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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 2  |  Issue : 3  |  Page : 167-170

Medicolegal Investigation of Medical Negligence in India: A Report of Forensic Autopsy Case


Department of Forensic Medicine and Toxicology, Tezpur Medical College and Hospital, Tezpur, Assam, India

Date of Web Publication30-Sep-2016

Correspondence Address:
Raktim Pratim Tamuli
Department of Forensic Medicine and Toxicology, Tezpur Medical College and Hospital, Tezpur, Assam
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2349-5014.191471

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  Abstract 

In general negligence means failure to take proper care over something and according to law negligence means breach of a duty of care which results in damage. Medical negligence is not very uncommon; every now and then cases of medical negligence are reported in the electronic media. Medical Negligence is doing something that one is not supposed to do, or failing to do something that one is supposed to do. Role of Forensic Pathologist in cases of Medical Negligence is always unquestionable. Forensic Pathologists need to explore and maintain a high degree of transparency between the doctors, patients and the law enforcing agencies. In the present case, a person was attacked by a wild animal and he fell down on a rough surface. Immediately he was rushed to a local hospital. The treating doctor stitched the external injury and allowed him to go home; he neither advised any investigation nor kept him under observation to rule out any internal injury. After 12 hours the victim succumbed to death. At autopsy a fractured skull with underlying subdural haemorrhage was noticed. Was not the treating doctor negligent in this case? Were the protocols followed? What should be the role of a Forensic Pathologist in such kind of cases?

Keywords: Autopsy, forensic pathologist, head injury, medical negligence


How to cite this article:
Tamuli RP. Medicolegal Investigation of Medical Negligence in India: A Report of Forensic Autopsy Case. J Forensic Sci Med 2016;2:167-70

How to cite this URL:
Tamuli RP. Medicolegal Investigation of Medical Negligence in India: A Report of Forensic Autopsy Case. J Forensic Sci Med [serial online] 2016 [cited 2019 Aug 26];2:167-70. Available from: http://www.jfsmonline.com/text.asp?2016/2/3/167/191471


  Introduction Top


Medical negligence or malpractice can be defined as "Doing something which a prudent and reasonable man would not do, or omission to do something which a reasonable man would do" [1] or in other terms, it can also be defined as "Want of reasonable degree of care and skill or will full negligence, on the part of a medical practitioner in the treatment of a patient with whom a relationship of professional attendant is established, so as to lead to his bodily injury or the loss of his life." [2]

Medical negligence is not very uncommon. Patients may suffer due to a negligent act of either the treating doctor alone or due to the careless act of his supporting staff. Summation of these two acts usually creates a greater problem. However, error or carelessness on the part of the doctor or supporting staff leading to the death of a patient cannot be simply excused as human error. Every country has their own laws to restrain the negligent acts of doctors, and our country India is no exception. In India, medical negligence is chiefly classified as civil and criminal negligence.

Civil negligence is a form of negligence in which a patient brings an action for damages in a civil court against his medical attendant, who owned him a duty in tort of care if he had suffered an injury in consequence of negligence or unskilled treatment. [3]

The question of criminal negligence may arise - when a doctor shows gross absence of skill or care during treatment, resulting in serious injury or death of the patient, by the acts of omission or commission. [4]

Negligence arises if the following things are satisfied:

  • Duty - Existence of a duty of care by the doctor
  • Dereliction - The physician must conform to the standard of a "prudent physician" under similar circumstances
  • Direct causation - Failure to exercise a duty of care must lead to damage
  • Damage - The damage should be of a type that would have been foreseen by a reasonable physician. [4]
Professional negligence of doctors leading to the death of a patient is punishable in India under Section 304-A of the Indian Penal Code. According to this section, "Whoever causes the death of any person by doing any rash or negligent act not amounting to culpable homicide, shall be punished with imprisonment of either description for a term which may extend to 2 years, or with fine, or with both." [1]

The earliest reported case of medical malpractice was Stratton v. Swanlond, decided in 1374; and since then various doctors are being sued for their negligent acts. [5]


  Case Report Top


A stout dead body was brought by a local police station for medicolegal autopsy. Relatives and the accompanying police gave a history of fall on a rough surface following an attack by a wild animal (tiger) on the day before; after the incident, he was rushed to a local government hospital. The on duty doctor examined him and stitched the lacerated wound present over the scalp. He/ She neither advised any investigation nor kept the patient under observation to rule out any internal injury. Next day morning, the person was found dead on his bed.

Neither police nor the relatives made any complaint regarding medical negligence. Police registered a case of unnatural death. Death was classified as unnatural since it was not properly describable as death by natural causes.

Autopsy findings

A swarthy complexioned dead body was seen lying on the autopsy table with the following notable findings. Garments that it wore did not show any blood stain.

  • Lacerated injury of size 3.1 cm × 0.4 cm × muscle deep, was present over outer aspect of the right eyebrow [Figure 1]
  • Lacerated injury of size 1.8 cm × 0.2 cm × subcutaneous tissue deep, was present over the outer aspect of the right eyebrow, 1 cm below and lateral to the previous injury [Figure 1]
  • Periorbital bruising (black eye) on the right side [Figure 1]
  • A stitched wound of length 3.3 cm was seen over the right frontal area of the scalp. On removal of the stitches, a lacerated injury of size 3.3 cm × 0.6 cm × bone deep was found [Figure 2].
On opening the scalp, a contusion was seen just beneath the external injury present over the right frontal area. Skull bone under this injury showed one penetrating injury (fracture) of size 0.8 cm in the longest diameter [Figure 3] and [Figure 4].
Figure 1: Black eye

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Figure 2: Laceration of scalp

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Figure 3: Penetrating fracture of skull

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Figure 4: Penetrating fracture of skull seen from inside

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Membranes and the brain underlying the fracture were found lacerated along with surrounding subdural and subarachnoid hemorrhages after opening the skull cap [Figure 5].
Figure 5: Lacerated brain with subdural and subarachnoid hemorrhages

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Viscera and blood samples were sent for toxicological analysis to the State Forensic Science Laboratory, which did not reveal the presence of alcohol, drug, or any other poison.

Histopathological examination reports of heart, lung, brain, and liver were also found normal.

At the end of the autopsy, we opined that death was due to head injury following blunt force impact.


  Discussion Top


The prescription [Figure 6] clearly demonstrates the degree of negligence on the part of the treating doctor. This act of the treating doctor can easily be categorized as criminal negligence according to the Indian law - he neither admitted the patient nor kept him under observation, nor he asked him to consult a Surgeon in the outpatient department. The doctor should have also advised computed tomography scan of head and neck region, to rule out head injury. Fracture present over the skull bone could have also been diagnosed by digital examination at the time of stitching. The case distinctively exemplifies every aspect of negligence - the duty, dereliction, direct causation, and the damage. [1]
Figure 6: Prescription

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Duty - It is the duty of a doctor to carefully examine each and every injury present on the body of a patient; in this case, the doctor did not examine the laceration present over the scalp properly, and thus he missed the fracture of the skull.

Dereliction - Failure to execute such duty by the doctor; he/she had neither advised any investigation nor kept the patient under observation.

Direct causation - Failure to execute his duty led to the loss of life of that particular individual.

Damage - Such damage could have easily been avoided by a physician with reasonable degree of skill and care.

Black eye present in this case might be absent at the time of examination by the on duty doctor; but had the doctor kept the patient under observation, there was every possibility of the development of black eye which would have given him a chance to think about any serious internal injury.

All medical negligence cases do not prove fatal. Most dramatic events that can occur during medical negligence are the lethal cases. All such cases need a thorough and meticulous autopsy to reveal the truth. Investigating lethal cases of medical malpractice and their objective clarification by autopsies as additional sources for the evaluation and prevention of errors requires sampling of cases, not only on a local but also on a national or, better, international level. [6]

Autopsy is nowadays an efficient method of clarifying medical malpractice claims. [7],[8] The value of autopsies for verifying medical negligence also became evident in a study conducted in the UK. [9] Major discrepancies between clinical diagnosis and postmortem findings are encountered in 20.3% (81 of 346) of autopsies. Similar results are known from other studies. [7],[8]


  Conclusion Top


The highest degree of skill or knowledge cannot be expected from every medical practitioner. A medical practitioner is required to possess the reasonable medical knowledge, and to exercise reasonable skill and care in the treatment of his/her patients. A doctor must therefore merely follow the prevalent standard procedures and methods of diagnosis and treatment. No doctor can possess all currently available medical knowledge, nor he/she is expected to apply all known diagnostic and therapeutic techniques. One cannot compare the skills of a House Surgeon to a Consultant's, but at the same time, the former is expected to provide a standard level of medical care and competence.

Now, the question might arise: what should be the role of an autopsy surgeon in such cases of negligence, especially when the case is not registered under medical negligence section of law?

  1. Should we report such cases directly to the police, so that they can initiate the legal proceedings against that doctor?
  2. Should we report these cases to the relative (informally, because we cannot do this legally) and ask them to lodge a complaint against the treating doctor?
  3. Can we report such findings (mistakes) to the treating doctor after giving a guarded opinion at the autopsy report? Will this step help the treating doctor to find out and rectify his mistakes?
Till now, previous two options are mostly employed by the autopsy surgeons, without, however, any positive outcome. Does it at all help in reducing the number of medical negligence cases? Certainly, it will not; such cases are escalating at an alarming rate.

Now, we can try to choose the third option available: interaction with the treating doctor. We autopsy surgeons sometimes see a lot of discrepancies between clinical or radiological findings and our autopsy findings, even though the case has nothing to do with medical negligence, and died because of some other reason.

Medical negligence law in India is capable enough to protect the victims and prevent the occurrence of such incidents. Only thing lacking is the awareness among common people; they can be made aware through community meetings or by involving Nongovernment Organizations about their rights, privileges, and risks while signing agreements of medical treatment. In this present scenario, one can also think of making use of social media.

Hence, at last, what we as autopsy surgeon can suggest is - arrange a monthly meeting with the clinicians/radiologists of the hospital where you are working, sort out the common mistakes they make during treatment or diagnosis, discuss with them and find out a common solution. Such a meeting should not end up with finding the faults of your fellow colleagues. Once you feel that you have become successful in reducing the number of such cases in your own hospital, you can think of spreading the same to other nearby hospitals from where medicolegal cases regularly come to your mortuary.

An often-heard criticism of medical negligence is that it fails to prevent medical mistakes. Cannot we initiate a movement to prove this proverb wrong?

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Pillay VV. Textbook of Forensic Medicine and Toxicology. 16 th ed. Hyderabad: Paras Medical Publisher; 2011. p. 31-3.  Back to cited text no. 1
    
2.
Kannan KV, Mathiharan K, editors. Modi A Textbook of Medical Jurisprudence and Toxicology. 24 th ed. Gurgaon: LexisNexis; 2012. p. 121.  Back to cited text no. 2
    
3.
Mahanta PM. Modern Textbook of Forensic Medicine and Toxicology. 1 st ed. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd.; 2014. p. 42-5.  Back to cited text no. 3
    
4.
Reddy KS. The Essentials of Forensic Medicine and Toxicology. 33 rd ed. Hyderabad: K Suguna Devi; 2012. p. 32-8.  Back to cited text no. 4
    
5.
The History and Origins of Medical Malpractice Litigation. Available from: http://www.bsmph.com/Articles/TheHistoryandOriginsofMedicalMalpracticeLitigation.shtml. [Last Cited on 2015 Jan 29 at 12. 24PM].  Back to cited text no. 5
    
6.
Hasan DA, Shehab AM, Kotb H. Alleged Medical Malpractice: A Retrospective Study of Forensic Evaluation of Cases in Cairo and Giza regions - Egypt (2009-2011). Available from: http://www.omicsonline.org/open-access/alleged-medical-malpractice-a-retrospectivestudy- of-forensic-evaluation-of-cases-in-cairo-and-giza-regionsegypt- 21577145.1000239.pdf. [Last cited on 2015 Feb 11, 11:45 am].  Back to cited text no. 6
    
7.
Perkins GD, McAuley DF, Davies S, Gao F. Discrepancies between clinical and postmortem diagnoses in critically ill patients: An observational study. Crit Care 2003;7:R129-32.  Back to cited text no. 7
    
8.
Shojania KG, Burton EC. The vanishing nonforensic autopsy. N Engl J Med 2008;358:873-5.  Back to cited text no. 8
    
9.
Shojania KG, Burton EC, McDonald KM, Goldman L. Changes in rates of autopsy-detected diagnostic errors over time: A systematic review. JAMA 2003;289:2849-56.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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