Legal ethical issues & MLC

Mrs. Harpreet Kaur,
MSc Nursing 2nd Year
NIMS College of Nursing
NIMS University, Jaipur

As a nurse, it has become an important necessity to be
aware of the legal aspects associated with caring and
helping people in the health industry today . The first
nursing law created was that of nursing registration in
1903 and they have only evolved and expanded over
the years to create a thick book which must be studied
today by aspiring nurses.

Following legal issues recur frequently in nursing practice:-
i) PERSONAL LIABILITY: As an educated professional, nurses
are always legally responsible or liable for their action. The
physician and supervisor giving the directions may be liable if
harm results but that would not remove your liability. Although
each person is legally responsible for his or her own actions,
there are also situations in which a person or organization may
be held liable for actions taken by others.

ii) EMPLOYER LIABILITY:-
In many instances ,an employer can be held responsible for
torts committed by an employee. This is called the doctrine of
respondent superior(let the master respond). Therefore if a
nurse, as an employee of a hospital, is guilty of malpractice,
the hospital may be named in the suit. It is important to
understand that this doctrine does not remove any
responsibility from the individual nurse, but it extends
responsibility to the employer in addition to the nurse.

iii) CHARITABLE IMMUNITY:-
In some states, non-profit hospitals have charitable
immunity. This means that the non profit hospital cannot
be held legally liable for harm done to a patient by its
employees. The employees of that nonprofit hospital are
still legally for their own actions. If you are employed by
a non profit institution, it is important that you know
whether the law in your state provides charitable
immunity for the institution.

iv) SUPERVISORY LIABILITY:
When a nurse is in the role of charge nurse ,head nurse,
supervisor or any other role which involves supervision
or direction of other people ,the nurse is potentially liable
for the actions of others .The supervising nurse is
responsible for good exercising good judgement in a
supervisory role .This includes making appropriate
decisions about assignments and delegation of tasks .

v) DUTY TO REPORT OR SEEK MEDICAL CARE
FOR A PATIENT:-
A nurse who is caring for the patient has legal
duty to ensure that the patient receives safe
and competent care .This duty requires that
the nurse maintain an appropriate standard
of care and also that the nurse take action to
obtain an appropriate standard of care from
other professionals when that is necessary.

VII) FRAUD:-
Fraud is deliberate deception for the purpose of personal
gain and is usually prosecuted as crime situations of
fraud in nursing are not common. One example would be
trying to obtain a better position by giving incorrect
information to a prospective employer. By deliberately
stating(falsly) that you had completed a nurse practitioner
program to obtain a position for which you would
otherwise be ineligible,you are defrauding the employer.

VIII) MEDICATION ERRORS:-
Some errors results from drugs with similar names
,look alike medication containers, poor systems for
communication in which hand writing problems may
contribute to lack of clarity. When medications
errors do occur, fraud or intentional concealment
may be charged and may contribute to the
awarding of punitive damages as well as ordinary
damages.

IX) TORTS:
Torts are civil wrongs committed by one
person against another.The wrong may
be physical harm, psychological harm or
harm to reputation, livelihood or some
other less tangible value.Types of torts:
1. Intentional torts 2. Quasi-intentional
torts 3. Unintentional torts

a) Assault :-
Assault is any intentional threat to bring
about harmful or offensive contact. No
actual contact is necessary. The law protects
clients who afraid of harmful contact. It is an
assault for a nurse to threaten to give a
client for an X-ray procedure when the client
has refused consent. The key issue is the
client consent.

b) Battery :-
Battery is un-consented or unlawful touching of a person. For
battery to occur ,the touching must occur without consent.
Remember that consent may be implied rather than
specifically stated. Therefore, if the patient extends an arm for
injection, he cannot later charge battery, saying that he was
not asked. But if the patient agreed because of a
threat(assault), the touching would still be considered battery
because the consent was not freely given.

c) False imprisonment: :-
• Preventing movement or making a person stay in a place
without obtaining consent is false imprisonment.
• This can be done through physical or non physical
means. Physical means include using restraints or locking a
person in a room.
• In some situations, restraints and locking patients in a
room are acceptable behaviour. This is the case when a
prisoner comes to the hospital for treatment or when a
patient is a danger to self or others. To restrain a person
requires a physician‘s order and permission of the patient
or the patient‘s family members.

Invasion of privacy :-
Invasion of privacy is the intrusion into
the personal life of another, without
just cause, which can give the person
whose privacy has been invaded a right
to bring a lawsuit for damages against
the person or entity that intruded.

Common examples of nursing negligence include
malnutrition, inadequate hydration, physical abuse,
medication errors, and mental and emotional abuse. In
nursing homes or other places of long-term care, there
are also often injuries due to bedsores, infections and
falls. Malnutrition and dehydration cases come from
leaving a patient unattended for too long, ignoring his
needs, or simply refusing to feed and provide water.
Examples of breach of duty, which may be considered
negligent under certain circumstances may include
"doing something which a reasonably prudent person
would not do, or the failure to do something which a
reasonably prudent person would do, under
circumstances similar to those shown by the evidence.

b. Malpractice :-
Medical malpractice is defined as a wrongful act by a physician,
nurse or other medical professional in the administration of
treatment or the omission of medical treatment. It is professional
negligence by act or omission by a health care provider in which
care provided deviates from accepted standards of practice in the
medical community and causes injury or death to the patient.
Nursing malpractice takes many forms, including: - Medication
errors ,Failure to follow a physician‘s orders , Delaying patient
care and/or failure to monitor a patient , Incorrectly performing a
procedure, trying to perform a procedure without training
,Documentation error ,Failure to get informed patient consent .

a. Nursing Shortage :-
The nursing shortage is a major issue facing the
biggest licensed profession in the health-care
system. This shortage will affect health care more
each day, as it appears not much is being done to
stop it. Many emergency rooms have longer wait
times due to less nursing staff, and hospital floors
are feeling the effects as well. This is affecting
patient care because the number of patients to one
nurse is increasing, therefore decreasing the quality
of care.

b. Low salaries:- low salary of nurses in India is also patient care
issue because as the nurse is not satisfied with their salary so
they show less interest in patient care. This leads to migration of
nurses to abroad.
c. Patient Satisfaction:- • Patient satisfaction is an important and
commonly used indicator for measuring the quality in health care.
Patient satisfaction affects clinical outcomes, patient retention.
Patient satisfaction leads to :- • customer (patient) loyalty. •
Improved patient retention • Consistent profitability • Increased
staff morale with reduced staff turnover also leads to increased
productivity • Reduced risk of malpractice suits • Accreditation
issues are resolved. • Increased personal and professional
satisfaction

d. Permission to treat:-
When people are admitted to hospitals, nursing homes,
and home health services, they sign a document that
gives the personnel in the organization permission to
treat them. Every time the nurse provides nursing care
to person, however, permission must be obtained.

e. Service excellence :-
Today the patient sees himself as a buyer of health
services. patient satisfaction is an important tool for
the success of their organization. Service excellence
revolves around three factors: doctor, patient, and
organization.
Doctor should do following- • Secure confidentiality
and privacy • Preserve dignity & Respond quickly .
Patient- Patients expect their doctors to keep up the
timings, behave cordially, and communicate in their
language. They expect care, concern, and courtesy in
addition to a good professional job.

h. Confidentiality:-
The law requires you to treat all such information
with strict confidentiality. This is also an ethical issue.
Unless a patient has told something that indicates
danger to self or others, you are bound by legal and
ethical principles to keep that information
confidential.
I. Informed consent :-
The concept of permission to treat is closely tied to
the concept of informed consent. The law states the
persons receiving health care must give permission
to treat based on informed consent.

j. Negligence:- Negligence occurs when a person fails to perform
according to the standards of care or as a reasonably prudent person
would perform in the same situation. It is the responsibility of the nurse
to monitor the patient.
k. Malpractice:- Malpractice specifically refers to negligence by a
professional person with a license. Nurse can be sued for malpractice
once have your LPN license.
l. Assault & Battery :- • Assault is the threat of unlawful touching of
another, the willful attempt to harm someone. • Battery is the unlawful
touching of another without consent, justification, or exercise. In legal
medicine battery occurs if a medical or surgical procedure is performed
without patient consent. • Assault can be verbally threatening a patient.
m. False Imprisonment :-• Preventing movement or making a person stay
in a place without obtaining consent is false imprisonment. • This can be
done through physical or non physical means.

a. Turnover :-
Maintaining adequate staffing levels is a major issue in
nursing management. Representatives working in nurse
management and leadership are often faced with the
responsibility of controlling turnover rates. Nurses
faced with long work hours for relatively little pay have
few motivations to remain in one position and often
seek employment opportunities at competing hospitals
and neighboring clinics.

b. Funding :-
Lack of funding is an issue for many nurse
managers who seek to provide sufficient
compensation to existing nurses as well as
offer suitable compensation in an attempt to
recruit new nursing professionals for hire. An
underfunded institution cannot attract and
provide for the right professionals, and
funding inadequacies can also become a
detriment to the needs for medical equipment
and supplies.

c. Workload :-
Individual nurse manager workload and overall
medical workload are issues in leadership. The
medical profession is one that never sleeps and has
an almost constant need for qualified professionals
both in hiring and scheduling. Not only do nurse
professionals work long hours and many days per
week, but nurse managers and leaders are also faced
with an ever-increasing workload. Dealing with patient
concerns, providing training and support to nurses,
and acting as Many nurses are unwilling to enter into
the nurse management field because of the added
stress and responsibility.

e. Ethics :-
Nurses are held to a high standard of ethics when it comes
to patients, co-workers and themselves. They provide care,
promote human rights and values, and help meet the needs
of the less fortunate and vulnerable. A major ethical goal is
to also keep patients' information confidential, and this
includes not discussing patients in public places. Another
ethical issue is protecting patients from negligent co-workers
who may endanger them.

f. Effect :-
Effects of reform, shortages, ethics and salaries are
issues that keep nurses constantly thinking,
growing and changing. In order for nursing to
succeed, there needs to be qualified candidates
educated, but with these low salaries nurses are not
flocking to this career path. Without these types of
nurses being adequately filled then qualified
candidates will not have the opportunity to be
taught. These salaries need to be increased, and
colleges and universities need to see the value in
these instructors.

h. Collaboration issues :-
The nursing profession is faced with
increasingly complex health care issues
driven by technological and medical
advancements an ageing population,
increased numbers of people living with
chronic disease, and spiraling costs.
Collaborative partnerships between
educational institutions and service agencies
have been viewed as one way to provide
research which ensures an evolving health
care system with comprehensive and
coordinated services that are evidence based,
cost effective and improve health care
outcomes.

a. Issues related to Nursing Shortage :-
The nursing shortage is another international
event. The nurse shortage itself is a
contributing factor because the shortage
creates staffing problems, mandatory
overtime, and constant calls for additional
shift work. National nursing organizations are
making strong efforts at stopping the
shortage by mandating better nurse- to-
patient ratios, eliminating mandatory
overtime, and increasing salaries and
benefits for nurses.

b. Issues in Nurse Migration :-
Nurse migration has attracted a great deal of
political as well as media attention in recent years.
The rights to healthcare as well as workers‘ rights
are paramount to understanding the interests of
health sector stakeholders, including the consumer
or patient, the government or employer, and the
worker or health professional. In this section a
discussion on the right to work and the right to
practice is, by necessity, followed by a warning that
cases of exploitation and discrimination often occur
when dealing with a vulnerable migrant population

C.The Right to Work and the Right to Practice:-
Professionally active nurses are important players
in an increasingly competitive and global labor
market. Unable to meet domestic need and demand,
many industrialized countries are looking abroad for
a solution to their workforce shortages. For nurses
to practice their profession internationally, they
need to meet both professional standards and
migration criteria. The right to practice, e.g., to hold
a license or registration, a professional criteria, and
the right to work, e.g. to hold a work permit, a
migration criteria, are sometimes linked. Yet they
often require a different set of procedures with a
distinct set of competent authorities.

e. Essential Terms and Conditions in an Employment contract :-
An employment relationship has traditionally been governed by the
terms and conditions of the employment contract. Previously, the
employer retained sole control in respect of the terms and conditions of
employment to be incorporated into the employment contract. However,
over the years there has been an increase in the implied terms and
conditions which are also read into the contract. Additionally, then there
are the statutory terms and conditions which also apply. A badly drafted
employment contract which does not correctly express the intentions of
the employer on such matters as working hours, prolonged illness, bonus
payments, usage of office computer facilities, transfers, retirement age,
confidentiality, conflict of interest, disciplinary action and imposition of
punishment, etc.

g. Misconduct and imposition of punishment
It has long been held that the employer has the inherent right to discipline his
workers. the employer after a proper inquiry can impose a suitable punishment,
including dismissal if the offence committed was of a serious nature.The
decision on the type of punishment to be imposed is under all circumstances a
subjective one. The Courts will interfere if, among others, the action taken by
the management was baseless or unnecessarily harsh or was not just or
fair.There have been occasions where employers have imposed the punishment
of dismissal for misconduct which they have assessed as serious but these cases
have been reviewed by the Industrial Court and the decision of the employer
substituted.

k.Diploma vs degree in nursing for registration to practice
nursing :-
This issue need in depth study of merits and demerits
as well as its feasibility before it could come on the
surface.
l. Specialization in clinical area :-
It could be either through clinical experience or
education. Specialization in cure and specialized care
required for patients demand that nurses be highly
skilled in the unit. Generalization of care seems remote
and unacceptable for patients under specialized
treatment.

m. Unsatisfactory work performance and termination
of employment :- The Courts have time and again
reiterated that employees enjoy security of tenure of
employment. However, when an employee has an attitude
problem or whose work performance is not up to the
expectations he cannot be terminated by the employer
simply by invoking the termination clause in the
employment contract. The employer has to follow certain
rules and procedures and only at the end of it can he
terminate the services of a non-performing employee.
n. Nursing care standards:-
Standards must be laid down and followed so that clients
understand the quality of care expected from the nurses.

Medico-legal Case (MLC) can be defined as a case
of injury or ailment, etc., in which investigations by
the law-enforcing agencies are essential to fix the
responsibility regarding the causation of the said
injury or ailment.In simple language it is a medical
case with legal implications for the attending
doctor where the attending doctor, after eliciting
history and examining the patient, thinks that
some investigation by law enforcement agencies is
essential.

Attending casualty medical officer (CMO) has the authority to decide
whether the case is to be registered as medico-legal or not. There is no
scope for acceding pressure from the relatives, patient himself regarding
the registration of MLC. Even if the incident has happened several days
ago MLC should be registered. A case should be registered medico-legal
even if the patient requires an OPD treatment. Failure to preserve the
necessary samples for subsequent examination in Forensic Science
Laboratory may render a doctor liable to be charged under IPC 201,
punishable with imprisonment up to 7 years and fine.

1. Cases of accidental death, RTA, Rail accidents,
Factory accidents ,Suspected Homicides, Suicides
,Suspected or evident poisonings, Alcohol
intoxication , Burn injuries due to any cause,
Physical assault cases , Animal attack, Snake Bite ,
Mass food poisoning , Cases of Sexual Assaults ,
evident Criminal Abortion .
2. Police should be immediately informed after
patient is declared “Dead on Arrival” in casualty or
dispensary, so that, an inquest can be arranged.

3. A patient may suddenly die after admission to the
Hospital. It is the duty of the Medical officer to inform such a
case of death to the Police, immediately.
4. The death of a patient within 24 hours of admission
should be reported to the Police, so that, they can arrange
for an inquest and a postmortem examination, if necessary.
5. Deaths in the Operation Theatre during Medical
Termination of Pregnancy, delivery, following sterilization or
any other surgical procedure should also be reported to
Police.
6. The Police should be informed about drug or alcohol
related death (including deaths of drug addicts).

8. Whenever a medico-legal case is
admitted in the ward, the concerned
consultant on call and the head of the unit
should be informed, about such admission.
10. If a patient is found absconding from
the wards, MLC should be registered
immediately.
11. MLC should be registered when a
patient has a fall or trauma during the
hospital admission and treatment.

DOCTOR AND MLC :- Every Doctor under law bound by a
contract to serve its patient and cannot refuse treatment. Medico-
legal case examination and reporting is one of the legal
responsibility of all doctors working in a hospital.
WHY TO MANAGE MLC :- MLC cases are just as Non MLC
sick/injured patients and the doctor is duty bound to treat as well
as document the details.
DOCTORS WORKING IN A PVT. HOSPITAL REPORT
HOMICIDAL POISONING TO THE POLICE (U/S 39
CRPC) FAILURE TO DO SO IS PUNISHABLE

FEAR OF MLC :- Every medical practitioner at any time
during the practice of his profession, would have encountered
certain cases. Many a practitioners are usually apprehensive in
dealing with these cases as they feel, an MLC means
‘Entangling’ in police cases ‘ indefinite hours’ to be spent in
the court. Because of this “fear-factor”, they either try to avoid
or try to manipulate them as non MLC. The best way to deal
with these cases is to understand them clearly, analyze them
thoroughly, and then act accordingly.

A Doctor can receive a Medico-Legal Case in any
of the four situations:-
1. A case is brought by the police for examination
and reporting or order of the Court for medico-
legal examination.
2. The person in question was already attended
by a doctor and MLC was already registered in a
previous hospital and the person is now referred
for expert management/advice.
3. When patient himself expresses his intention to
register a case against the alleged accused.

THE BIRTH AND DEATH REGISTRATION ACT IS CLEAR THAT ALL
UNATTENDED AND UNCERTIFIED DEATHS ARE TO BE DEALT WITH AS
MLC’S - The job of a medical officer at casualty is to inform the police
in all brought dead cases. It is mandatory.
INFORM THE POLICE ALWAYS ( EVEN THOUGH THE RELATIVES ARE
REQUESTING YOU NOT TO INFORM)- ALL CASES OF DEATH ON
ARRIVAL/BROUGHT DEAD TO EMERGENCY / CASUALTY :- All
suspected unnatural deaths, Death of recently married woman, young
adult dying suddenly with no proper medical records, If you find any
injuries, ligature mark, nail marks and bite marks ,Signs of poisoning
etc.

ALCOHOL & MLC :-Drunken Driving ,
Misconduct in public ,Chronic Alcoholic-
causing trauma leading to Head injury ,
Drunken state and sudden death Preserve:
10 ml blood in sodium fluoride (100mg)+
Potassium oxalate.
DOMESTIC VIOLENCE AND ABUSE OF
WOMEN:-It include ongoing verbal,
emotional, sexual, physical, psychological
abuse may result in death, serious injury,
isolation and emotional damage. The
medical officer should remain vigilant about
such incidences.

GENERAL DETAILS :-1. Registration number 2. MLC no. 3. Name
4. S/D/W of 5. Age 6. Sex 7. Religion 8. Occupation 9. Residential
address 10. Brought by_____ 11. Date & time of Examination 12.
Name of Police Station.
TIME LIMIT FOR REGISTERING A MLC :- A medico-legal case
should be registered as soon as a doctor suspects foul play or
feels it necessary to inform the police at arrival, At any time after
admission. A case may be registered as an MLC even if it is
brought several days after the incident if suspected. No MLC
should be back-dated.

COLLECTION AND PRESERVATION OF SAMPLES
:- Gastric lavage, Vomitus in poisoning cases,
Blood in Alcoholic/poisoning cases/drug abuse/ or
for DNA test (preserve in Refridgerator, Clothes in
Assault/Injury/Burn cases etc if recovered Vaginal
swabs/ smears /Pubic hairs in Rape cases.

ADMISSION AND DISCHARGE :- Whenever a
medico-legal case is admitted or
discharged,the same should be intimated to
the nearest police station at the earliest. It is
always better to inform the police through the
casualty of the hospital where the medico-legal
register is usually maintained and necessary
entries can be made in it.  While discharging
or referring the patient, care should be taken to
see that he receives the Discharge
Card/Referral Letter, complete with the
summary of admission, the treatment given in
the hospital.

ABSCOND/DEATH OF MEDICO-LEGAL CASE :-In case a person
admitted as a medico-legal case expires or absconds, Inform the police
immediately. Send the body to the hospital mortuary for preservation, till the
legal formalities are completed and the police releases the body to the
lawful heirs. The dead body should NEVER be released to the relatives; it
should only be handed over to the police.
COMMON MISTAKES IN A MLC:- Missing…..  Sign, Date, place 
Consent of the person  Identification points  MLC no.  Nature of injury 
Type of injury  Short ,Investigations advised  Police station  Provisional
diagnosis,

1. BT Basavanthappa text book of nursing administration ,1st
edition,jaypee brothers medical publishers(p) ltd,new
delhi,2000.
2. Bessieh.Marquis, Carol J.Hustan, Lippincott ,text book of
leadership roles & management function in nursing theory &
application,3rd edition ,2000
3. BT Basavanthappa ,Management of nursing services &
education,1st edition,jaypee brothers medical publishers(p)
ltd,new delhi,2011
4. http://www.barc.gov.in/publications/tb/mg2009.pdf

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