Profile of Medico-Legal Cases in Accident & Emergency Department of SSKH, LHMC, New Delhi During Pre-Covid-19 and Covid-19 Periods

Medico-legal cases presented to the Accident & Emergency department vary from hospital to hospital. Profiling these cases from time to time provides an insight into the workload of medico-legal cases as well as what is going on in and around the locality. The present study was conducted at LHMC, New Delhi from January 2021 to June 2022 from the available records of MLCs from 1st January 2019 to 31st December 2021. Out of a total of 5702 MLCs, males were 85.77%. Victims of the age group 21–30 years formed the majority (36.30%) of the cases followed by age groups 31–40 years (25.44%). The time of incidence was between 6 p.m. and 11.59 p.m. in the majority (42.00%) cases. The time of reporting was between 6 p.m. and 11.59 p.m. in the majority (40.05%) of cases. A majority (56.92%) of the victims had reported within 1 hour of the incident. The cause was blunt force trauma in more than half (51.05%) cases, followed by RTA (17.93%) and poisoning (17.84%). In more than half (56.51%) cases, the manner was homicidal, followed by accidental including RTA (23.95%) and suicidal (19.35%). The surgery department was found involved in more than 2/3 (69.15%) cases, followed by Orthopaedics (31.85%), Medicine (20.199%) and ENT (19.52%). In 85.50% of cases, the victims were discharged within 24 hours. Hospital death in MLCs was 4.15% whereas 1.87% of victims were referred to other hospitals for further management.

Introduction

Analysis of the medico-legal cases presented to the casualty of a hospital gives an understanding of what unnatural things are happening to human beings in and around the particular locality. Lady Hardinge Medical College & Smt. S.K. Hospital is situated in the heart of Delhi, adjacent to Connaught Place catering for the people of New Delhi and central Delhi districts. However, two other large government hospitals, LNJP Hospital and Dr RML Hospital are also lying within a distance of 2–5 km. Therefore, patients turn to these hospitals because of their convenience and the kind of services available in these hospitals. In case of emergency medical needs, odd hours or medico-legal cases, the casualty remains the target place for the patients and police. Thus analysis of the medico-legal cases of a hospital from time to time helps to fulfill the medical needs of the nearby patients with the development of proper infrastructures, manpower, strategy and policies.

Aim and Objectives

1. To analyze the profile of medico-legal cases presented to the Accident & Emergency Department, SSKH, New Delhi.
2. To compare the volume of medico-legal cases during the 2019 non-Covid and 2020–2021 Covid periods.
3. To analyze the nature, manner and outcome of the medico-legal cases.

Materials and Methods

After obtaining ethical clearance from the institutional ethics committee, the present 2-year retrospective (from 1^st January 2019 to 31^st December 2020) and 1-year prospective study (from 1^st January 2021 to 31^st December 2021) study was conducted in the Department of Forensic Medicine, Department of Accident & Emergency and Medical Record Department at Lady Hardinge Medical College & Smt. S.K. Hospital, New Delhi from January 2021 to June 2022 by collecting all the relevant data available in the MLC records of the study period using pre-designed pro forma, then transferred to MS Excel sheet and analysed.

Results and Discussion

Magnitude of MLCs at LHMC, New Delhi

The total number of MLCs registered from 1^st January 2019 till 31^st December 2021 was 5702. Out of those, 2581 (45.26%) MLCs were found registered in the year 2019 (Pre-Covid year), 1955 (34.28%) MLCs were registered in the year 2020 and 1166 (20.44%) MLCs were registered in the year 2021 (Table I). Hence, there was a significant drop in MLCs during the Covid-19 period.

Table I. Number of Medico-Legal Cases

Sl. No.	Year	No. of MLCs	Percentage
1	2019	2581	45.26
2	2020	1955	34.28
3	2021	1166	20.44
Total		5702	100

Sex

Out of a total of 5702 cases, males were found in 4891 (85.77%) MLCs whereas females were found in 810 (14.20%) MLCs. Only one transgender individual was involved in MLC as a case of RTA in the year 2021 (Table II). Our findings were similar to the studies reported by references [1]–[38].

Table II. Gender of the Individuals in Medico-Legal Cases

Sl. No.	Year	Male	Percentage	Female	Percentage	Transgender	Percentage	Total
1	2019	2275	88.14	306	11.85	0	0	2581
2	2020	1725	88.23	230	11.76	0	0	1955
3	2021	891	76.41	274	23.49	1	0.08	1166
Total		4891	85.77	810	14.20	1	0.01	5702

Age

Out of a total of 5702 MLCs, victims of the age group 21–30 years (N = 2070; 36.30%) form the majority of the cases followed by age groups 31–40 years (N = 1451; 25.44%), and 41–50 years (N = 918; 16.09%), respectively (Table III). The age range was from Newborn baby to 95 years old. The average age of the victims was 34.53 years and the median age was 32 years. Our findings were similar to the studies reported by references [1], [3]–[9], [11], [13], [15], [16], [18]–[25], and [27]–[38].

Table III. Age Groups of the Individuals in Medico-Legal Cases

Sl. No.	Age Group in Years	Number of Cases	Percentage
1	1–10	1	0.01
2	11–20	587	10.29
3	21–30	2070	36.30
4	31–40	1451	25.44
5	41–50	918	16.09
6	51–60	427	7.48
7	61–70	190	3.33
8	71–80	42	0.73
9	81–90	15	0.26
10	91–100	1	0.01
Total		5702	100

However, the medico-legal cases in the paediatric age group in our study do not reflect the true figures as the data were collected from Sucheta Kripalini Hospital only. Lady Hardinge Medical College has a separate Kalavati Saran Children’s Hospital to deal with paediatric age group patients.

Time of Incidence

Barring 93 MLCs where details were not available and 469 cases where natural disease cases were registered under MLCs, among the rest 5140 MLCs, the time of incidence was between 6 p.m.–11.59 p.m. in majority (N = 2159; 42.00%) cases, followed by 12 p.m.–5.59 p.m. (N = 1313; 25.54%) and 6 a.m.–11.59 a.m. (N = 943; 18.34%), respectively (Table IV).

Table IV. Time of Incidence

Sl. No.	Time of Incidence	Number of Cases		Percentage
1	12 a.m.– 5.59 a.m.	725	Subtotal = 5140	14.10
2	6 a.m.–11.59 a.m.	943		18.34
3	12 p.m.–5.59 p.m.	1313		25.54
4	6 p.m.–11.59 p.m.	2159		42.00
5	Details not available	93	Total	100
6	Not Applicable (Natural Diseases)	469
Total		5702

Reference [6] has reported that the majority (29.49%) of the incidents occurred between 12 p.m. to 4 p.m., followed by 27.29% between 4 p.m. to 8 p.m. Reference [9] reported that the majority of the incidents occurred during the evening. Reference [24] reported that the majority (37.6%) occurred between 12 p.m. to 6 p.m., followed by 34.3% between 6 p.m. to 12 a.m. Reference [36] reported that the peak time of incidence was between 4 p.m. to 8 p.m. (33.5%).

Time of Reporting

Among the 5140 MLCs, the time of reporting was between 6 p.m.–11.59 p.m. in the majority (N = 2059; 40.05%) cases, followed by 12 p.m.–5.59 p.m. (N = 1327; 25.81%) and 12 a.m.–5.59 a.m. (N = 971; 18.89%), respectively (Table V). Thus evening hour was the busiest period to deal with medico-legal cases at the Accident & Emergency Department at SSKH.

Table V. Time of Reporting at the Hospital

Sl. No.	Time of Reporting	Number of Cases	Percentage
1	12 a.m.–5.59 a.m.	971	18.89
2	6 a.m.–11.59 a.m.	783	15.23
3	12 p.m.–5.59 p.m.	1327	25.81
4	6 p.m.–11.59 p.m.	2059	40.05
Total		5140	100

Reference [5] reported that the peak time of reporting was between 12 p.m. to 6 p.m. Reference [15] reported that the majority (36.9%) of victims reported between 12 p.m. to 6 p.m., followed by 35% between 6 p.m. to 12 a.m. Reference [19] has reported that majority (31.18%) of victims reported between 6 p.m. to 12 a.m., followed by 30.59% between 12 p.m. to 6 p.m. Reference [21] has reported that the majority (40.8%) of victims reported between 8 p.m. to 8 a.m., followed by 32.8% between 2 p.m. to 8 p.m. Reference [23] reported that the majority (37.44%) of victims reported between 12 p.m. to 6 p.m. Reference [24] reported that the majority (36.7%) of victims reported between 12 p.m. to 6 p.m., followed by 34.3% between 6 p.m. to 12 a.m. Reference has reported that the majority (40.5%) of victims reported between 6 p.m. to 12 a.m., followed by 32.5% between 12 p.m. to 6 p.m. Reference [37] reported that most of the cases reported between 12 p.m. to 6 p.m. (35.61%) followed by 6 p.m. to 12 a.m. (35.23%).

The Time Gap between the Incidence and Reporting

Out of 5140 MLCs, the victims had reported within 1 hour of the incidence in the majority (N = 2926; 56.92%) of cases, followed by within 1–2 hours (N = 1368; 26.61%) (Table VI). Our findings were similar to the studies reported in References [5], [14], [20], [22], [23], [30]–[32], and [38].

Table VI. Duration between Time of Incidence and Time of Reporting

Sl. No.	Duration	Number of Cases	Percentage
1	<1 hour	2926	56.92
2	1–2 hours	1368	26.61
3	2–4 hours	464	9.02
4	4–12 hours	232	4.51
5	>12 hours	150	2.91
Total		5140	100

Person Presented the MLCs to the Hospital

The MLCs were presented to the hospital by the police in the majority (N = 1810; 31.74%) cases, followed by relatives (N = 1577; 27.65%), self (N = 1269; 22.25%) and by unknown person (N = 953; 16.71%) (Table VII). No other study was found to compare these findings.

Table VII. Person Who Presented the MLCs to the Hospital

Sl. No.	Presented by	Number of Cases	Percentage
1	Police	1810	31.74
2	Relative	1577	27.65
3	Self	1269	22.25
4	Unknown	953	16.71
5	Details not available	93	1.63
Total		5702	100

Alleged History of the Causes of MLCs

Out of 5140 MLCs, the alleged history of a causative factor was blunt force trauma in more than half (N = 2624; 51.05%) cases, followed by RTA (N = 922; 17.93%) and poisoning (N = 917; 17.84%), respectively (Table VIII). Our findings were similar to the studies reported by references [10], [25]–[27], and [29].

Table VIII. Alleged History of Causation in Medico-Legal Cases

Sl. No.	Alleged History	Number of Cases	Percentage
1	Blunt force trauma	2624	51.05
2	RTA	922	17.93
3	Poisoning	917	17.84
4	Sharp force trauma	311	6.05
5	Fall from height	213	4.14
6	Stabbing	42	0.81
7	Railways Injury	30	0.58
8	Electrocution	24	0.46
9	Industrial Accident	24	0.46
10	Hanging	13	0.25
11	Sexual Assault	8	0.15
12	Strangulation	3	0.05
13	Firearm Injury	3	0.05
14	Burn	3	0.05
16	Animal Bite	2	0.03
17	Smothering	1	0.01
Total		5140	100

However, references [3]–[8], [11]–[13], [15]–[17], [18], [20], [22]–[24], [28], [30], [32]–[37] have reported that Road Traffic Accidents were major causes of medico-legal cases presented to the hospitals. Reference [38] reported that poisoning was the major cause of admission to the casualty.

Manner of Causation in MLCs

Out of 5140 MLCs, more than half (N = 2905: 56.51%) of victims the manner was homicidal, followed by accidental including RTA (N = 1232; 23.95%) and suicidal (N = 995; 19.35%), respectively (Table IX).

Table IX. Manner of Causation in Medico-Legal Cases

Sl. No.	Manner of Causation	Number of Cases	Percentage
1	Accidental	1232	23.95
2	Homicidal	2905	56.51
3	Suicidal	995	19.35
4	Sexual assault	8	0.15
Total		5140	100

Reference [5] has reported that in the majority (69.03%) of MLCs, the manner was accidental. Reference [4] has reported that the manners were accidental-75.4%, suicidal-15.5% and homicidal-5.9%. Similarly, reference [31] reported that the manners were accidental-52.4%, suicidal-41.41% and homicidal-5.03%. Reference [32] reported that the manner was accidental in 79.9%. Reference [38] reported that the manner was an assault in the majority (39.6%) of cases.

Department Involved in Managing the MLCs

Out of a total of 5609 MLCs (5702-93), where details were available, the Surgery department was found involved in more than 2/3 (N = 3879; 69.15%) cases, followed by the departments of Orthopaedics (N = 1787; 31.85%), Medicine (N = 1133; 20.199%), ENT (N = 1095; 19.52%), respectively. The Department of Forensic Medicine was found involved only in 1 (0.01%) case (Table X).

Table X. Department Involved in Managing the MLCs

Sl. No.	Department	Number of Cases	Percentage
1	Surgery	3879	69.15
2	Orthopaedics	1787	31.85
3	Medicine	1133	20.19
4	ENT	1095	19.52
5	Psychiatry	479	8.53
6	Dental	377	6.72
7	Ophthalmology	364	6.48
8	Obstetrics & Gynaecology	24	0.42
9	Anaesthesia	3	0.05
10	Dermatology	3	0.05
11	FMT	1	0.01
Total		9145

Reference [12] reported that the majority (52.94%) of the MLCs were managed by the Surgery department, followed by 43.28% by the Orthopaedics department. Reference [21] also reported that the majority (93%) of MLCs were managed by the Surgery department, followed by the Orthopaedics and Neurosurgery departments, respectively. Reference [32] reported that the majority (69.96%) of the MLCs were managed by the Surgery department, followed by Orthopaedics (58.99%) and Medicine (35.88%), respectively.

Number of Department(s) Involved in Managing the MLCs

Out of a total of 5609 MLCs (5702-93), where details were available, the majority (N = 2562; 45.67%) cases were handled and managed by a single department whereas in 2299 (40.98%) cases, they were managed by two departments and in 748 (13.33%) cases, they were managed by more than two departments (Table XI). Reference [32] reported that in the majority (64.93%) of MLCs, opinions were sought from a single department, followed by two departments (26.72%) and more than two departments (8.35%), respectively.

Table XI. Number of Department(s) Involved in Managing the Medico-Legal Cases

Sl. No.	Number of Department (s) involved	Number of Cases	Percentage
1	1	2562	45.67
2	2	2299	40.98
3	>2	748	13.33
Total		5609	100

Radiological Investigations Required in MLCs

Out of a total of 5609 MLCs (5702-93), where details were available, a radiological investigation was advised in the majority (n = 3038; 54.16%) cases followed by CT scan (N = 1883; 33.57%), USG (N = 1655; 29.50%) and MRI (N = 39; 0.69%), respectively (Table XII). No other study was found to compare these findings.

Table XII. Radiological Investigations Required in Medico-Legal Cases

Sl. No.	Nature of Investigation	Number of Cases	Percentage
1	X-Ray	3038	54.16
2	CT scan	1883	33.57
3	USG	1655	29.50
4	MRI	39	0.69
Total		6615

Duration of Stay in the Hospital in MLCs

Out of a total of 5609 MLCs (5702-93), where details were available, in 4796 (85.50%) cases, the stay of the victims in the hospital was less than 24 hours whereas in 813 (14.49%) cases, the stay in the hospital was more than 24 hours and maximum up to 97 days (Table XIII). Most of the patients who stayed in the hospital for longer durations were victims of RTA with bone fractures.

Table XIII. Duration of Stay in the Hospital in Medico-Legal Cases

Sl. No.	Duration of Stay		Number of Cases		Percentage
1	<24 hours	Discharged	3254	4796	85.50
		Absconded	1384
		Death	139
		LA.M.A	15
		No Records	1
		Admission Cancelled	3
2	>24 hours (Maximum up to 97 days)			813	14.49
Total			5609	100

Reference [23] reported that the majority (90.89%) of the victims of MLCs were discharged from the hospital within 1 week of admission to the hospital.

Outcome in the MLCs

Out of a total of 5702 MLCs, about 1/3 i.e., 3789 (66.45%) victims were discharged followed by those who absconded from the hospital (N = 1544; 27.07%), death (N = 237; 4.15%) and referred for further management (N = 107; 1.87%), respectively (Table XIV).

Table XIV. Outcome in the Medico-Legal Cases

Sl. No.	Outcome	Number of Cases	Percentage
1	Discharged	3789	66.45
2	Absconded	1544	27.07
3	Death	237	4.15
4	Referred for treatment	107	1.87
5	LA.M.A	21	0.36
6	Admission cancelled	3	0.05
7	No records	1	0.01
Total		5702	100

Reference [13] reported that 0.6% of victims of MLCs were referred to other higher hospitals for treatment and LA.M.A cases were 1.63%. Reference [14] reported that 85.71% of MLCs in the paediatric age group were discharged, 1.68% absconded, 5.04% were referred to other hospitals for further management and deaths were 2.06%. Reference [20] reported that 80.69% of MLCs were discharged, deaths were 9.68% whereas 4.45% of MLCs were referred to other hospitals for further management. Reference [24] reported that 66.1% of MLCs were discharged, deaths were 9.9% whereas 11.6% of MLCs were LA.M.A. Reference [30] reported that 78.4% of MLCs were discharged, deaths were 9.59% whereas 4.69% MLCs were referred to other hospitals for further management. Reference reported that 81.84% of MLCs were discharged, 12.03% were referred to other hospitals for further management whereas deaths were 5.9%.

Conclusion

The Accident & Emergency Department of SSKH, Lady Hardinge Medical College deals with a reasonable number of MLCs due to the large urban population and easy accessibility from nearby areas. There was a significant drop in MLCs during Covid periods 2020 & 2021 from non-Covid period 2019. As the busiest hours to deal with MLCs were found between 6 p.m. and 11.59 p.m., hence, the concerned Surgery, Orthopaedics, Medicine and ENT departments should remain vigilant with well-trained manpower during those hours. The majority of the MLCs were found blunt force trauma caused by homicidal assault, followed by RTA and poisoning respectively that reflected the mindset of the people living in the region. Referral of 1.87% MLCs to other hospitals for further management and death of 4.15% victims of MLCs need to be addressed properly with the overall augmentation of medical facilities and services. The clinical forensic medicine branch should be developed well to deal with MLC documentation for the administration of proper justice in the court of law at a later stage.