Maxillofacial Surgeon Medico-Legal Expert

Maxillofacial Surgeon as fact Witness for Medico-
legal Cases
Dr. Sandeep Sagar Panda
First Year Post graduate student.
Oral & Maxillofacial Surgery
SCBDCH
(2018)

Contents
• INTRODUCTION
• DUTIES OF REGISTERED MEDICAL PRACTITIONER
• REGISTRATION OF MEDICO LEGAL CASE
• DOCUMENTATION OF A MEDICOLEGAL CASE
• PREPARATION OF MEDICO LEGAL REPORT
• MEDICO LEGAL ASPECTS OF INJURIES
• MAINTENANCE OF RECORDS
• ADMISSION AND DISCHARGE OF MLC
• LEGAL PROVISIONS
• CONCLUSION
• REFERENCE

Introduction
An Oral and Maxillofacial surgeon at any time during the
practice will encounter medico legal cases (MLC).
In today’s arena, it is of utmost importance to be aware of
legal system and law of the land. An OMF surgeon needs to have
thorough understanding in recording and maintenance of the
details of all MLCs and presenting the same in the court.
Professional guidelines for expert witness are often not well
recognised as those relating to the clinical practice. Surgeon has an
obligation to conduct him/herself to highest ethical standards.

What?
A medico-legal case is one where besides the medical
treatment; investigations by law enforcing agencies, are
essential to fix the responsibility regarding the present
state / condition of the patient. The case therefore has
both medical and legal implications

Who?
The doctor who has -First contact with patient should
prepare an ML case report
In rape victims the examination and preparation of MLC
report 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?
• Road Traffic Accidents, 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

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.

1. Consent
2. Confidentiality
3. Maintenance Of Records
4. Collection And Preservation Of Samples
5. Dying Declaration
DUTIES OF REGISTERED MEDICAL
PRACTITIONER

Consent for Medical Examination
Consent for medico legal examination to be taken in written in all cases. In MLC
an informed consent includes information that :
a)The examination to be conducted would be a medico legal one and would
culminate in the preparation of medico legal injury report.
b) All relevant investigations needed for the said purpose would be done.
c) Findings of the report my go against the patient if they don’t tally with the
history given.
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.

Confidentiality: A doctor is required to keep secret all information regarding the
patient that he comes across during course of treatment.ML reports are to be
treated as confidential. It should not be directly issued to patient. They have to be
handed to the police official ,after getting them duly received on the carbon copy of
the same.
Collection and Preservation of Samples :all relevant specimen should be collected
and after proper labelling are to be sealed under doctor supervision. This should be
handed over to concerned police along with ML report. Proper requisition letter
detailing the tests to be conducted on such samples.

Life saving is the foremost duty of a doctor and a hospital,
in accident or medico-legal cases. 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.
ALL Legal Formalities stand Suspended till this is
achieved.
This has been clearly exemplified by Hon’able
Supreme court of India in Parmananda katara vs Union of
India.
REMEMBER

TREATMENT is PRIORITY
THE PRIME RESPONSIBILITY
OF
DOCTOR IS THE INSTITUTION OF
PROPER TREATMENT TO THE
PATIENT PROMPTLY

Registration of medico legal case
The decision to register any case as a medico legal case
rests solely with the doctor who attends to the case. Any
requests by the relatives ,friends or the patient himself for
not registering the case as MLC should not be entertained by
the attending doctor. Even if the incident [e.g.trauma] has
happened several days ago, if the complaints merit an MLC
,then MLC should be registered.

Contd..
When the patient has been referred by another hospital where a
MLC has been registered, mention of the same should be made in the
patient admission records.
In cases where a MLC has not been registered in the previous
hospital, a copy of the referring notes should be attached with the
medico-legal report.
In cases where MLC is not registered initially and if a treating
doctor or specialist feels that a case has to be registered as MLC, same
has to be communicated with the casualty medical officer (CMO) for
necessary action.

Failure to preserve the necessary samples for subsequent examination
in Forensic Science Laboratory or releasing the dead body of a patient
in a criminal case without inquest and Post- Mortem (PM) may render a
doctor liable to be charged under IPC 201, punishable with
imprisonment up to 7 years and fine, for causing disappearance of
evidence.

Intimation to Police
For all the MLC that are registered, written intimation
must be sent to the police station that falls in the
area of jurisdiction.In larger hospital a police
constable is available round the clock and he takes
cognizence of such medico legal cases.All this is
necessary to avoid any future complaint that police
was not been informed in time.

Time Limit for Registering a Medico
Legal Case
A MLC should be registered as soon as a doctor suspect foul
play or feels it is necessary to inform to Police at any time after
admission. There should not be any unnecessary delay.
 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.
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.
 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.
No Abbreviation or short form written.
Legible Handwriting is maintained.
Two copies are done orginal copy given to police and
the carbon copy remained with …
DOCUMENTATION OF A MEDICOLEGAL CASE contd..

Preparation of Medico Legal Report
1. Preamble :
(a) Registration no
(b) MLC No.
(c) name of the individual, age, sex, address.
(d) Brought by
(e) Date and time of Examination
A short description of the ‘‘alleged history’’ should be mentioned along with
where and when it happened. In cases where a patient cannot give any history
himself, the name and particulars of the person giving the alleged history should be
mentioned.

2. Findings/observations
As in all cases, examination starts with general physical
examination and recording of vital parameters. The mental status,
vomiting, seizures level of orientation must be mentioned. Two
identification marks like scars, moles or tattoos should be noted. The
report should include a full description of any injuries or other conditions
found. While describing an injury its type (abrasion, contusion, laceration,
stab or incised wound), its dimension (length, breadth and depth where
possible) and location (position in relation to a bony point) must be
mentioned.

3. Opinion
This includes the classification of injuries, whether simple or
grevious, the nature of the weapon used and any other information that
may be helpful to police. While giving opinion on the age of injuries
findings such as fresh hemorrhage, clot, colour changes in healing, bruise,
pus formation should be taken into account.

• In case an opinion regarding the nature of injury cannot be
given on clinical examination alone, opinion may be
reserved till the receipt of x-ray or other investigation
reports. When x-ray examination is to be carried out
,radiologist should mention MLC number in the film and also
in the x-ray report. Mention must be made of any material
found on the body and all samples collected and sealed.

• Report should be completed as early as possible after examining a
person and instituting life-saving treatment where required. Two
copies of a report should be prepared.The original is handed over to
the police and a copy kept for reference. The reporting registered
doctor/medical practitioner must sign the report, write his name and
affix the official stamp.

The word injury denotes kind of physical trauma which causes structural anatomical
change is called injury. Among the various aspects of injury, nature, severity, and
circumstances, of any injury have great importance in criminal law. Injury can be classified
in two different aspects namely legal and medico legal.
Classification as per law
1.Simple
2.Grevious
Medico-Legal classification
1.Accidental
2.Self-inflicted
3.Homicidal
4.Fabricated
Medico Legal aspects of injuries

Maxillofacial surgeon should be conversant with the
following provisions of the Indian Penal Code
(IPC),1860 that have a bearing upon the legal
consequences of the classification of a wound or injury
into simple or grevious:
Section 319, I.P.C—Hurt-whoever causes bodily pain,
disease or infirmity to any person is said to cause hurt
Section 320, I.P.C—Grevious hurt-the following kinds of
hurt are designated as grevious:

Firstly-Emasculation
Secondly-Permanent Privation of the Sight of Either
Eye
Thirdly-Permanent Privation of the Hearing of Either Ear
Fourthly-Privation of any Member or Joint

Fifthly-Destruction or permanent impairment of the
powers of any members or joint
The functional loss of a limb or its part constitutes grevious
injury. The loss of function might be partial or complete.
Sixthly-Permanent Disfiguration of the Head or Face

Seventhly- Fracture or Dislocation of a Bone or Tooth
Eighthly-Any hurt which endangers life or which causes
the sufferer to be, during the space of twenty days, in
severe bodily pain, or unable to follow his ordinary
pursuits.
There are three classes of injury that are defined as
grevious hurt under this clause.
1.Endangering life
2.Severe bodily pain for twenty days
3.Inability to follow ordinary pursuits for twenty days.

The legal importance of these eight conditions lies in
the enhanced punishment that might be awarded to
the person found guilty in inflicting grevious injuries
as compared to the person who has inflicted a simple
injury.
Legal process starts almost immediately after any
injury is reported to the police. The importance of an
injury is directly related to its severity in the clinical
practice and superficial injuries tend to receive little
attention. Every injury leads to the detection of the
agent or weapon that caused it. Therefore proper
descriptive terms should be employed to record
findings. Accuracy of terminology used is of
paramount medico-legal importance.

Medico-Legal Aspects of Abrasions
An abrasion is a superficial injury involving only the outer
layers of the skin. It is caused by the friction or pressure
between the skin and some rough object
Depending upon the manner in which they are caused
abrasions are classified into:
Scratch or linear abrasion

Graze or sliding abrasion
Patterned or imprint
abrasions

Abrasions are generally of simple injuries and at times they may
be the only external sign of a serious internal injury. Extensive
abrasion is usually suggestive of an accident, while the
patterned or imprint abrasion helps to know the type of weapon
used. The linear or graze abrasion helps in assessing the
direction of application of force and the relative position of the
victim and the assailant.

Medico-Legal Aspects of Bruises or Contusions
A contusion is produced by extravasation of blood into the
tissues, as a result of damage to small vessels by a blunt
impact. There is no disruption in the continuity of the skin. A
fresh bruise is usually tender and slightly raised above the
surface of the skin.

Bruises are usually accidental and are seen over bony
prominences. Self-inflicted bruises are rare, as their
production is painful. Patterned bruising helps in
identification of object or weapon.

Medico-Legal Aspects of Lacerations
Lacerations are tears or splits of the skin, mucous
membranes, muscles or internal organs produced by
application of blunt force, which crushes or stretches
tissue beyond the limits of their elasticity. The margins
are irregular, ragged and frequently bruised. There may
be strands of bridging tissues consisting of blood
vessels, nerves, elastic and connective tissue fibre
across the floor.

Medico-Legal Aspects of Incised Wounds Incised wound is one
produced by a sharp edged weapon, whose length on the skin is
greater than
its depth. The margins are well defined, cleanly cut and free from
contusions and abrasions.

Medico-Legal Aspects of Stab or Punctured
Stab wounds are produced by a pointed instrument, in which
the depth of penetration into the body is greater than the length
of the wound on the skin. A knife is the most common weapon
used to produce a stab wound.

Common Mistake committed in the emergency
department from medico legal point of view;
Inaccurate description of a wound.
Failure to correlate circumstances of a case with clinical findings,
before venturing to record findings resulting in incorrect
description of wounds in general and firearm wounds in
particular.
Ignoring stains and tears in clothing Failure to preserve clothing
where required.
Ignorance leading to non-recognition of signs of physical abuse
of children, elderly, intimate partner or spouses.
Misinterpretation of physical injuries like describing an incised
wound as a laceration, or firearm entry wound as a laceration or
an exit wound.
Destruction of gross and trace evidences in the course of patient
care.

Maintenance of Records
 The record should be kept in lock and key in
custody of doctor concerned or may be kept in
central record room, in hospital where such facility
is available; as per the institution rule.
 Most Hospital have a policy of maintaining all
Medico Legal Records for variable periods. However
as per Law there is no specified time limit after
which the MLRs can be destroyed.
 In view of the multitude of the cases against the
doctors under the consumer protection act, it is
advisable to preserved MLC records for a period of
atleast 10-Years or till the disposal of case by Court.

Dying declaration(Section 32 of Indian
Evidence act)
 A dying declaration or statement made by the person on the
verge of death as to the cause of his death or as to any of the
circumstances of the transaction which resulted in death, Such a
statement, Oral or in writing, made by the deceased to the witness
is a relevant fact and is admissible in evidence.
 Provided it has been made by the deceased while in a fit mental
condition certified by the doctor

Admission and Discharge of
MLC
• Whenever a medico-legal case is admitted the same no 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

Fact witness Patient’s attorney may request for information
regarding the injury. It may be an informal discussion or a request for
providing copies of the treatment records. A formal information may
be asked by the issue of summons.
Summons in law means an official order to appear in a court of
law or authoritatively call on someone to be present as a witness in a
law court. Summons may be issued in the name of the CMO or the
operating surgeon depending on the need decided by the court for the
purpose of either submitting the evidence and/or for disability
assessment and cross examination.
In addition, summons may compel the surgeon to bring certain
documents to the court like case records, photographs,radiographs,
discharge summary and disability assessment reports.

Preparation Before Attending the Court
OMF surgeon is expected to carry the summons issued and the
identification card representing the institution/hospital to the court.
Once the summons is received patient may be recalled for a
disability assessment in road traffic accident cases, which includes
clinical and radiographic examination. The guidelines for disability
assessment for facial injuries is not very clear and there are no
quantified disability criteria for dental and maxillofacial impairment in
India.

The McBrides criteria (1955) was the established reference in
India till 1980 and it was replaced by the ‘‘Manual for doctors to
evaluate permanent physical impairment (1981)’’.
Manual for Doctors to Evaluate Permanent Physical Impairment
is based on Expert Group Meeting on Disability Evaluation and
National Seminar on Disability Evaluation and Dissemination, D.G.H.S
—W.H.O -A.I.I.M.S, NEW DELHI -1981.

• Guidelines for evaluation of physical impairment in Facial injuries
considering head and neck as a unit for 100 points are mentioned in
Table 3 and split up ten point formula followed for each component
is detailed in Table 4. Cranial nerve disability for sensory and motor
• nerves are mentioned in Table 1. Guidelines for evaluation of
physical impairment for Burns of Head and Neck considering head
and neck as a unit for 100 points are mentioned in Table 2 and split
up ten point formula followed for each component is detailed in
Table 3 .
• The surgeon may state that the injury is grievous or not, and may
also elaborate on the actual disability that the defect might cause.

Guidelines for Evaluation of Physical impairment in facial
injuries: Head and Neck as a unit-100 points
Sl No Component Points
1 Scalp and vault including forehead 10
2 Eye brows right and left (5 + 5) 10
3 Eyelids right (upper 6 + lower 4)
Eyelids left (upper 6 + lower 4)
10
10
4 Pinna right
Pinna left
10
10
5 Nose 10
6 Middle and lower third of face (excluding nose and pinna) 30

Guidelines for evaluation of physical impairment in
facial injuries: Split of 10 point formula for each
componentSl no Region Defecit points points
1 Scalp and vault including
forehead
Scalp (disfigurement alone)
Scalp and bone
2.5
10
2 Eyebrows Part of one or both, each side
Total loss of one or both, each side
2.5
10
3 Eyelids upper
Eyelids lower
Skin disfigurement alone, each side
Deformity or full thickness loss, each side
Skin disfigurement alone, each side
Deformity or full thickness loss, each side
1.5
6
1
4
4 Pinna Anterior or posterior skin, disfigurement alone, each side
Deformity due to full thickness involvement of skin and cartilage
without obliteration of meatus, each side
Deformity due to full thickness involvement of skin and cartilage
with obliteration of meatus, each side
2.5
7.5
10
5 Nose Skin cover disfigurement alone
Deformity due to full thickness involvement with both nares
patent
Full thick deformity with one nare obliterated (7.5 + 1.25)
Full thick deformity with both nares obliterated
2.5
7.5
8.75
10
6 Middle and lower third of
face
Only aesthetic loss due to soft tissue/skeletal damage
Functional loss (with malocclusion and mastication)
Both aesthetic and functional lossess
7.5
22.5
30

Cranial Nerve Disability
Sl.No Nerve Disability rate
1 Motor cranial nerves: total or partial 20 % for each nerve
2 Sensory: total or partial 10 % for each nerve
3 Optic or auditory nerves:
Mild
Moderate
Severe
Unilateral
20%
40%
60%
Bilateral
30%
70%
100%

Suggestion and Recommendation:
1.The medical ethics, acts related to medical practice
should be emphasized in post graduate curriculum and
examinations.
2.Doctor should know his Duties regarding general aspects
of medical practice, Duty to Up-to-date his knowledge and
skill, Duty to attend the patient, Duty to special attention to
sick and patient of tender ages, Duty to proper
investigations, Duty to proper prescription and instructions,
Duty to issue the needful certificates, Duty to inform the
concerned responsible authorities and Duty to act in
accordance with the law.
3. Doctor should also know about need of proper
information to the patient and proper inform consent and to
maintain professional secrecy.

4. Doctor should be well acquainted about Duties in relation to
operative case that Not delegate duty to operate another doctor,
Not to experiment without valid reason and without consent,
Inform the patient about nature of operation and risk involved,
Particular about site and extent of operation, Assistance by
qualified and experienced anaesthetist only, Use only properly
sterilized instruments, Care not to leave any instrument or swab
in body cavity, Proper post operative care.

5 Doctor should well acquainted about Duties while dealing
with poisoning cases that utmost priority to save the life, give
emergency treatment, if necessary refer to higher center if
condition demands and permit the shift, Doctor should himself
record full history, Collect and preserve the vomits, stool,
urine, blood, clothes, doubtful container, Arrange reliable
attendant for patient, Police information, Dying declaration if
death is apprehend and Recommendation for PM Examination
if death.

Conclusions and
Recommendations
• Casualty of a medical college receives all type of
emergency cases including medico legal cases. Lots
of medico legal work is done, which puts a lot of
burden in the causality.
• The sensitive job of medico-legal work should be done
under the supervision of senior medical officers as
part of their training in the field, so as to avoid
imprecision in giving the opinion. Poor opinion is no
good than any opinion at all, as the later can mislead

REFERENCE
1. Harish D, Chavali KH (2007) The Medico-Legal case—should we be
afraid of it? Anil Aggrawal’s internet. J Forens Med Toxicol [serial online]
8(1): 15 http://www.anilaggrawal.com/ij/
vol_008_no_001/others/pg/pg001.html
2. Parmanada Katara Vs Union of India .AIR 1986 SC 2039.
3. Lyon (2005) Medical jurisprudence and toxicology, 11th edn. Delhi Law
House, New Delhi
4. Sarkar PC (1998) Chapter X. Section 172. Sarkar on criminal major acts
with practice, procedure and state amendments, 6th
edn. G.D.Kataria for
Orient law house, New Delhi, p 101.
Orient law house, New Delhi, p 102

7. Manual for Doctors to evaluate Permanent Physical Impairment, 1981.
http://archive.india.gov.in/allimpfrms/alldocs/12097.pdf
Orient law house, New Delhi, pp 103–104
Orient law house, New Delhi, pp 104–105 J. Maxillofac. Oral Surg.

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
underSection302,304,382,393,394,395,396,397,398,4
02,435,436,449,450,457,458,459 and 460

•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)

• 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)

•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)

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