. Consent of the patient/ relatives is not required for labelling the case as MLC. In fact, even if the patient is stressing that he does not want MLC, it should still be made. Delay if occurred in initially labelling a case as MLC , it can also be labelled at any later date and time after patient has been admitted in ward. Labelling a case as an MLC

4. Private practitioners can also make MLC. The practice of sending patients to Govt. hospitals for getting registered as MLC cases is wrong. If the patient is serious and dies on the way to the govt. hospital, the private practitioner can be sued under section 304A IPC. If a case is being labeled as MLC and has been referred to another hospital, it is in second doctor’s interest to make a fresh MLC(second MLC), so as to record meticulously his own finding, because when he gets summoned in the court , he has to go by his own findings. All cases which are pronounced dead on arrival at hospital must be labelled as MLC and police informed. If a patient is being admitted as non-MLC, suspicion raised by relatives after death (especially when death is alleged due to medical negligence), MLCs are not made in such cases. Instead, Patient’s attendant lodges a complaint with the police. Police arrives at the hospital, seizes the body and if after inquest thinks that there is necessity of postmortem, sends the body for autopsy.

5. Following are the examples of MLCs. Other cases not enumerated in the list could also be registered on the basis of professional judgement of medical officer. Accidents like Road Traffic Accidents (RTA),industrial accidents etc. Assault, including domestic violence and child abuse Cases of trauma with suspicion of foul play Alcohol intoxication, poisoning What incidents come under MLC

6. Undiagnosed coma Chemical injuries Burns and scalds Firearm injuries Attempted suicide Dead brought to the emergency dept and deaths occurring within 24 hrs of hospitalisation without establishment of diagnosis Death in operation theatre Custodial deaths Unnatural deaths Sexual offences Poisoning

7. The police should be informed under Section 39 of Criminal procedure code. The attending MO is legally bound to inform the police about the arrival of a MLC. If the doctor does not inform the police, and does not hand over relevant pieces of evidence (injury report, blood stained clothes, weapon, recovered bullets, pellets etc.), he may be charged for causing disappearance of evidence u/s 201 IPC. Verbal communication should invariably be followed by communication in writing. POLICE INTIMATION

8. Government doctors - All government hospitals and large nursing homes have a police official posted there. Information is given to that police official, who passes it on to the respective police station (of the area where crime was committed). Private Practitioners - Must ring up the local police station, or better call police control room (100) because all calls made to police control room are recorded. The doctor should ask the police official on the phone the daily diary number (DD no), and should record it in his injury report to save himself from harassment later. The date and time of making a call, as also the name and number of the police official informed should be noted. How to communicate with police

9. In emergencies, resuscitation and stabilization of the patient is of utmost priority and medicolegal formalities may be completed subsequently. The consent for treatment is implied in all emergencies. Medicolegal documents should be prepared in duplicate, with utmost care giving all necessary details, preferably written with a ball-point pen and avoiding overwriting. If any overwriting or correction is made, it should be authenticated with the full signature and stamp of the MO. Abbreviations should be avoided. HANDLING MEDICOLEGAL CASES

10. Patient arrested by police- If the patient is arrested and brought by police, no consent needs to be taken. The doctor can proceed with examination u/s 53 CrPC . The doctor must still first try to take consent upholding the principle of human rights. If consent is not given, examination must then be proceeded u/s 53 CrPC Essential components of examination u/s 53CrPC – (a) Person should be arrested. (b) Request should be from a police officer not below the rank of sub-inspector or any person acting in good faith in his aid and under his direction. (c) If person resists, reasonable force can be used to restrain him. (d) If the arrested person is a female, her examination can be performed only by or under the supervision of a female doctor (s53 (2) CrPC ). (e) What must be examined - "examination" shall include the physical examination as well as examination of blood, blood stains, semen, swabs in case of sexual offences, sputum and sweat, hair samples, and fingernail clippings by the use of modern and scientific techniques including DNA profiling and such other tests which the registered medical practitioner thinks necessary in a particular case (s53(2)[a] CrPC ). Consent for examination

11. Patient reported directly to Doctor- Even if the doctor the doctor is suspecting some foul play and has informed police, he would still need patient’s consent for examination until and unless the police official has arrested him. For labeling a case as medicolegal, the doctor does not need patient's consent (even if he is a victim, and does not want a police case), but for examination he would still need his consent, if the police official has not arrested him.

12. Identification marks:- Two identification marks must be taken. They are necessary to identify the person in court. One identification mark is more likely to lead to mistaken identification, as it can be duplicated in another person. Two identification marks are less likely to lead to errors. Three would cause still less errors, but it is not practical to take more than two. They should be on exposed parts, and not on hidden parts, so patient faces no embarrassment in court where these marks may be tallied. General condition of patient:- Whether the patient is conscious or unconscious. If conscious, whether anxious, tense, afraid, agitated, subdued. Bleeding from nostrils, ears, mouth, other natural orifices (vagina in case of sexual assault, anus in the case of buggery). Pulse rate, blood pressure, temperature, whether in a state of shock, paralyzed or not. If the police wants a statement from the victim, the doctor must first certify that the patient is compos mentis.

13. All injuries, however insignificant they may appear, should be recorded. Proper, adequate, and complete documentation is very necessary for all medicolegal work. Legally, only those injuries are present that have been recorded. Whatever has not been recorded was not present. Similarly, whatever procedures have been recorded were performed; whatever was not recorded was not performed. If necessary, photographic documentation should be performed. Even old injuries should be recorded. Type of each injury (e.g. whether it is an abrasion, contusion, laceration, incised wound, stab, burn, scald, fracture, dislocation of tooth etc.) should be noted. Systematic entries - In order not to miss any injury, a systematic plan should be adopted. The best is to go round the patient in this manner; start with head and neck → right upper limb → right lower limb → left lower limb → left upper limb → front of the chest and abdomen → genitalia → back of chest and abdomen. Type of Injury

14. Lens must be used in order to be able to differentiate between incised and incised looking lacerated wounds, or for noting other minute details such as singeing of hairs around firearm entry wounds. Presence of any foreign material – Note presence on the body or within the wound e.g. broken off point of a knife, bullets, coal, dirt, dust, fibers, glass, grass, gravel, grease, hair, metal, mud, oil, paint, pellets, powder, sand, shots, splinter of wood, synthetic materials, wads etc. These can often help identify the weapon, and indicate the manner in which injury was inflicted e.g. Tip of a stabbing weapon may sometimes break when it strikes a bone [sternum, rib, skull, or when it gets lodged in a vertebra]. A recovered piece of broken knife tip can be matched to a knife with a missing tip. Similarly, recovered bullet can be matched to the suspect firearm. Limitations – (I) Transparent materials (e.g. glass) are difficult to detect especially when they are masked by fluid, tissues, crusted blood and by the infiltration of particles in folds of tissues etc. (II) Material washed away during washing and cleaning of wound or during copious loss of blood. All recovered foreign material should be preserved, sealed, and handed over to the police official for further examination

15. Size of each injury should be noted, after measuring them with a ruler. No reliance should be made on guesswork. Shape of injuries - whether linear, triangular, circular, elliptical, oval, irregular or any peculiar shape. Direction of wounds - Whether horizontal, vertical, oblique or in any particular direction. Relationship with an organ is desirable (e.g. directed toward the heart, or away from the heart). Beveling of edges is particularly helpful in determining this. Labelled sketches of all injuries should be made. This helps lay persons like judges and lawyers to understand the injuries better. Size, shape and direction of each injury

16. Exact location of the injury in relation to important landmarks (e.g. midline, navel, nipple, outer canthus of the eye, a joint, a bony structure [e.g. knuckle]) should be noted. Distance from landmarks should be noted. Avoid technical terms as far as possible (e.g. instead of writing "medial malleolus", "inner bony prominence of the ankle“ could be written). There is nothing wrong in writing technical terms, and if the doctor cannot think of a suitable common name, he can use technical terms too. A good alternative is to use the technical term and then common name within brackets, e.g. "Right anterior superior iliac spine (bony prominence on the right side of the waist)". Concealed wounds - If the patient is unconscious (i.e. can't point to areas of pain), a careful search must be made for wounds in areas such as ears, nostrils, vagina, rectum, etc. On what part is injury inflicted

17. Age of each injury should be noted after noting gross changes in the wounds (e.g. color of a bruise, condition of scab in abrasions, infection etc.). Routine histological, histochemical and immuno-histochemical examinations are not possible in casualty setup, and should be undertaken only in extremely sensitive cases. If necessary, help of a pathologist may be taken. Age of injury confirms or refutes the allegations of the victim. For instance, he may be alleging that he was attacked in the morning and showing some old injuries to corroborate his statement. In the case of battered baby syndrome, since the injuries occur at different time periods, all injuries will be of different ages. The step-parent may falsely allege that the child fell down the stairs. If that be the truth, all injuries must be of the same duration. Age of injury

18. Against each injury, its nature should be noted (e.g. simple, grievous or dangerous). If nature of injury is not immediately apparent, patient must be kept under observation and following entry made in the relevant column "patient under observation.“ Similarly, if X-rays or other investigations have been ordered and their reports awaited, following entry should be made "Awaiting X-ray report." Patient may have to be kept under observation in obscure head or abdominal injuries. After observation period is over, or when the lab reports and X-reports have come, and the doctor is ready to opine on nature of injuries, they could be given on a separate piece of paper. This is called "subsequent opinion." Many hospitals have dedicated forms for giving such opinion. Nature of each injury

19. Examination of wounds and clothes can indicate the nature of the weapon - whether sharp edged or blunt; or if sharp-edged, whether single-edged or double-edged. Blunt and sharp weapons - A weapon which when used with some force can cause fractures, is loosely referred to as a "heavy blunt weapon". For eg : In case of cranial trauma, a cricket bat was shown in court and was asked if it was a "heavy blunt weapon"? The answer was "yes". The lawyer asked, "if I take off 100 g from it, would it still remain a heavy weapon"? Answer - Yes. Q - If I take off another 100 g would it still remain a heavy weapon? Answer - We can remove as much as you want. The answer does not lie in weight. Rather if that weapon when used with force can cause a fracture or not. If it does then it could be classified as a “Heavy blunt weapon”. Similarly, a single piece of paper and knife’s edge are both sharp. So, does it mean, it is as deadly as a blade or dagger? Ans - No. The answer does not lie in the sharpness of the edge but whether it can produce an incised wound or not. Since the edge of the paper cannot produce an incised wound, we cannot classify it as a "sharp weapon". Wounds caused by glass – ( i ) Are incised but may show some irregularities at the edges. They should not be confused with lacerated wounds. (ii) Finding of broken pieces of glass in the wound confirms causation by glass. Wounds caused by teeth - lacerated. Incised looking lacerated wounds must be differentiated from true incised wounds, with the help of a lens. If suspect weapon is presented by the police official, the doctor should examine the weapon in detail before giving any opinion . By what weapon is injury inflicted

20. If weapon is produced at the time of examination, the opinion regarding weapon is given on the MLC itself; if weapon is recovered and produced after some days, the opinion should be given on a separate weapon examination form. Doctor should enquire from the police official if the weapon has already been sent to fingerprint examiner and serologist (to determine blood group and DNA profile of the blood over it). If the reply is in the affirmative, the doctor must accept the parcel, otherwise it must be advised to have them examined first by a fingerprint official and then by serologist and finally submit it to him. Description of parcel - The weapon is always sealed in a parcel by the police official after recovery from the crime scene or suspect. The doctor should describe the parcel with number of seals. The seals bear the mark of police station. These marks must be mentioned. Items recovered and examined – The contents of the parcel should be described in detail. There can be more than one weapon. Tracing of each weapon must be made on the "weapon examination form" and various dimensions mentioned, e.g. length and width of the blade, presence or absence of hilt, condition of the tip (whether pinpoint or rounded), condition of the edges (whether serrated or not). Examination of weapon

21. In the case of heavy blunt weapon, weight of the weapon must be recorded. Opinion - After complete and thorough examination of the weapon, the doctor must give opinion on whether the given injuries could have been produced by the said weapon or not. Affixing doctor's signatures on the weapon - After examination is over, the doctor must affix his signature and date over some suitable spot on the weapon with an indelible ink (e.g. wooden handle in case of knife, dagger or hammer). This is necessary as the doctor would be asked to identify the weapon in the court. Summons regarding a particular offence are issued some months or even years later by the court. By that time, the doctor is likely to have forgotten the case completely. Signature on the weapon will help him in identification. Resealing of weapon and handing over to the police official The weapon must then be resealed in doctor's own seal or hospital seal), and the parcel returned to the police official along with the opinion. The doctor must take police official's signature on his own copy stating that an opinion as well as a weapon has been returned to the police official.

22. This would include entries not covered elsewhere, e.g. condition of clothes (whether they are blood stained or stained by other body fluids like semen, saliva etc., torn, buttons missing, burnt etc., or not). Whether wet, dry or show corrosion, (if hot fluid was thrown on the body [as in scalds], they would be wet. In case of vitriolage , they would show corrosive marks). If blood stained, or if showing associated defects due to firearms, they must be sent to the forensic science lab for examination of gunshot residues (to enable estimation of distance of fire). The doctor must encircle each cut/defect he wants an opinion on, number it, and then seal the clothes in a packet with a hospital seal. The sealed packet is to be handed over to the accompanying police official, and an entry should be made in the MLC regarding it. Doctor should try to associate each cut with the injuries (a typical entry is like this- "cut no. 1 on the shirt corresponds to injury no. 3"). More than one cut can be corresponded to a single injury. Remarks

23. If the death occurs during treatment, the police must be informed, and body handed over to him. It should never be handed over to the relatives. Dying Declaration:- In cases where the patient wishes to make a dying declaration, the magistrate will be intimated. If the Magistrate is unable to come and record a statement or where the MO feels that he might not be able to reach the patient in time, the MO may record the dying declaration himself in presence of two independent witnesses whose signatures are also affixed in the document. The MO will certify the soundness of mind of the person making the dying declaration. If a death has been reported by the hospital authorities as medicolegal and is decided otherwise by the police after investigation, a certificate to that effect is required to be obtained from the investigating officer along with a copy of the Panchnama when the body is returned to the hospital. Special situations

24. Medicolegal evidence should be preserved and subsequently sent or handed over to the investigating authorities for forensic examination and production as evidence in a court of law. All evidences will be identified, sealed and labeled properly. They will be kept in safe custody and handed over to the investigating officer of the case. Once collected, loss / destruction of evidence is a punishable offence. Failure to collect, destruction or loss of such an exhibit is punishable under Sec 201 of I.P.C. Guidelines for preservation of medicolegal evidence

25. The evidence required to be preserved is related to the nature of a case. In injury cases, the following articles should be preserved in sealed envelopes: Clothing worn by the patient showing evidence of injury such as tears, bullet holes, cuts, blood stains etc. In case of multiple tears, cuts or holes etc., each piece of evidence will be encircled and numbered with matching description in the MLC report and case sheet. Bullets recovered from a body should be marked by etching an initial or a mark on the bottom before preservation. All evidence collected should be mentioned in medicolegal documents to establish the chain of custody in a court of law subsequently.

26. Original copies of all medicolegal documents will be produced whenever asked for in a court of law. All original copies of certificates and reports issued for medicolegal purposes are to be preserved till the finalization of case in the court of law. Commandant/CO of the hospital will ensure that the documents are kept in the custody of an appropriate officer till the case is finally decided or cleared by the police and judicial authorities. In the case of units other than hospitals, the safe custody will be under unit arrangements. Guidelines for preservation of Medicolegal documents

27. A subpoena is a writ issued by the govt. Agency, most often in court, to complete testimony by witness or production of evidence under a penalty for failure. 2 main types:- Subpoena ad testificandum :- Orders a person to testify before the ordering authority or ally. The subpoena can also request the testimony to be given by phone or in person. Subpoena dues tecum :- Orders the person or organization to bring physical evidence before the court. SUBPOENA OR COURT SUMMONS

28. In most instances, a subpoena can be issued and signed by an attorney on behalf of the court in which the attorney is authorized to practice law. If subpoena for a for a higher level Govt. official, then it must be signed by an administrative law judge. Who issues a subpoena?

29. A subpoena should not be ignored. It is a part of court’s legal procedure and failure to respond to it is considered as a contempt of court in most states. The next step is to read through the subpoena, what is being asked or who is being asked to appear. Lastly we should look to see who is requesting the information and for what purpose, so that we can prepare for any testimony that we are required to give at the trial or other proceeding. Finally, the hearing date and time should be checked to avoid penalties and other consequences. Responding to a subpoena

30. Because a subpoena is a court ordered command, a person who fails to obey it, is subjected to civil or criminal contempt of court charges. Civil contempt occurs when the person knowingly fails to produce papers or documents requested or otherwise fails to obey the terms of subpoena. Criminal contempt generally refers to disruptive conduct or disrespectful behavior at court. Criminal contempt can also include refusal to turn over the documents or the other data. PENALTIES

31. Type of wound

32. Abrasion :- An abrasion is a destruction of the skin, which usually involves the superficial layers of the skin only. Caused by friction against a rough surface. Types :- (1) Scratches- A linear abrasion with length but no significant width, (2) Grazes - Most common. Occurs when there is movement between skin and rough surface in contact with it. (3) Pressure abrasions- caused by crushing of the superficial layers of the epidermis (4) Impact/ Patterned abrasions- caused by impact with a rough object, when the force is applied at or near right angles to the skin surface. Age of abrasions :- Fresh – Bright red 12 to 24 hrs - Bright red scab 2 to 3 days- Reddish- brown scab 4 to 7 days- Dark-brown to brownish-black After 7 days- Scab dries and falls leaving depigmented area underneath

33. Contusions (Bruises):- Effusion of blood into the tissues due to the rupture of blood vessels. Painful swelling with crushing and tearing of the subcutaneous tissue usually without destruction of the skin. Age:- At first : Red. Few hours to 3 days : Blue. 4th day : Bluish-black to brown( haemosiderin ). 5 to 6 days : Greenish ( haematoidin ). 7 to 12 days : Yellow (bilirubin). 2 weeks : Normal. Lacerations :- Tears or splits of skin, mucous membrane, muscles and internal organs produced by application of blunt force to broad area of body. Types :- Split lacerations – Due to crushing of skin between two hard objects. Stretch lacerations – Due to overstretching of skin. Avulsion- Laceration produced by shearing force delivering at an acute angle to detach a portion of a traumatised surface or viscus from its attachments.

34. Incised wounds:- Clean cut wound through the tissues, usually the skin, subcutaneous tissue, blood vessels) caused by sharp edged instrument. Wound is longer than it is deep. Age:- Fresh: Hematoma formation. 12 hours: The edges are red, swollen and adherent with blood and lymph 24 hours : A continuous layer of endothelial cells covers the surface; overlying this a crust or scab of dried clot is seen. Incised looking lacerated wound:- Blunt force on areas where skin is close to bone and the subcutaneous tissue is scanty. Sites : Scalp, eyebrows, cheek bones, lower jaw, iliac crest, perineum and shin.

35. Stab wounds:- Produced when the force is delivered along the long axis of a narrow or pointed object such as knife, dagger, sword, chisel, nail, needle, arrow, screw driver etc. Types :- Puncture wounds- When soft tissues are involved. Penetrating wounds- When they enter in a body cavity or a viscus. Perforating wounds- When the weapon enters the body on one side and comes out from other side (through and through) Chop wounds:- Deep gaping wounds caused by blow w ith sharp edge of a fairly heavy weapon like axe, chopper , meat cleaver etc.

36. Grievous hurt:- Under section 320IPC, following injuries comes under grievous. ( 1) Emasculation. (2) Permanent privation of sight of either eye. (3) Permanent privation of hearing of either ear. (4) Privation of any member or joint. (5) Destruction or permanent impairing of the power of any member or joint. (6) Permanent disfiguration of the head or face. (7) Fracture or dislocation of a bone or tooth. (8) Any hurt which endangers life, or which causes the victim to be in severe bodily pain, or unable to follow his ordinary pursuits for a period of twenty days. Dangerous to life:- Those injuries which cause imminent danger to life, either by involvement of important organs or structures, or extensive area of the body. If no surgical aid is available, such injuries may prove fatal. Examples : stab on the abdomen or head or vital part, hurt causing rupture of spleen. Squeezing testicles, incised wound on the neck. Compound fracture of the skull, rupture of an internal organ, injury of a large blood vessel. Opinion about injury

37. Consent – Intensive Care Unit (ICU) - If the patient is in ICU and there is no relative, do not proceed with an examination. While treatment can be done without consent in emergency (s92IPC), medicolegal examination cannot, certainly when treatment has already been started, and medicolegal examination has no bearing on treatment. Minor - If the patient is minor, insist on consent from parents only. If they are not present in hospital, doctor must insist that they be called. Doctrine of loco parentis applies in emergency treatment only and not in medicolegal examination; thus aunt, uncle, etc., present in the ward cannot give consent for medicolegal examination. Marks of identification - Preferable to note two identification marks. Always write in duplicate with carbon paper – ( i ) There is generally no MLC register in wards as one has in casualty. All history, observation, notes, etc., should be written on loose papers. (ii) Make a request to sister-in-charge to give several papers with carbon papers. (iii) The papers should not be blank A4 sheets, but official hospital papers with its names, etc., on the top. Blank A4 sheets can be challenged later in court as having been made outside. SUMMARY

38. Numbering of pages – ( i ) All pages of case sheet are to be numbered. (ii) The numbering should be at top right and signed by sister-in-charge below the numbering. (iii) Original copy should be affixed to the case sheet. Carbon copy should be brought back to the department for filing. This will be useful for a later appearance in court. Sign all pages - to prevent anyone adding pages later. Examination - Make a complete body examination, even if you have been specifically called only for local examination. Diagrams - Labeled diagrams indicating location, size, and shape must be made. Take photographs - For better recall during court hearings, etc. Information to Police - This will almost always be required. Sister-in-charge usually has a ward book/call book, etc., through which doctors are called to visit wards. On the same book, an entry can be made for police. The ward boy can take it to the casualty outside which policeman is normally posted. He signs the register and keeps a copy of doctor's request. Be polite

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