Overview

Overview of
of Medico-
Medico-
Legal
Legal Report
Report
preparation
preparation
Dr Gautam Biswas
Prof. & Head
Dept. of Forensic Medicine
• Casualty medical officer or any other
registered medical practitioner may
be called upon to examine the injured
person.
• Medico-legal injury cases should be
examined without delay at any time
of the day or night.
• All details of examination of the injured
person, whether admitted into hospital or
treated in OPD have to be entered in a
Medico-legal Register.
• This register is a confidential record and
should be in safe custody of the medical
officer. It has to be produced in court of
law, if asked for.
• The doctor is required to fill in a
printed form of injury certificate,
one copy of which is given to the I.O.
in a sealed cover and the other
retained, for future reference.
 Particulars to be noted
• Serial number, admission number.
• Preliminary particulars: Name, age, sex, address,
and father’s/husband’s/guardian’s name.
• Name of the person who accompanied the injured
person with address and relation.
• Date, time, and place of examination.
• Name and number of the accompanying police
constable and police station to which he belongs.
• Consent of the person for examination.
• Two identification marks.
Age
• It is to be noted as 'stated age‘ as
expressed by the patient/legal
guardian or ‘about…..’ years.
 Brought and identified by
• The identifying person will affix his
signature with date (in case of police
personnel - designation/No. and the
name of the police station where he
is attached is to noted).
 CONSENT
• Before starting of examination,
informed consent from the patient or
the legal guardian is to be taken in
writing and that also in duplicate
(preferably in presence of witness).
The statement is to be recorded as:
• I am willing for my medico-legal
examination
• I have not been examined earlier
• I will show all my injuries on my person
• I have been explained that the result of
the examination may go in my favor or
against.
Signature / LTI with date of the
person/guardian
 Identification marks
• It is better to note down at least 2
identification marks.
• If only one identification mark is recorded,
there may be a chance of loss of one mark
due to any reason - scarification or
amputation of that part; and during
subsequent examination it may cause
difficulty in identification.
The marks used for identification:
• Congenital marks - birth marks,
moles, nevus, supernumerary
teeth/fingers, cleft palate etc.
• Acquired marks - scar, tattoo,
deformities, malunited fractures etc.
E.g.:
• White scar mark 1.2"xO.1" placed obliquely
over anterior surface of left forearm, 8"
below elbow joint and 9Y2" above wrist
joint.
• Black mole of O.2"x0.1" size placed over
right side of face, 1" in front of right
antitragus, 3 "to the right of midline and
5.5"below vault of scalp.
 History
• ‘Alleged’ short history of the case as
stated by the patient/by the persons
accompanying the patient.
• If the patient is conscious and able to
speak, history of the incidence is recorded
from the patient.
• If the patient is unconscious, history of
the incidence is then taken from the
persons accompanying the patient.
• If the condition of the patient is
serious, arrangement for dying
declaration should be made.
• During examination of a female
subject, a nurse/female attendant
MUST BE PRESENT.
 General physical
examination
• Consciousness, orientation, pulse,
temperature, blood pressure,
reaction of pupils to light
• Size of the victim i.e. stature, weight
and development.
 Type of injury
• All injuries observed, even
insignificant, should be noted. Nature
of injuries i.e. abrasion, contusion,
laceration, incised wound etc. should
be noted.
• Multiple injuries can be grouped
anatomically e.g. injuries of head, of
the trunk or of limb.
• A lens should be used to get an
accurate idea of the nature of edges,
ends and floor of the wound.
• Presence of any foreign material in
wound e.g. glass, hair or dirt should
be noted.
 Size of injury
• All injuries should be measured with
a tape and never guessed, and amount
of blood extravasated should be
measured and photographs or
sketches showing the position and
size of the wound are desirable.
 Shape & direction of injury
• Shape of the wound e.g. circular, oval
or triangular should be noted and also
the beveling of the edges.
• Direction of the wound i.e. horizontal,
vertical or oblique should be noted
with regard to anatomical position of
the body.
 Location of injury
• Exact situation of wound with
reference to some anatomical
landmark e.g. midline, bony structure,
umbilicus should be mentioned.
• Technical terms should be avoided as
far as possible.
 Management
• It is appropriate to mention the
investigations, procedures and
management of the patient.
• If investigation or treatment is
ongoing, a further (supplementary)
report may be required.
 Samples & specimens
• Samples and specimens collected should be
properly identified, sealed and labeled.
• They should be kept in safe custody and
handed over to the I.O. of the case.
• Specimens 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 IPC.
• All evidence collected should be
mentioned in MLR to establish the
chain of custody in a court of law
subsequently.
 What was the type of
weapon used?
• In many cases, examination of the
wound and clothing give fairly
definite information about the kind
of weapon.
• With stabs and incised wound there is
not much difficulty.
 What was the nature of
the injury ?
• Opinion is given as to whether the
injuries were simple, grievous or
dangerous in nature.
• Against each injury, it should be
noted whether it is simple, grievous
or dangerous.
 Grievous hurt/injury
Sec. 320 IPC defines the grievous hurt and
comprises of 8 clauses:
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 impairment of
the powers of any member or joint
6. Permanent disfigurement of the head or
face
7. Fracture or dislocation of a bone or tooth
8. Any hurt which:
a. Endangers life
b. Causes the victim to be in severe bodily pain for
20 days
c. Unable to follow his ordinary pursuits for a period
of 20 days
• Dangerous injuries are those which
cause imminent danger to life without
medical/surgical intervention either
by involvement of important organs
or structures, or an extensive area
of the body.
• E.g. Any tear in dura mater,
intracerebral hemorrhages, cutting of
trachea, laceration of lungs resulting
in hemothorax, rupture/perforation
of GIT, any rupture of large
arteries/veins.
• Injured person must be kept under
observation, if nature of particular
injury cannot be made out at the time
of examination e.g. head injury or
abdominal injury.
• In all injuries, when fracture of a
bone is suspected, an X-ray should be
done for confirmation.
• Whether an injury is simple, grievous
or dangerous, is decided on the basis
of status of injury at the time of
infliction and not after
medical/surgical intervention.
 What is the time passed
since infliction of the injury?
• Opinion is based on the state of
healing of the injuries as was
recorded in the column of
examination of the injuries.
 Certification
• All the particulars are entered in the
injury report by the doctor in his own
handwriting.
• After completion of the report, the
doctor must sign along with his name,
designation & registration no. at
appropriate place.
 Comments
• It is advisable to distinguish between
fact and opinion.
• The facts being what was seen or done
and the opinion being what was
inferred or assumed.
• The doctors experience and expertise
are fundamental to the weight given
by the court to their opinion.
• Some opinions sought may be beyond the
expertise of the doctor. It is perfectly
reasonable to decline to provide a
statement in this situation.
• Resist fitting opinions to the allegation and
acknowledge and weigh alternative
conclusions.
• When formulating an opinion it is essential
to maintain impartiality and objectivity.
• Whenever possible, ask a colleague/
senior to review and comment upon
the report prepared.
• It is difficult to alter a report once
it has been issued.
• Constructive criticism at this time is
preferable to cross-examination in
the witness box.
• When a victim of suicide, homicide or
accident dies in hospital, the medical
officer should report the matter to the
police immediately.
• When a dead body is brought to the
hospital, do not examine the injuries.
• Any weapon sent by the police, which is
alleged to have been used in producing
injuries should be examined for marks of
bloodstains, hair or pieces of cloth
adherent to it and should be returned to
the police after it is sealed.
• Clothes should be examined for the
presence of cuts, tears or burns and it
should be seen whether these correspond
to the injuries on the body.
 Conclusion
• The preparation of a MLR is an
essential part of the service
provided by hospital doctors.
• Task should be approached with a
desire to accurately communicate the
clinical situation encountered.