Poison is defined as any substance which when introduced into the living body or brought in contact with any part thereof will produce ill effects or death by its local or systemic action or both. (Vijay H Mate et al., 2017)According to the Accidental Deaths & Suicides in India (ADSI) – 2023 report published by the National Crime Records Bureau under the Ministry of Home Affairs, a total of 1,71,418 suicides were reported nationwide in 2023. During the same period, 4,44,104 accidental deaths were documented across the country.

The principal causes of accidental deaths included road traffic accidents, drowning, lightning, heart attacks, falls, fire accidents, and poisoning. Among poisoning-related fatalities, 7,743 deaths were specifically attributed to accidental pesticide/insecticide poisoning in 2023.^{(National Crime Records Bureau. Accidental Deaths & Suicides in India – 2023. New Delhi: Ministry of Home Affairs, Government of India; 2025., n.d.)}

These figures highlight that poisoning remains a major public health concern and a frequent cause of emergency admissions in India, contributing significantly to morbidity and mortality across all age groups (Hande et al., 2025a)

Tertiary health care centres serve as referral centre for most of poisoning cases, necessitating prompt medical management along with meticulous medico-legal handling.(Rishipathak et al., n.d.)

Healthcare professionals managing poisoning cases are required to perform early stabilization, identify the likely poison, initiate appropriate decontamination and antidote therapy, and simultaneously ensure compliance with medico-legal obligations such as documentation, police intimation, and sample preservation.(Raut et al., 2020) (Agrawal et al., 2024)Failure in any of these aspects can adversely affect patient outcomes and compromise legal proceedings.(Husain et al., n.d.)

Healthcare professionals working in tertiary care centres are often the first point of contact for patients with suspected poisoning. Apart from life-saving interventions, they bear the legal responsibility of registering medico-legal cases, ensuring proper documentation, preserving, sealing, labelling, and timely forwarding of biological samples and related materials to forensic laboratories. (Godara et al., 2019)In fatal cases, the practitioner must refrain from issuing a death certificate and ensure referral for medico-legal autopsy. maintaining chain of custody, and communicating with law-enforcement agencies as mandated under the Bharatiya Nagarik Surksha Samhita and Bharatiya Nyaya Samhita.(MINISTRY OF LAW AND JUSTICE (Legislative Department) ,BNSS 2023.)  (BNS, 2023).Errors or gaps in these processes may compromise toxicological analysis, judicial proceedings, and ultimately the delivery of justice.(Kumar V et al., 2025)

Despite the high burden of poisoning cases, studies from India indicate variability in knowledge and practices among healthcare professionals, particularly at the level of interns and junior doctors.(Rishipathak et al., n.d.) The Knowledge, Attitude, and Practice (KAP) model is a widely accepted framework to assess preparedness and identify gaps in healthcare delivery.(Chhetri et al., 2025) However, institution-specific data remain limited.

This study was therefore undertaken to assess the KAP of healthcare professionals regarding handling of poisoning cases in tertiary care centres and to generate evidence for targeted interventions. Assessing the KAP of healthcare professionals in this domain is essential to identify existing gaps, plan targeted training programs, and strengthen institutional protocols. The present study was therefore undertaken to evaluate the knowledge, attitude, and practice of healthcare professionals regarding the handling of poisoning cases in tertiary care centres, with special emphasis on medico-legal responsibilities.

AIMS AND OBJECTIVES

1. To assess the level of knowledge among healthcare professionals regarding poisoning case management.
2. To evaluate their attitude toward standardized protocols, medico-legal responsibilities, and training.
3. To analyze current practices followed while managing poisoning cases in tertiary care settings.

MATERIALS AND METHODS

Study Design

Hospital-based cross-sectional study.

Study Setting

Tertiary health care centres.

Study Population

Healthcare professionals including teaching faculty, residents, medical officers, interns, and nursing staff.

Sample Size

A total of 236 participants, based on voluntary participation during the study period

Study Tool

A structured questionnaire was developed and validated by the investigators, consisting of:

• Section A: Demographic and professional details (not scored)
• Section B: Knowledge-based questions
• Section C: Attitude-based statements
• Section D: Practice-based questions

The purpose, voluntary nature, and confidentiality of the study were clearly explained to participants

KAP poisoning questions:

Section A:  Demographic and Professional Details of Participants (Section A – Not Scored)

Section B: Knowledge Assessment Questions on Medicolegal Handling of Poisoning

Section C: Attitude Toward Medicolegal Management of Poisoning Cases

(5-point Likert scale: Strongly agree – Agree – Neutral – Disagree – Strongly disagree)

Section D: Practice Patterns in Handling Poisoning Cases

Data Analysis

Responses were entered into a spreadsheet and analysed using descriptive statistics. Results were expressed as frequencies and percentages.

Ethical Considerations

Institutional approval was obtained. Participation was voluntary, anonymous, and confidential.

RESULTS

A total of 236 healthcare professionals were included from various departments and professional categories in the present cross-sectional study. The study assessed their knowledge, attitude, and practice regarding the medicolegal management of poisoning cases. The results are summarized and presented in the following tables.

1. Characteristics of study population

The study population predominantly comprised interns (34.3%), followed by junior residents (17.8%) and medical officers (15.7%). Participants were mainly from the Medicine (27.5%) and Forensic Medicine (26.7%) departments, together accounting for more than half of the respondents. With respect to clinical experience, a majority of the participants had less than five years of clinical experience (84.8%), while only a small proportion had more than ten years of experience (7.2%).

Table 1. Baseline characteristics of the study participants (n = 236)

2. Knowledge of study participants

The knowledge of the study participants regarding the medicolegal aspects of poisoning cases shows high proportion of respondents were aware that poisoning cases should be registered as medicolegal cases and that gastric lavage constitutes an important sample for toxicological analysis. However, comparatively lower levels of knowledge were observed regarding the appropriate preservatives for blood samples and consent requirements in unconscious patients.

Table 2. Knowledge of study participants regarding medicolegal aspects of poisoning cases (n = 236)

3. Attitude of the study participants

The attitude of the study participants towards the medicolegal management of poisoning cases observed that overall, participants demonstrated a moderately positive attitude towards medicolegal responsibilities; however, apprehension regarding legal consequences and lack of confidence in handling medicolegal procedures were commonly reported.

Table 3: Attitude of study participants towards handling poisoning cases (n=236)

4. Practices of the study participants

It is observed that the self-reported practices of the study participants with respect to the medicolegal management of poisoning cases a majority of respondents reported adherence to essential medicolegal practices, notable gaps seen in consistent documentation and procedural compliance.

Table 4. Practice of study participants regarding medicolegal management of poisoning cases (n = 236)

5. Study participant & difficulty in handling medicolegal cases

It was observed that 78.8% of study participants reported experiencing difficulty or confusion while handling the medicolegal aspects of poisoning cases. This variable was considered a key outcome measure for further association analysis.

Table 5:  Difficulty faced by study participants in handling medicolegal aspects of poisoning cases (n = 236)

Relation between the clinical experience and difficulties faced

A significantly higher proportion of difficulty was reported among healthcare professionals with lesser clinical experience. Difficulty was reported by 89.1% of participants with less than one year of experience and 82.8% of those with 1–5 years of experience, whereas markedly lower proportions were observed among professionals with 6–10 years (42.1%) and more than 10 years of experience (29.4%). This gradient indicates that increasing clinical experience is associated with a significant reduction in difficulty faced while handling medicolegal aspects of poisoning cases.

Table 6. Relation between clinical experience and difficulty faced in medicolegal handling of poisoning cases

An association analysis was performed to assess the relationship between years of clinical experience and difficulty faced in handling medicolegal aspects of poisoning cases using the Chi-square test.

Chi-square analysis demonstrated a statistically significant association between years of clinical experience and difficulty faced in medicolegal handling of poisoning cases (χ² = 46.84, df = 3, p < 0.001).

Association between professional category and difficulty faced

The association between professional category and difficulty faced in handling medicolegal aspects of poisoning cases was assessed using the Chi-square test. Professional categories were arranged in descending order based on the proportion of participants reporting difficulty.

Table 7. Association between professional category and difficulty faced in medicolegal handling of poisoning cases (n = 236)

A statistically significant association was observed between professional category and difficulty faced in medicolegal handling of poisoning cases

(χ² = 12.84, df = 5, p = 0.025)

DISCUSSION

This cross-sectional study assessed the knowledge, attitude, and practice (KAP) of healthcare professionals regarding the medicolegal management of poisoning cases in a tertiary care hospital. While the study identified significant associations between perceived difficulty and both clinical experience and professional category, the findings primarily reinforce patterns consistently reported in prior literature—namely, adequate foundational awareness coexisting with persistent gaps in technical knowledge, procedural confidence, and practical execution of medicolegal responsibilities.

Knowledge regarding medicolegal aspects of Poisoning

Participants in the present study demonstrated satisfactory awareness of core medicolegal principles, including mandatory registration of poisoning cases as medico-legal cases, informing the concerned authorities, and the role of gastric lavage in toxicological analysis. However, notable gaps were observed in technical knowledge areas such as appropriate preservatives for blood samples and consent procedures for unconscious patients.

These findings closely align with several KAP studies conducted across India. A tertiary care–based study from Madhya Pradesh (Hande et al., 2025) reported that majority (>85%) of the participants had high recognition of poisoning as a medico-legal case and those written police intimation is mandatory but documented gaps in sealing and labelling of evidence containers and timely despatch of samples. Similar deficiencies have been reported in studies conducted in Meghalaya among the registered medical practitioners where the 67% had adequate knowledge regarding consent and registration of medico legal cases whereas 1.8% of them had poor knowledge. (Nath et al., 2022). Intern-focused surveys further indicate limited familiarity with chain-of-custody requirements and medico-legal documentation, often attributed to insufficient practical exposure during undergraduate training (Gajmer, 2024a). In their study it was reported that out of 131 cases, 87.3% of the interns knew that all the poisoning cases must be registered as medico legal case.

Collectively, existing evidence suggests a persistent disconnect between theoretical teaching and real-world medicolegal application in poisoning cases, a pattern reaffirmed by the present study.

Attitudinal Assessment of Participants Toward Medicolegal Responsibilities in Poisoning

The findings in our study indicate that participants generally expressed confidence in managing the medicolegal aspects of poisoning cases and perceived existing hospital protocols to be largely adequate. At the same time, apprehension regarding potential legal consequences appeared to influence clinical decision-making in a notable proportion of respondents. Encouragingly, most participants recognized the importance of meticulous medicolegal documentation as being equally significant as clinical management. There was also strong support for the inclusion of structured forensic training, highlighting the perceived need to strengthen practical competence in handling poisoning cases within medicolegal frameworks.

These attitudinal trends mirror those observed in multiple KAP studies. In a study conducted by (Hande et al., 2025) , it was seen that the respondents agreed that proper medicolegal training is compulsory and that maintaining a chain of custody was both a legal and ethical obligation. Healthcare professionals frequently express a sense of ethical responsibility toward medicolegal duties while simultaneously reporting anxiety related to litigation, police involvement, and court proceedings. [(Gajmer, 2024]. Studies among interns and junior residents consistently indicate that fear of legal consequences influences clinical decision-making, occasionally leading to defensive practices or reluctance to engage fully with medico-legal protocols.  (Gajmer, 2024)

Research among MBBS students further demonstrates positive attitudes toward transparency and forensic consultation but identifies perceived complexity of medico-legal procedures, inadequate hands-on training, and workload pressures as major barriers. International studies echo similar concerns, particularly in emergency department settings where time constraints and high patient volumes exacerbate medico-legal uncertainty (Alabdulqader et al., 2023) The present study reinforces the broader consensus that favourable attitudes alone are insufficient to ensure confident medicolegal practice in the absence of structured training and institutional support.

Practice Implementation Gaps

Although self-reported practices in the present study indicated reasonable compliance with fundamental medicolegal procedures—such as police intimation, sample labelling, and documentation—a substantial proportion of participants reported difficulty or confusion while handling medicolegal aspects of poisoning cases. Significant associations were observed between difficulty faced and both clinical experience and professional category.

These findings are strongly supported by prior research. Several studies document inconsistencies in real-world medico-legal practices, with documentation lapses, improper sample handling, and delayed police intimation reported in approximately 30–40% of poisoning cases (Hande et al., 2025c). Emergency department–based studies done previously attribute these shortcomings primarily to time constraints, staff shortages, and absence of standardized protocols rather than intentional non-compliance (Gupta et al., 2025).

The inverse relationship between clinical experience and perceived difficulty observed in the present study has been consistently reported in the literature. Senior clinicians demonstrate higher knowledge scores, greater procedural accuracy, and increased confidence in medico-legal interactions compared to interns and junior residents. Nursing staff, who often play a critical role in documentation and sample handling, have similarly been shown to experience significant challenges due to limited formal training in medico-legal procedures (Adal et al., 2023) These patterns emphasize that medicolegal competence in poisoning cases is largely experience-dependent and inadequately addressed during early professional training.

Comparative Contextualization and Novel Contributions

The demographic composition of the study population—predominantly interns, junior residents, and early-career professionals—reflects staffing patterns commonly reported in emergency departments of Indian tertiary care hospitals (Hande et al., 2025b). Unlike autopsy-based studies that focus on epidemiological profiles and toxicological patterns of fatal poisoning cases (Agrawal et al., 2024), the present study emphasizes medicolegal challenges encountered during the management of living patients, where timely evidence preservation and documentation directly influence judicial outcomes.

National medico-legal guidelines mandate prompt police intimation, systematic sample collection, and appropriate preservation to prevent evidentiary compromise and potential legal consequences under the Bharatiya Nyaya Sanhita (Bharatiya Nyaya Sanhita & Ministry of Law and Justice, 2023) The persistence of practice gaps despite the availability of such guidelines—observed both in the present study and prior literature—highlights deficiencies in implementation rather than awareness alone. This underscores the need for institution-level operationalization of medico-legal protocols tailored to emergency care settings.

Limitations

The study relies on self-reported data, which may be influenced by recall bias or social desirability bias, although anonymous data collection likely mitigated these effects. The single-institution design may limit generalizability; however, the consistency of findings with multi-center studies suggests broader applicability. The absence of objective audits or direct observation of medico-legal practices represents an additional limitation commonly acknowledged in KAP research.

Implications for Policy and Practice

The convergence of evidence across studies highlights the need for structured, competency-based interventions to strengthen medico-legal preparedness in poisoning cases. Curriculum enhancement with simulation-based forensic modules, mandatory continuing medical education programs, and institution-specific standard operating procedures have demonstrated measurable improvements in documentation quality and procedural compliance (Hande et al., 2025b). Standardized checklists and strengthened collaboration between clinical and forensic departments may further reduce experience-dependent variability and alleviate medico-legal anxiety among healthcare professionals.

Future Directions

Future research should employ longitudinal and interventional designs to assess changes in KAP following targeted training initiatives. Multi-regional studies incorporating rural and peripheral healthcare settings, along with objective audits of clinical records, would enhance generalizability. Qualitative exploration of perceived barriers and pilot testing of digital decision-support tools may further improve medico-legal compliance and confidence in poisoning case management.

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