The document provides an overview of medicolegal issues and handling complaints in a hospital setting. It discusses the establishment of a new Unit Etika & Medikolegal at Hospital Kuala Lumpur including its roles and organizational structure. Key topics covered include classification of complaints, statistics on complaint types and resolutions, the complaints handling process, issues related to communication and medical documentation, and principles of obtaining valid informed consent from patients.

1. Recognizing and Handling
Medicolegal Issues: Overview
Dr Zulkefli Abdul Rani
Unit Etika & Medikolegal
Hospital Kuala Lumpur

2. Outline
• Introduction
• Management of Complaints and Medicolegal Cases
• Communication
• Medical Documentation
• Consent
• Medical Negligence
• References

3. Unit Etika & Medikolegal
HKL

4. • Established on 4th January 2019
• Headed by Timbalan Pengarah (Perubatan) III
• Consist of :
• Ketua Penolong Pengarah Kanan(1)
• Pegawai Perubatan Pentadbir (2)
• Pembantu Tadbir (PT)
• Unit Komunikasi Korporat(UKK)
• Unit Rekod Perubatan

5. Organizational Chart
CARTA ORGANISASI
UNIT ETIKA & MEDICOLEGAL
HOSPITAL KUALA LUMPUR
KETUA
UNIT MEDICOLEGAL HKL
PENYELIA JURURAWAT
(MATRON)
PEMBANTU TADBIR (PT)
TIMBALAN PENGARAH III
(PERUBATAN)
PENGARAH
HOSPITAL KUALA LUMPUR
JUSA B
MEDICAL OFFICER (MO)
KETUA JURURAWAT
KETUA
UNIT KOMUNIKASI KORPORAT (UKK)
HKL
MEDICAL OFFICER (MO) MEDICAL OFFICER (MO)

6. Main Roles of the Unit
1. To facilitate complaints and medicolegal processes
2. Reference centre for medicolegal issues and cases
3. To provide medical education regarding legal issue pertaining
medical practice

7. Complaints and Medicolegal
Cases

8. SIAPA PELANGGAN HKL?

9. APA KATA PELANGGAN ????
Lambat
Tidak kompeten
Perkhidmatan out-dated
Swasta lebih baik!
Tidak mesra pelanggan
Fail selalu hilang
Menunggu lama
Sistem yang mengelirukan
Komunikasi kurang berkesan

10. Source of Complaints
Complaints
Complaint
forms
Walk in
Public
Complaints
Bureau
(BPA)
Newspaper
Social
media
E-
complaints
Email
Letters/Fax
Phone

11. 15 HARI BEKERJA
16 -365 HARI
5 HARI BEKERJA
Classification of Complaints

12. PENGHARMONIAN KLASIFIKASI KOMPLEKSITI ADUAN
JENIS
ADUAN
KRITERIA ADUAN CONTOH ADUAN
MUDAH
(Penyelesaian 5
hari bekerja)
 Aduan tidak memerlukan lawatan ke lokasi mahupun
melibatkan penubuhan Jawatankuasa Siasatan
 Aduan panggilan telefon Klinik Oftalmologi tidak
berjawab
 Masalah parking
 Aduan kebersihan tandas, kafetaria & wad
 Aduan pegawai bercakap kasar/tidak senyum
 Mempunyai maklumbalas ‘standard’ seperti isu parking, shuttle,
doktor tidak senyum
 Memerlukan tindakan pembetulan segera
 Aduan dikemukakan untuk perhatian dan penambahbaikan
segera pihak jabatan terlibat (penyelesaian terus peringkat
jabatan)
SEDERHANA
(Penyelesaian 15
hari bekerja)
 Aduan memerlukan siasatan lanjut/lawatan ke lokasi  Kualiti perkhidmatan dan layanan yang tidak
memuaskan
 Aduan keracunan makanan, tarikh luput, makanan
rosak
 Kegagalan komunikasi (verbal/non-verbal)
 Aduan memerlukan tindakan pembetulan segera, kelewatan
boleh mendatangkan mudarat kepada orang awam
KOMPLEKS
(Penyelesaian 365
hari bekerja)
 Aduan memerlukan siasatan yang terperinci melibatkan lawatan
ke lokasi dan penubuhan Jawatankuasa Siasatan dan yang
berkaitan
 Aduan salahlaku anggota perubatan/anggota lain
(disiplin, integriti, kesilapan perawatan/diagnosis)
 Kelewatan laporan perubatan, kelewatan
pembedahan
 Aduan kelewatan tindakan
 Semua aduan klinikal medico legal atau berpotensi medico legal

13. TAHUN 2012 2013 2014 2015 2016 2017
ADUAN MUDAH / ( ADU AM) 171 180 166 148 191 155
ADUAN SEDERHANA - - 93 139 119 110
ADUAN KOMPLEKS / (ADU KES) 100 57
*9
60
*16
77
*23
121
*10
161
*16
MASJA - 68 143 136 - -
JUMLAH 271 305 462 500 431 426
PENGHARGAAN 82 103 258 250 187 180
CADANGAN 102 111 69 49 39 33
PERTANYAAN - - 181 292 177 446
JUMLAH 184 214 508 591 403 659
Petunjuk:
* Kes Potensi
Medico Legal
STATISTIK MAKLUMBALAS PELANGGAN
TAHUN 2012-2017

14. BULAN/
PERKARA
JAN FEB MAC APR MEI JUN JULAI OGOS SEPT OCT JUMLAH
ADUAN
MUDAH
14 11 30 16 18 13 9 15 18 8 152
ADUAN
SEDERHANA
25 13 11 7 16 11 36 19 (5) 17 (9) 15 (13) 170
ADUAN
KOMPLEKS
14 19 (5) 19 (6) 9 (6) 8 (6) 15 (12) 25 (17) 18 (16) 9 8 144
Petunjuk: ( ) aduan masih dalam siasatan

15. BULAN/
PERKARA
JAN FEB MAC APR MEI JUN JULAI OGOS SEPT OCT JUMLAH
PENGHARGAAN 35 16 17 27 19 8 61 31 29 6 249
CADANGAN 6 5 10 7 5 3 3 2 6 6 53
PERTANYAAN 32 30 85 64 52 30 94 33 20 30 470

16. STATISTIK ADUAN
KES MEDICO LEGAL 2012-2017
TAHUN 2012 2013 2014 2015 2016 2017 JUMLA
H
SIASATAN DALAMAN 5 13 9 6 13 6 52
JAWATANKUASA PENYIASATAN BEBAS 6 11 9 - 9 6 41
JUMLAH 11 24 18 6 22 12 93

17. Medicolegal Statistics 2018
2018
Aduan Medikolegal 12
Jawatankuasa Penyiasatan Bebas
(JKPB)
6
Kes Mesyuarat Ex Gratia (MEG) 2
Kes Litigasi 2

18. Medicolegal Statistics (Department 2018)
DEPARTMENT TOTAL NO OF CASES
GENERAL MEDICINE 2
GENERAL SURGERY 2
OBSTETRIC & GYNAECOLOGY 2
EMERGENCY & TRAUMA 1
ORTHOPAEDIC 1
OPTHALMOLOGY 1
DERMATOLOGY 1
ONCOLOGY & RADIOTHERAPY 1
NATIONAL TRANSPLANS UNIT 1

19. Ex Gratia Payout 2016-2018
YEAR AMOUNT
2016 RM 613,488.93
2017 RM 359,332.00
2018 RM 16,947.00

20. Ex Gratia Payout (Department 2016-2018)
DEPARTMENT AMOUNT
GENERAL SURGERY RM 10,837.80 (1 CASE)
OBSTETRIC & GYNAECOLOGY RM 761,528.93 (3 CASES)
ORTHOPAEDIC RM 17,200.00 ( 2 CASES)
EMERGENCY & TRAUMA RM 61,402.93 ( 3 CASES)
ENT RM 40,000.00 (1 CASE)
NEUROSURGERY RM 24,800.00 (1 CASE)
UROLOGY RM 30,000.00 ( 1 CASE)

21. Complaints : Flow Chart
CARTA ALIRAN ADUAN KOMPLEKS (MEDICOLEGAL) HKL
ADUAN
MUDAH SEDERHANA KOMPLEKS
POTENTI NON-MEDICOLEGAL
SIASATAN
SURAT
MAKLUM
NO
YES
TAMAT
GRIEVAN INTERNA EXTERNA
KKM
YES
KKM
NO
NO EX GRATIA
TAMAT YES
TAWARAN EX GRATIA
TAK TERIMA TERIMA PENANG
KKM
TAMAT
INQUIRY
EXTERNAL
INQUIRY

23. COMMUNICATION

24. Issues Related to Communication
Tidak mesra pelanggan
Kasar
Sombong
Salah maklumat
Pilih bulu
Masalah dalaman Jabatan
Lambat
Masalah saluran komunikasi
Sikap kakitangan
Kurang prihatin

25. ‘Hand over/pass over’ kes/syif
Tidak dokumenkan dalam BHT/ buku log
Kurang fasiliti
Kekurangan maklumat
Boss vs leader
Cara penerangan/penjelasan
Berbincang di hadapan pesakit
Kurang ‘common sense’
Tiada komunikasi dalaman / ‘silo’

26. NON VERBAL COMMUNICATION

27. Medical Documentation

28. Medical Records
• A medical records is documented information about the health of an
identifiable individual recorded by a practitioner or other healthcare
professional either personally or at his or her instructions.
• It should contains sufficient information to identify the patient,
support the diagnosis based on history, physical examination and
investigations, justify the professional management given, record the
course and results thereof and ensure the continuity of care provided
by practitioners and other healthcare workers to that particular
patient.
MMC Guideline 002/2006 : Medical Records and Medical Reports

29. • Medical records
-Doctor/Nursing notes
-Charts
-Investigations results – laboratory, imaging
-Prescription
-Forms – Consent,SSSL form

30. • The records should be reliable to provide a comprehensive
and satisfactory explanation to what happened at that
material time.
• Proper and appropriate medical documentation is the
hallmark of good medical practice

32. Issue Related to Documentation
• Missing page or missing crucial part of documentation
-Make police report
-Paginate every page
• If it isn’t written down, you didn't do it
eg: Explanation on treatment or procedure
Explanation on risk

34. • Chartology
-Documentation in chart/patient’s note doesn’t reflect
patient’s condition
• Illegible handwriting
• Incomplete entry (eg: date,time,name of doctors/nurses)
• Unorganized entry
• Computerized system : copy and paste

36. Good Medical Records
• Entry should be legible
• Time and date included
• Signature with stamp
• Use standard and accepted abbreviations
• Each page should have patient’s name and ID
• Never tamper or alter the information that has been recorded
• Additional information for previous record should be marked
as ‘addendum’ and signed with current date

38. The Past Speaks
• It is well to remember that issues related to medical documentation
will not come into play in the near future but will be called into
questions years later when the practitioner or members of the
healthcare team that provided the care will no longer be at the scene,
or even if they are there they will not be able to recollect exactly what
happened to that particular patient, having attended to hundreds, if
not thousands of patients subsequently.
• Only the actual medical records will be there to tell the story

39. Litigation Aspect - DEFENCE
•Do proper medical records - will have better
evidence before the court if documented
thus better chance of success
•Full disclosure – do not hide

40. • Write and keep proper medical records
• Maintain accurate and proper documentation of care
No record = No defence
Bad records = Bad defence
Good records = Good defence
• If something wasn’t recorded, it wasn’t done

41. Good Medical Practice
10 Golden Rules of Good Medical Practice :
1. Practice with kindness, ethics and honesty
2. Upgrade professional knowledge and clinical skills
3. Maintain good patient records
4. Maintain good communication with patients and relatives
5. Maintain doctor-patient confidentiality
6. Allow second opinion and referral to colleagues
7. Maintain good working relationship with colleagues
8. Be conscious of cost of healthcare
9. Avoid publicity, self-promotion and abuse of position
10. Be a partner in promoting global health

42. CONSENT
MORE THAN JUST A FORM

43. CONSENT
• CONSENT is the voluntary acquiescence by a person to the proposal
of another; the act of result of reaching an accord; a concurrence of
minds; actual willingness that an act or an infringement of an interest
shall occur
MMC Guideline : Consent for Treatment of Patients by Registered Medical Practitioner

44. The General Legal and Ethical Principle
• For adult patients of sound mind is that, legally valid consent must be
obtained before a doctor or other health professional can start
treatment for a patient.
• Without legally valid consent, the doctor will be committing trespass
to person, namely battery (non-consensual touching).

45. Types of Consent
• Implied consent
• Expressed consent
• Verbal consent
• Non-verbal consent
• Informed consent
• Valid consent

46. • Expressed consent: usually occurs when the patient signs the consent
form.
• Implied consent: could be by offering one’s arm for injection in a
surgery
• A signed consent form is merely evidence that the patient signed the
form but does not mean that he necessarily understood the
significance or implications of the treatment, which is being proposed
in the form

47. Informed Consent
• Medico legal requirement to ensure that a patient knows all of
the risks and costs involved in a treatment
MMC Guideline : Consent for Treatment of Patients by Registered Medical Practitioner

48. Legally Valid Consent
• Mental competence – reach the age of majority, given by a person
with legal capacity – able to have sufficient understanding
• Own free will – no duress, undue influence
• Sufficient information of the proposed treatment – consent must be
real, must be informed in nature not just “in a form” only
• In the language that the patient understands
• Witness (another doctor, nurse etc.)

49. Who can take consent?
• REGISTERED MEDICAL PRACTITIONER
• Practitioner & patient must have met or know each other: doctor
patient relationship
• The practitioner who is planning to do the procedure/surgery must
establish personal contact before the intended procedure
• Nature, objectives & alternatives must be explained
• Risk & complications

50. Who can give consent?
Malaysian Law
• Age of Majority Act 1971
• S2: Subject to section 4, the minority of all males and females shall cease
and determine within Malaysia at the age of eighteen years and every such
male and female attaining that age shall be of the age of majority.
• When a child presents with an adult, establish the relations of the adult
• Parents
• Legal guardian

51. Mental Health Act 2001
• Persons who are incapable or impaired decision making ability
• If emergency situation – previous condition applied
• For elective or non-emergency procedure, consent from relative/next of
kin/legal guardian if available
• If no relative/next of kin/legal guardian and patient incapable of giving
consent, consensus from two psychiatrists (one must be the primary
doctor) must be obtained
• S 77: consent – by patient; guardian; 2 psychiatrists
• S77(5): capability of patient giving consent (factors to be considered)

52. MEDICAL NEGLIGENCE

53. Medical Negligence
• Defined by Winfield as “the breach of a legal duty to take care
which results in damage, undesired by the defendant, to the
plaintiff.”
• In Loghelly Iron & Coal v M’Mullan [1934] - Lord Wright stated
“Negligence means more than heedless or careless conduct…it
properly connotes the complex concept of duty, breach and
damage thereby suffered by the person to whom the duty was
owing.”

54. • Prof. Fleming: Negligence is the conduct falling below the standard
demanded for the protection of others against unreasonable risk of
harm.
• Blyth v Birmingham Waterworks Co (1856) 11 Ex 781: Negligence is
the omission to do something which a reasonable man, guided upon
those consideration which ordinarily regulate the conduct of human
affairs would do or doing something which a prudent and reasonable
man would not do.

55. Medical Negligence…
• Failure to meet the standard of practice of an average qualified
doctor practicing in the specialty in question
• Occurs not merely when there is an error, but when the degree of
error exceeds the accepted norm

56. Principal Elements of Negligence
• a) duty of care or an existing legal duty on the part of the defendant
to the plaintiff to exercise care in such conduct of the defendant as
falls within the scope of the duty;
• (b) breach of duty or failure to conform to the standard of care which
the defendant owes the plaintiff;
• (c) causation or consequential damage to the plaintiff , that is, the
plaintiff suffers damage as a result of the defendant’s breach of duty.

59. REFERENCES
1. Guidelines on the Management of Complaints and Medicolegal Cases ,
Medical Practive Division MOH March 2007
2. Guidelines on Ex Gratia for Medicolegal Complaints
1st Edition October 2018 Medicolegal Section,Medical Practice Division
3. Medical Negligence Law in Malaysia
Dr Puteri Nemie Jahn Kassim
4. Garis Panduan Pengendalian dan Pengurusan Reod Perubatan Pesakit bagi Hospital Hospital
dan Institut Perubatan .Pekeliling KPK Bil 17/2010
5. Guideline of The Malaysian Medical Council 002/2006 : Medical Records and Reports

60. Thank You