Dr M C Gupta, a doctor turned lawyer, provides medico-legal opinion on a frequently asked question, especially after the recent murder of a doctor in Chennai, What should doctors and nursing homes do to prevent and manage violence by patients’ relatives?
Dr Gupta holds an MD (Medicine) from All India Institute of Medical Sciences (AIIMS), an LLB from Delhi University and LLM from Kurukshetra University. He has served as a faculty member at AIIMS for 18 years and as professor and dean at the National Institute of Health and Family Welfare. Currently, Dr Gupta is a practising advocate with health and medical law as the area of special interest. He is a member of the Supreme Court Bar Association and Indian Law Institute.
“Doctors in Jharkhand are endangered by violent attendants of the patients. There is no medical protection act in our state. What should we do?” — Dr Deonis Xess, MD, Consultant Rheumatologist, Apollo Hospital Ranchi
Dr Gupta Comments:
You should do as follows:
I. Preventive Action By Individual Practitioners
A) The Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002, should be strictly complied with.
B) Keep liaison with the local police.
C) Keep proper records.
D) Do not commit negligence. Be knowledgeable in your subject. Do not venture out of your area of work/expertise.
II. Preventive Action By Nursing Homes / Hospitals
It needs to be appreciated that violence against hospitals occurs mainly because of lack of information and misunderstanding. It also occurs because of negligence or crudeness or arrogance or greed on the part of nursing homes and hospitals.
The nursing homes and hospitals should do the following:
A) They should take steps to minimise the possibility of such attacks. Examples of such steps are:
1) The Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002, should be strictly complied with by the doctors working in the nursing homes and hospitals.
2) A notice should be prominently displaced providing information to the public about the actions that an aggrieved patient may take. Such information may include:
a) Name and mobile/telephone number of the person/doctor who is officially assigned the duty of attending patient complaints / emergencies on 24 hour basis;
b) Name of the person-in-charge and the members of the ‘Patients’ Grievance Redressal Committee’ of the hospital or nursing home concerned and the time limit [say, 48 hours] during which the committee would take initial necessary action;
c) The mechanism for supplying a copy of patients’ medical records on request, including the fees and time limit for the same;
d) Name and address of the local IMA’s Patients Grievance Cell, if such a cell exists;
e) Name and address of the state medical council;
f) Name and address of the District Consumer Forum.
3) The following information should also be prominently displayed:
a) Schedule of hospital charges;
b) Name, qualifications and the medical council registration number of all doctors.
B) The nursing homes and hospitals should buy a hospital professional indemnity policy through a legal risk cover company. While choosing the legal risk cover company, they should choose that company whose terms and conditions include a written clause that the company will provide legal services in connection with criminal/police complaints related to violence against the hospital.
C) The nursing homes and hospitals should organise a collective nursing home defence mechanism through the local IMA (Indian Medical Association). If this is not possible, a few nursing homes should come together on their own and form such a joint defence mechanism (JDM). The JDM would do the following:
1) It would collect fees from members and keep proper accounts of the funds collected and spent.
2) It would provide the following services to the members:
a) Liaising with the police.
b) Organising joint seminars on the issues related to nursing home protection. The local police officers, CMO (Chief Medical Officer), DM (District Magistrate), media and some persons from the legal field, if possible the magistrate or sessions judge, should be invited on these occasions and they should be requested to express their views.
c) Engaging the services of an advocate on the criminal side to act as a standing counsel for the member nursing homes for any legal help at times of violence.
d) Engaging the services of a security agency to provide security cover in normal times as well, additionally, in emergencies, to the member nursing homes.
D) The cost of the JDM incurred by the member nursing homes should be recovered, in part or full, as appropriate, from the patients by adding an item in the bill, such as, ‘Protection Against Violence Charges’. Such charges should be levied in a transparent manner and should be supported by proper accounting procedures. The consent form signed by the patient at the time of admission should clearly state that the signatory consents to pay the “hospital patients’ protection charges”.
E) The nursing homes and hospitals should take the following ‘miscellaneous’ actions / precautions:
1) Only MBBS doctors should be employed in the hospital. Paramedical staff should be adequately qualified/trained.
2) A written undertaking should be taken from the patient and two relatives that they would not indulge in violence and that any loss to the hospital property as a result of violence caused by them would be recoverable from them by various means, including but not restricted to adjustment against the advance deposit and any bank guarantee or any other guarantee provided on behalf of the patient at the time of admission.
3) Hospital records in respect of patients (case sheets) should be properly kept.
4) Treating doctors should spend sufficient time with the patients and relatives to answer their doubts and queries.
5) The consent form should not be got signed in a cursory manner. It should be an informed consent in the true sense.
6) No false assurances, even verbal, should be given to patients.
7) Patients’ attendants should be clearly and documentally told that they are free to shift their patient to any other hospital at any time.
(8) Prompt police complaints should be made against those who commit violence. Video cameras should be installed at a few places to record the photographs and voice of any bad elements who commit violence. This would greatly help in making a police complaint and pursuing it.
9) Patient records should be properly maintained. They should be kept in proper custody of the hospital and should not be loosely displayed. However, proper and detailed referral letters and discharge summaries, containing necessary details, should be given to patients under signature when they leave the hospital.
Some nursing homes may be small nursing homes with only a few beds. However, all the above measures need to be taken by every nursing home, big or small. The smaller the hospital, the more the chances of violence against it.
III. Preventive Action By the IMA
A) The state IMA and the city/district branches should establish patient grievance redressal cells to look into the complaints of medical negligence. These cells, if they function properly, would help prevent or minimize the incidents of this type (violence by patients’ relatives).
B) The state and district IMA branches should organize discussion meetings with the police regarding atrocities and injustice against doctors.
C) The state and district IMA branches should organize regular medico-legal updates for members with focus on medical negligence and grievances of doctors.
IV. Action To Be Taken When Violence Occurs
A) Depute someone (preferably beforehand) to take photographs and, even, audio recordings of the violence.
B) Depute someone to immediately get the medical record of the patient photocopied, preparing at least 3 copies. These will be useful for giving to the patient’s relatives, the police and to the court. If the mob carries away the original record, the photocopies will be useful.
C) Inform your advocate.
D) Inform the police immediately by phone etc and keep a record of such phone call etc.
E) Identify the trouble makers / leaders in the mob and talk to them and try to pacify them, even though you may have to go out of the way to a certain extent.
F) Get written, signed statements from the persons present (doctors, staff, patients, relatives, others) regarding the occurrence of violence. An advocate’s help in this would be especially useful. [Note: Such statements are crucial as regards the legal course of the incident and may not be easily available later).
G) Lodge an FIR (First Information Report) with the police. It is better to let the advocate prepare the FIR.
H) Issue a press statement about the incident.
I) The aggrieved doctor should not be left alone. The local IMA should provide him all support in the interest of the profession. The support should be on the following lines:
a) It should immediately constitute a high powered committee including, amongst others, its counsel and also, preferably, a retired judge (and maybe also a police officer), to probe into the incident and submit its report along with the plan of action;
b) It should get published in the newspapers a balanced and correct version of the incident so that the public understands the facts of the situation. This may be by way of a press release or an advertisement.
c) It should take direct action, within law, against the culprits. It should circulate amongst the members the names of those involved in the incident with a request that members may, at their discretion, decline to provide services to them except in emergency, unless they submit apology to the concerned doctor and to the state IMA in writing.
V. Getting The Protection Act Passed In Your State
Press the state IMA to pursue with the state government to pass an act on the lines of the acts in other states such as the ‘Punjab Protection of Medicare Service Persons and Medicare Services Institutions (Prevention of Violence and Damage to Property) Act, 2008’ or the ‘Tamil Nadu Medicare Service Persons and Medicare Service Institutions (Prevention of Violence and Damage or Loss to Property) Act, 2008’.
Demand from the local MLAs and the health minister that pending the framing of a regular act, an ordinance may be passed immediately as was done in Andhra Pradesh. At the same time, in consultation with an advocate, file a PIL (Public Interest Litigation) in this connection after necessary groundwork.
Editor: Readers are welcome to send their medico-legal queries to firstname.lastname@example.org and we will try to get them answered by Dr M C Gupta and publish the same on AalaTimes.com. Please mention your full name, designation/specialization and organisation in your email.