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

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.

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.

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.
a) Accidents like Road Traffic Accidents (RTA),industrial
accidents etc.
b) Assault, including domestic violence and child abuse
c) Cases of trauma with suspicion of foul play
d) Alcohol intoxication, poisoning

6. e) Undiagnosed coma
f) Chemical injuries
g) Burns and scalds
h) Firearm injuries
i) Attempted suicide
j) Dead brought to the emergency dept and deaths
occurring within 24 hrs of hospitalisation without
establishment of diagnosis
k) Death in operation theatre
l) Custodial deaths
m) Unnatural deaths
n) Sexual offences
o) 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.

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.

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.

10.  Patient arrested by police-
i. 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.
ii. 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
iii. 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).

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.

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.

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.

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.

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.

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.

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 –
(a) The contents of the parcel should be described in detail. There can be more than one
weapon.
(b) 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).

21. (c) In the case of heavy blunt weapon, weight of the weapon must be recorded.
(d) 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.
(e) 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.
(f) 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.

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.

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.

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:
i. Clothing worn by the patient showing evidence of injury such as tears,
bullet holes, cuts, blood stains etc.
ii. 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.
iii. Bullets recovered from a body should be marked by etching an initial or a
mark on the bottom before preservation.
iv. 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.

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.

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.

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.

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.

32. Due to blunt
force
• Abrasions
• Contusions
• Lacerations
• Fractures
and
dislocations
Due to sharp
force
• Incised
wounds
• Stab wounds
• Chop
wounds
Firearms
• Firearm
wounds
• Blast injuries

33.  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

34.  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 :-
i. Split lacerations –Due to crushing of skin
between two hard objects.
ii. Stretch lacerations – Due to overstretching of
skin.
iii. Avulsion- Laceration produced by shearing force
delivering at an acute angle to detach a portion of
a traumatised surface or viscus from its
attachments.

35.  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.

36.  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:-
i. Puncture wounds- When soft tissues are
involved.
ii. Penetrating wounds- When they enter
in a body cavity or a viscus.
iii. 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 with sharp edge of a fairly
heavy weapon like axe, chopper, meat
cleaver etc.

37.  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.

38.  Consent –
(i) 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.
(ii) 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.

39.  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