UNIVERSITY INSTITUTE OF LEGAL STUDIES

MEDICO-LEGAL
REPORTS

Submitted by:-
Submitted to:-

Dr. Ajay Ranga

Dishant Mittal

Assistant Professor, Uils, 130/15 (13754)

Panjab University. Section C

B.com L.L.B
 SUPERVISOR’S CERTIFICATE
This is to certify that the work incorporated in the project report titled ― “MEDICO LEGAL
REPORTS” submitted by Dishant Mittal, (130/15) in partial fulfilment of the requirement for
the award of internal assessment in the subject of Forensic Science to University Institute of
Legal Studies, Panjab University, Chandigarh is a record of the candidate’s own work carried
out by him under my guidance and supervision. To the best of my knowledge and belief the
project report:

1. Embodies the work of the candidate herself,

2. Has duly been completed,

3. Is up to the desired standard both in respect of contents and language for being referred to
the examiners.

Dr. AJAY RANGA

Assistant Professor, Uils,

Panjab University,

Chandigarh.
 STUDENT CERTIFICATE
I, the undersigned, hereby solemnly declare that the Project Report titled: “MEDICO LEGAL
REPORTS”, submitted to the University Institute of Legal Studies, Panjab University,
Chandigarh, in partial fulfillment of the requirement for the award of internal assessment in
the subject of Forensic Science, is an original and bonafide research work of mine and has
been done under the supervision of Dr. Ajay Ranga (Asst. Professor), University Institute of
Legal Studies, Panjab University, Chandigarh. The project has not been submitted anywhere
else at any time and all the information declared hereby is true to the best of my knowledge.

Place: Chandigarh
Dishant Mittal

130/15
 Acknowledgement

Success is a blend of multiple efforts. The final import of this project is also a
result of the sheer hard work and constant support of many people. I would like
to take this opportunity to thank all of them.

To begin with, I would like to express my humble gratitude to my teacher, DR.

AJAY RANGA, for her able guidance and mentoring. The meticulous manner in
which she teaches has paid significantly in the completion of this project.

Secondly, I would like to thank my department, University Institute of

Legal Studies, Panjab University, Chandigarh, for providing such an
expansive library which provided me all the relevant material required for this
project.

Last but not the least, I would like to express my profound gratitude to my
parents and my friends who have constantly supported and motivated me
throughout this project.

Dishant Mittal
 Table of Contents
SUPERVISOR’S CERTIFICATE...................................................................................................2

STUDENT CERTIFICATE.............................................................................................................3

Acknowledgement...........................................................................................................................4

Table of Contents.............................................................................................................................5

INTRODUCTION: FORENSIC SCIENCE....................................................................................6

MEDICO-LEGAL REPORTS.........................................................................................................7

Types of medico-legal reports:....................................................................................................7

Format for a medico-legal report.....................................................................................................8

Sample Report.................................................................................................................................9

Procedure to admit Medico-Legal reports before court.................................................................10

Reasons to form Medico-Legal reports.........................................................................................12

Obligations on treating Doctor while preparing Medico-Legal report..........................................13

Professional obligations.............................................................................................................13

Legal obligations.......................................................................................................................13

Conclusion.....................................................................................................................................15

BIBLIOGRAPHY..........................................................................................................................16
 INTRODUCTION: FORENSIC SCIENCE
Forensic science, also known as criminalistics. It is the application
of science to criminal and civil laws. Mainly on the criminal side during criminal
investigation, as governed by the legal standards of admissible evidence and criminal
procedure.

Forensic medicine is a branch of science; which deals with the application of medical
knowledge to aid in the administration of justice. Forensic science is the application of
medical knowledge, scientific knowledge and technical aspects to solve the crime and to aid
in justice.

Forensic scientists collect, preserve, and analyze scientific evidence during the course of an

investigation. While some forensic scientists travel to the scene of the crime to collect the
evidence themselves, others occupy a laboratory role, performing analysis on objects brought
to them by other individuals1.

Forensic Science Laboratories are multi-disciplinary system, well equipped with extremely
specialized and rationalized infrastructure of international standards. It is competent of
carrying out any challenging scientific work related to crime. The directorate analyses
various criminal cases under different laws like I.P.C., Cr.P.C, Indian Arms Act, NDPS Act,
Explosive Substances Act, Petroleum Act, Mumbai Police Act, Essential Commodities Act,
Bombay Prohibition Act, Motor Vehicle Act, I.T.Act, Wild Life Protection Act, TADA,
MCOCA etc and

Forensic evidence is also used to link crimes that are thought to be related to one another. For
example, DNA evidence can link one offender to several different crimes or crime scenes (or
exonerate the accuse d).Linking crimes help law enforcement authorities to narrow the range
of possible suspects and to establish patterns of for crimes, which are useful in identifying
and prosecuting suspects. Forensic scientists also work on developing new techniques and
procedures for the collection and analysis of evidence. In this manner, new technology can be
used and refined not only to keep forensic scientist on the cutting edge of science, but to
maintain the highest standards of quality and accuracy.

1
K.S. Narayan Reddy, Medical Jurisprudence and Toxicology (Law Practice and Procedure) (ALT Publications,
2006)
 MEDICO-LEGAL REPORTS
Medico legal reports are the documents prepared by the medical officers in the role of a
medical expert witness in a legal case in obedience to a demand by an authorised police
officer or a Magistrate and are chiefly referred to in criminal cases relating to assault, rape
murder, and poisoning accidents. These reports consist of three parts, namely:-

1. Introductory or preliminary data, for example full name, age, address, date, place and
time of examination, including identity marks;
2. the facts observed on the examination; and
3. the opinion or the inference drawn from the facts2.

Types of medico-legal reports:

A request for a treating doctor to prepare a report for legal purposes may be received from:

a) a patient
b) a solicitor
c) an insurer
d) a statutory authority (eg WorkCover)
e) an employer
f) the police
g) a court.

2
K. Kannan and K. Mathiharan, Textbook of Modis Medical Jurisprudence and Toxicology (Buttersworths
India, 2012)
 Format for a medico-legal report
In the report, it is useful to include headings and, if the report is long, numbered paragraphs.
A suggested format for a medico-legal report is as follows:
a) patient’s name and date of birth
b) requesting party’s name, date of the request and purpose of the report
c) your credentials, including professional address, qualifications, experience and
position at the time you were involved in the patient’s management
d) medical facts in chronological order:
– presentation (history and symptoms)
– examination findings
– investigations
– provisional diagnosis
– treatment/management
– current condition
e) response to questions (if any)
f) your opinion (if appropriate)
g) signature and date of the report.

The extent of the medical information included in the report will be dependent on the nature
of the report and is a matter of clinical judgement. Information that is not relevant to the
report need not be included but relevant matters must not be omitted (eg a pre-existing
history of back pain should be disclosed in a workers compensation claim for a back injury).
 Sample Report
1. On 1 February 2018 I was contacted by Constable Smith and asked to provide a statement
in relation to the care of Jane Doe. Consent for the report was provided by Ms Doe.

2. In preparing this statement, I have referred to the medical records from a consultation with
Ms Doe on 1 December 2017. I have a good recollection of the events discussed in this
statement and have refreshed my recollection by referring to the medical records.

3. I am a registered medical practitioner. I obtained my medical qualifications, MBBS,

following completion of my degree at Bland University in 2016.

4. At the time of seeing Ms Doe, I was employed by the Royal Big Hospital (RBH) as an
intern. I have been employed in this capacity since January 2017.

5. On 1 December 2017 I was working in the Emergency Department of RBH, commencing

at 2.00pm. At approximately 5.00pm I examined a female patient who identified herself as
Jane Doe.

6. When asked what happened, Ms Doe stated her husband had punched her in the face. She
had not lost consciousness.

7. On examination, I noted the patient was tender under her left eye (infraorbital margin) and
cheek bone (zygoma), with widespread fine bruising (petechiae). The patient was fully
conscious. There was blood inside her left eye, in front of the iris (hyphaema), with markedly
decreased visual acuity (V/A).

8. I ordered an x-ray of the facial bones. The x-ray did not reveal any fractures.

9. As a result of my examination and investigations, I am able to state that the following

injuries were present: hyphaema of the left eye (blood inside the eye) with decreased vision
in the left eye; bruising of the left zygoma (cheekbone) with no fracture on x-ray.

10. I referred the patient to a specialist Ophthalmologist for ongoing care and follow-up. I
had no further contact with the patient. I am unaware of the expected prognosis.
 Procedure to admit Medico-Legal reports before court
In India, we have adversarial system of justice administration and ordinarily medical
evidence is admitted only when the expert gives an oral evidence under oath in the courts of
law expect under special circumstances like:

a) When evidence has already been admitted in a lower court;

b) Expert opinions expressed in a treatise;

c) Evidence given in a previous judicial proceeding;

d) Expert can not be called as witness;

e) Hospital records like admission/discharge register, birth/death certificates etc.

In order that they may be admitted as exhibits in evidence, these reports should be written by
the medical officer at the time of the examination or immediately afterwards. They form the
chief documents in judicial inquiries and likely to pass from the lower to higher courts, as
well as to be placed in the hands of pleaders. Hence, utmost care should be used in preparing
them. No exaggerated terms, superlatives, or epithets expressing one's feelings should be
used; they should not be judgmental. For instance, one should never say that 'extensive
damage to the skull and brain was the result of a particularly brutal, murderous assault, or the
deceased was evidently subjected to a particularly murderous attack in which throttling was
also indulged in3.

After noting the facts accurately and in detail, the opinion should be expressed briefly and to
the point. The medical officer must remember that he should always base his opinion on the
facts observed by him and must not be influenced by the statements made by others. In
drawing conclusions in medico legal reports, he should not depend upon information derived
from any other source. However, if these opinions tally with the information supplied, he
should so in his report4.

If it is not possible to form an opinion immediately after examining him, an injury case
should be kept under observation, and the fact notified to the police. A hasty opinion must not
be formed, even if pressed by the police.

3
http://www.legalserviceindia.com/article/l153-Forensic-Evidence.html.
4
“Evidence-based evidence: a practical method for Bayesian analysis of forensic evidence”, Law, Probability
and Risk, Volume 14, Issue 2, June 2015, Pages 135–145, https://doi.org/10.1093/lpr/mgu019
A post-mortem or injury report must be proved by the examination in the court of the medical
officer who conducted the post-mortem or injury examination, unless the case falls under
section 291 of CrPC, its genuineness has been admitted by the accused under section 294 of
the CrPC. Mere tender of the post-mortem report or injury report in evidence is not enough.
The report of the doctor must be filed in the court. The contents of the report contained in the
affidavit of another person are not admissible in evidence5.

5
K. Mathiharan and Amrit K Patnaik, Modi's Medical Jurisprudence and Toxicology (LexisNexis,
Buttersworth, 2010).
 Reasons to form Medico-Legal reports
In medical practice, most of the doctors would come across which at the time or
subsequently, would be called a "medico-legal case" (MLC). An MLC is a case of
injury/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 6. It can also be defined as a
case of injury or ailment, etc., in which investigations by the law-enforcing agencies are
essential to fix the responsibility regarding the causation of the said injury or ailment. Cases
that are to be treated as medicolegal are: (1) All cases of injuries and burns - the
circumstances of which suggest commission of an offense by somebody (irrespective of
suspicion of foul play); (2) all vehicular, factory, or other unnatural accident cases specially
when there is a likelihood of patient's death or grievous hurt; (3) cases of suspected or evident
sexual assault; (4) cases of suspected or evident criminal abortion; (5) cases of
unconsciousness where its cause is not natural or not clear; (6) all cases of suspected or
evident poisoning or intoxication; (7) cases referred from court or otherwise for age
estimation; (8) cases brought dead with improper history creating suspicion of an offense; (9)
cases of suspected self-infliction of injuries or attempted suicide; (10) any other case not
falling under the above categories but has legal implications7.

After examination of a medicolegal case, a medicolegal report should be issued. The reports
must be handed over to the police officials after getting them duly received on the duplicate
copy of the same. The records should be kept under lock and key, in the custody of the doctor
concerned or may be kept in the record room of hospitals, where such facility is available.
There is no specified time limit after which the medicolegal reports can be destroyed; hence,
they have to be preserved. In view of the multitude of cases against the doctors under the
Consumer Protection Act, it is advisable to preserve all the inpatient records for a period of at
least 5 years and outpatient department records for 3 years8.

6
Dogra TD, Rudra A. Lyon′s Medical Jurisprudence & Toxicology. 11 th ed. New Delhi: Delhi Law House;
2005. p. 367
7
Mathiharan K, Patnaik AK. Modi′s Medical Jurisprudence and Toxicology. 23 rd ed. New Delhi: LexisNexis
Butterworths; 2005. p. 350.
8
Singhal SK. Singhal′s the doctor and law. 1 st ed. Mumbai: MESH Publishing House Pvt. Ltd.; 1999. p. 137.
 Obligations on treating Doctor while preparing Medico-Legal report
Professional obligations
A Code of Conduct for Doctors in India states that good medical practice involves:

a. being honest and not misleading when writing reports and certificates, and only
signing documents you believe to be accurate
b. taking reasonable steps to verify the content before you sign a report or certificate,
and not omitting relevant information deliberately
c. preparing or signing documents and reports, if you have agreed to do so, within a
reasonable and justifiable time frame
d. making clear the limits of your knowledge and not giving opinion beyond those limits
when providing evidence.

Legal obligations
A number of courts have an Expert Witness Code of Conduct, which a person must comply
with in order for their report and evidence to be admissible in court. These codes are
applicable to a medical expert who is providing an opinion at the request of one of the parties
in the matter before the court. In most cases, these doctors will be independent medical
experts who have had no direct involvement in the care of the patient.

On occasion, however, a treating doctor may be asked to provide a report and abide by the
Expert Witness Code of Conduct. If you are asked to abide by the Expert Witness Code of
Conduct, you should ask the requesting party to provide you with a copy of the relevant code,
and seek advice if you are unsure of your obligations. Requirements in an Expert Witness
Code of Conduct include:

a. Duty to the court

– An expert has an overriding duty to assist the court on matters relevant to the
expert’s area of expertise.
– An expert is not an advocate for a party.
b. Form of expert report – the report must include:
– the expert’s qualifications
– all material facts and assumptions on which the report is based
– the reasons for each opinion expressed
 – if applicable, that a particular question or issue falls outside the expert’s area
of expertise
– references to any literature or other material relied on to support the opinion
– any examinations, tests or other investigations the expert has relied on, and
details of the person who carried them out
– acknowledgement of and agreement to abide by the code
– statement if the opinion is provisional because there is insufficient data or for
any other reason.

It is important to be aware that any opinions expressed in a medico-legal report will often
come under particular scrutiny by the reader of the report and may be publicly tested and
challenged in court. The weight given to the opinion will generally be dependent on the
expertise and experience of the author.

A treating doctor is not obliged to provide an opinion in a medico-legal report. Indeed, some
opinions may be beyond the expertise of the treating doctor. In these circumstances, it is
appropriate to decline to provide an opinion, and to provide factual information only. An
independent expert medical opinion may then be sought, based on the facts provided by the
treating doctor and/or the medical records.
 Conclusion
There is a unanimity that medical and forensic evidence plays a crucial role in helping the
courts of law to arrive at logical conclusions. Therefore, the expert medical professionals
should be encouraged to undertake medico legal work and simultaneously the atmosphere in
courts should be congenial to the medical witness. This attains utmost importance looking at
the outcome of the case, since if good experts avoid court attendance, less objective
professional will fill the gap, ultimately affecting the justice. The need to involve more and
more professionals in expert testimony has been felt by different organizations. The
American College of physician's guidelines for the physician expert witness emphasizes on
broad physician participation in providing this much-needed assistance to the legal system.
The college believes that more doctors should serve as experts as a component of their
professional activities in order to meet the need for medical testimony

This objective of greater expert participation can only be achieved by addressing to the
apprehensions that ponder the mind of medical professionals. In the light of new
developments in the forensic science, the home ministry, Govt. of India constituted a
committee under the chairmanship of Dr. Justice V.S Malimath to suggest reforms in the
criminal justice system. This committee suggested comprehensive use of forensic science in
crime investigation. According to the committee DNA experts should be included in the list
of experts given in section 293(4) of Cr.P.C, 1973
 BIBLIOGRAPHY

BOOKS

1.) K. Kannan and K. Mathiharan, Textbook of Modis Medical Jurisprudence

and Toxicology (Buttersworths India, 2012).
2.) K. Mathiharan and Amrit K Patnaik, Modi's Medical Jurisprudence and
Toxicology (LexisNexis, Buttersworth, 2010).
3.) K.S. Narayan Reddy, Medical Jurisprudence and Toxicology (Law Practice
and Procedure) (ALT Publications, 2006)

Websites

1.) “Evidence-based evidence: a practical method for Bayesian analysis of

forensic evidence”, Law, Probability and Risk, Volume 14, Issue 2, June
2015, Pages 135–145, https://doi.org/10.1093/lpr/mgu019
2.) Murphy, Erin. “The New Forensics: Criminal Justice, False Certainty, and
the Second Generation of Scientific Evidence.” California Law Review, vol.
95, no. 3, 2007, pp. 721–797 available at www.jstor.org/stable/20439109.