BACKGROUND. South Africa has one of the highest rates of interpersonal violence (IPV), in all its forms, in the world. Incidents of assault are
largely under-reported and place an immense burden on the healthcare, fiscal and judicial systems. The first contact a victim of IPV has
with a medical practitioner may be the only opportunity to identify, record and preserve valuable evidence, as evidence not captured on this
occasion may be lost forever. The accuracy and quality of clinical notes taken at the time may be of paramount importance in facilitating
the administration of justice.
OBJECTIVES. (i) To investigate the adequacy of medicolegal note keeping by doctors in cases where subsequent legal proceedings may ensue;
and (ii) to apprise clinicians of their shared responsibility in contributing to the administration of justice through both appropriate patient
management and objective and contemporaneous recording of findings from a medicolegal perspective.
METHODS. A prospective descriptive study was conducted over a period of 18 months from 2016 to 2018. The investigators reviewed patient
files and critically appraised first-contact clinical notes in fatal-outcome cases of IPV admitted to the Pretoria Medico-Legal Laboratory
during the study period. The cases were reviewed using rubrics specifically designed by the investigators to critically but consistently assess
the adequacy of documentation of the medicolegal aspects applicable to each case.
RESULTS. One hundred cases met the defined criteria for inclusion in the study. The victims were predominantly male (98%), and most (79%)
were aged <40 years. Blunt-force injuries were the most frequent type of injury (43%), while gunshot wounds accounted for 36% of cases
and sharp-force injuries were documented in 11%. Insufficient medicolegal documentation, wound description and evidence collection, by
medical practitioners, was identified across all wounding modalities in the study sample.
CONCLUSIONS. This study showed that medicolegal documentation in cases of IPV is suboptimal, with many important parameters not being
routinely recorded, which is likely to impact negatively on criminal investigations and downstream legal proceedings. Greater emphasis on
these issues is required during the undergraduate training of healthcare workers in a society as severely afflicted by IPV as SA. Although
this study focused on fatal-outcome cases, these conclusions are equally applicable to many more cases where investigators, prosecutors and
presiding judicial officers may be dependent on findings contemporaneously and objectively recorded by medical professionals.