Death certification

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Applicable-Guidance GRO National Statistics' Death Certification Advisory Group(July 2010) NB - the government has been consulting on changing the arrangements for death certification, and published its response to the consultation in June 2018.[1][2]

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Applicable- read Procurator Fiscal for Coroner -Scottish CMO on death certificates October 2014 Following 2011 legislation the Scottish MCCD process and form was updated in August 2014 (see Revised MCCD forms (form11) and electronic completion CMO letter June 2014 in preparation to going all electronic and removal of a separate cremation form the process in April 2015

(For more information about the Medical Examiner role, to be introduced in England and Wales from April 2019, see the ganfyd Medical Examiner page.)

Certifying death can refer to two separate, but often linked procedures (not including the completion of a cremation form).

Firstly, there is confirmation of death, more formally known as pronouncing life extinct. That is to say confirming the lack of vital signs and neurological response. This does not necessarily require a doctor. This process is, strictly speaking, not certification of death. Confirming brain death is more complex, typically involving neurological testing and other criteria.

Old medical certificate of cause of death (Scotland version). (no longer used after 6th August 2014)

Secondly, there is the administrative certification of death, or to be more accurate, certification of the medical cause of death which is part of the paper work required to obtain the actual death certificate. In England and Wales the process involves the General Register Office.[3] What doctors complete is the legal and formal medical certificate of cause of death (MCCD) stating the cause of death. There is comprehensive official guidance on completion of the MCCD.[4] Note that this certificate is a declaration of the cause of death, not the fact of death per se. Indeed, there are three options on the certificate:

  1. Seen after death by me
  2. Seen after death by another medical practitioner
  3. Not seen after death by any medical practitioner

There is a statutory duty of the doctor who has attended in the last illness to issue the MCCD. This duty will evolve to either a GP or in hospital deaths to the responsible consultant (who may delegate). In Northern Ireland attended relates to a doctor who has treated the deceased within twenty-eight days before the date of death. However, attended is indefinite in England and Wales although there is a different rule to ensure that if the patient was not seen in the 14 days preceding death, or the body not seen after death, the registrar must refer the death to the Coroner. Accordingly in England and Wales, the attending doctor is well advised to contact the Coroner (authorization to proceed may occur) before issuing the MCCD in these circumstances.

Deciding on the cause of death may require inspection of the body and less often an autopsy unless the circumstances are very clear cut.

In Scotland there have always been several variations on the system outlined above. Indeed the MCCD will replace the separate cremation forms from April 2015 and all MCCDs will be subject to random scrutiny by independent Medical Reviewers as implemented by Healthcare Improvement Scotland.

Often linked to issuing a death certificate is completion of a cremation form, necessary for a body to be cremated. This is a form stating that the medical practitioner feels that there is no obvious reason for further post-mortem examination. This is not a NHS duty and is, strictly speaking, considered private work (and is therefore taxable).

Legislation to change the processes of death and cremation certification was expected in November 2007,[5] but was dropped from the Queen's speech,[6] .In due course the implementation of the 2009 Coroner and Justice Act, which gained Royal Assent in November 2009, made the process more rigorous. The full process of implementation was planned to be completed in the UK during 2014[7], but has continued to be subject to delays and dilution.[8]

Contents

QuotationMarkLeft.png When a patient dies it is the statutory duty of the doctor who has attended in the last illness to issue the MCCD. There is no clear legal definition of “attended”, but it is generally accepted to mean a doctor who has cared for the patient during the illness that led to death and so is familiar with the patient’s medical history, investigations and treatment. The certifying doctor should also have access to relevant medical records and the results of investigations. There is no provision under current legislation to delegate this statutory duty to any non-medical staff.

In hospital, there may be several doctors in a team caring for the patient. It is ultimately the responsibility of the consultant in charge of the patient's care to ensure that the death is properly certified. Any subsequent enquiries, such as for the results of post-mortem or ante-mortem investigations, will be addressed to the consultant.

In general practice, more than one GP may have been involved in the patient’s care and so be able to certify the death. If no doctor who cared for the patient can be found, the death must be referred to the coroner to investigate and certify the cause.

If the attending doctor has not seen the patient within the 14 days preceding death, and has not seen the body after death either, the registrar is obliged to refer the death to the coroner before it can be registered. In these circumstances, the coroner may instruct the registrar to accept the attending doctor’s MCCD for registration, despite the prolonged interval. In contrast, a doctor who has not been directly involved in the patient’s care at any time during the illness from which they died cannot certify under current legislation, but he should provide the coroner with any information that may help to determine the cause of death. The coroner may then provide this information to the registrar of deaths. It will be used for mortality statistics, but the death will be legally “uncertified” if the coroner does not investigate through an autopsy, an inquest, or both. QuotationMarkRight.pngGuidance for doctors completing Medical Certificates of Cause of Death in England and Wales

Strictly the law requires that the doctor should complete an MCCD even when a death has been referred to the coroner. In practice, if the coroner has decided to order a post-mortem and/or to hold an inquest, he may tell the doctor not to complete the MCCD[9]

When to Involve the Coroner

  • Any suspicious or unexplained circumstances, including deaths which may be due to
    • Accident
    • Suicide
    • Violence
    • Neglect (by self or others)
    • Industrial disease
  • Death during or following surgery or an anaesthetic
  • Death in circumstances consistent with a state sanctioned deprivation of liberty (DOLS). This does not alter the need for a doctor to attend (or to do so out of hours) if they would not otherwise have had to do so. BMA guidance is clear: the DOLS guidance requirements "do not alter the responsibility of the GP in issuing a [medical certificate of the cause of death]… however and the guidance [general advice about death certification] above remains current".[10] So if medical attendance to confirm the cause of death is not othewise required, DOLS does not affect this.)
  • Individual or groups of coroners can issue their own more detailed guidance. For example some wish to have cases referred within a set period of hospital admission, require a doctor to have seen the patient within a set period before death and may wish particular acquired infections referred to them. In effect failure to consider the inconvenience of the registrar referring the death to the coroner because of say the 14 day rule (see quotations from guidance to the right of page) or say industrial exposure to asbestos acts as a very powerful incentive to get it right as letters of complaint from all and sundry may result, with theoretical GMC sanction.

The Procurator Fiscal is the Scottish equivalent of the coroner. For a more detailed explanation, see Death and the Procurator Fiscal.[11]

Confirmation of death

Doctors, and others, can confirm that a body is dead. A simple examination to confirm the absence of cardiac output, respiratory effort and response to external stimuli should suffice.

The question has arisen as to whether the on-call GP is required to attend to confirm death in a body found in a public place[12]. It seems that they are not. There is advice on this on the Kent LMC web site[13][14] CQC guidance confirms this.[15]

If police need a doctor to attend they should contact their Forensic Medical Officer.

Certification of brain death is a separate issue.

Ascertaining the cause of death

This can be suprisingly difficult.

MCCDs are issued on the balance of probability, not beyond reasonable doubt.[16] The mode of death (asphyxiation, cardiac failure) should not be included, but the pathology causing the death should be included.

For detailed guidance, refer to the guidance from the Office for National Statistics’ Death Certification Advisory Group.

Statutory Duties relevant to Death

  1. Report to the coroner as above
  2. Disclosure to a coroner's court - this information includes personal health information on the patient.
  3. Complete death certificate on the official form
  4. Complete appropriate part of cremation form
  5. Notification of certain infectious diseases on the official form

Death Certification in Hospital

Hopefully this is highly organised in a hospital near you. If not, complain.

  • Any large hospital will be able to justify paid central administrators to do the basic organisation.
    • With the New Deal these are essential as finding a doctor who has seen the patient can be extremely challenging.
    • They can also help find for you nurses and others present at the death to question in the case of a cremation
    • There will be clashes between convenience to these administrators and relatives and the New Deal, not to mention your prime commitment to the living. Coroners also have restricted availability (and must be treated with due precedence).
    • The administrators can notify the GP and others of the death, coordinate with the coroner and coroner's officer and generally make life easy for you by telling you what to do.
  • You should view the deceased ("External Inspection"). Make a decision whether you need to inspect the underside of the body, if you do, obtain sufficient assistance for manual handling, and do not on any account complete the certificate until you have made that inspection. If necessary discuss any pressure or attempts to persuade you with the Coroner's officer and/or senior colleagues. In practice this is rarely performed, not usually a problem, and pressure against such a decision should never occur.
  • always inspect in detail the recent medical record for issues that may be unknown to you.eg
    • The fall with head injury the night before a not unexpected death (subdural haematoma) - very embarrassing when the relatives mention the fall to the registrar of births and deaths and the coroner invites you to the court
LogoKeyPointsBox.pngHer Majesty's Coroner is very important.
  • Note that although a medical qualification alone is no longer sufficient to be appointed as Coroner, some coroners are doctors, and all Coroners have deputies, of whom some are doctors
  • Coroners are generally quite willing to talk to people, in person or by delegation, often the later to ensure minimum bias.
    • The rapidly demented elderly lady whose old notes are now seen by you for the first time and the MRSA wound infection after her fractured hip two months ago seems now relevant to her low grade pyrexia and vague neurological signs for which she never got a CT scan (right frontal lobe MRSA cerebral abscess) - again embarrassing when the relatives mention the recent #NOF to the registrar of births and deaths and the coroner invites you to the court
  • The Death Certificate should be discussed with others responsible for the care if you are not sure of all the details.
  • If you have reported the case to the coroner because of an event in hospital that might have contributed to the death such as a fall or postoperative or drug complication please tell the Medical Directors office (or equivalent, there will be a local procedure, perhaps phone escalation of a clinical incidence report). It can be a good idea to ensure a copy of the medical record will remain available (get a photocopy if it is still on paper) as it may be seized by the Police on instruction of the coroner and held by the coroner soon after. They may release the notes to you later to prepare a statement for the coroner and in general reasonable access would be expected to be allowed but this will be inconvenient if the Trust needs to investigate a clinical incident that involves you or others independent of the death.

Death certification in residential and nursing homes

There is BMA guidance (summarising the law) which states that, for expected deaths:[17]

  • If the death occurs in a residential or nursing home and the GP who attended the patient during the last illness is available, it is sensible for him or her to attend when practicable and issue a MCCD.
  • If an “on-call” doctor is on duty, whether in or out of hours, it is unlikely that any useful purpose will be served by that doctor attending the nursing or residential home. In such cases we recommend that the GP advises the home to contact the undertaker if they wish the body to be removed and ensures that the GP with whom the patient was registered is notified as soon as practicable.

Some way further down the guidance it states, in apparent contradiction:

If the doctor who has been treating the patient is not immediately available, a colleague should attend and then ensure that the doctor of the deceased patient is informed of the death as soon as possible and arrangements are put in place for the issuing of the MCCD and relatives informed of these.

It is not at all clear what the basis of this recommendation. While it may be appropriate to attend to care for a living patient, there is no obvious reason why a "colleague" of the deceased's normal doctor who is unable to issue the MCCD (not having attended the patient before death) should attend.

While the BMA guidance is clear that there is no obligation on a GP to attend a patient who has been declared dead (the only obligation is to notify the cause of death), it does emphasise the "the ethical and moral responsibility to make the experience of bereavement as gentle and easy as possible for relatives and friends".

Where an "unexpected" (but likely natural) death occurs in a care home out of hours, the BMA guidance recommends that "it would be helpful if an OOH GP does attend, therefore helping to prevent the potentially unnecessary attendance of the emergency services".

Death Certification of Stillbirths

Premature babies born at a non-viable gestation and who are born with signs of life require registration of death. An independent pulse and respiration are required to count as a liveborn; cord pulsation does not strictly count. Pragmatically, some individuals may have difficulty distinguishing between cord pulsation and feeble movements.

If no medical practitioner saw the baby during its brief life, then the case will require referral to the Coroner (or equivalent authority). As a pragmatic solution, some Coroner's will allow the obstetrician to complete the death certificate as they have loosely 'treated' the baby before death, albeit in utero. Some Coroner's will allow extreme prematurity as the cause of death, but in some cases an autopsy will be required.

Death Certification in Primary Care

  • Primary Care doctors have their own Death Certificate Books (The Registrar of Births and Deaths is required by law to provide upon request a book of death certificates to any registered medical practitioner practising or resident within his area.)
    • Secondary care doctors may wish to note this if they are asked to certify a recent discharge or outpatient attender and decide to cooperate and make a visit to an undertaker in the community. (most undertakers will recognise that it is more convenient for you to certify in such circumstances on hospital premises)

Post Mortem examinations

  • Consent and other issues such as religion are covered in post mortems

Coroners Courts

  • Reports to the coroner - ask advice from others if you are requested to provide one of these for the first time in the organisation you are working for. The document will become part of a public record and if there are any concerns ambiguous wording could be problematical
  • If invited to attend the court as a professional witness - if you are an employee please ask for support of the organisation immediately.
  • If you suspect issues involving your management of the patient contact your medical defence organisation (they tend to be much more supportive than NHS Trust staff who may not detect problems in draft reports to the coroner that would be obvious to any barrister).

Cremations

  • To take place these require certification by more than one doctor on a cremation form. You do get paid in the UK for doing these, as they are external to NHS work. The Inland Revenue has investigated in the past non-declaration of such fees, and of course, regard them as payment to you, so you have to pay tax on the full amount even if you pass some to the doctors mess by mutual agreement. Very uneven sharing of the fees could create bad feeling.
  • The process has become more rigorous since 2009. You are likely to have to interview those that nursed the patient, and there is a three stage medical certification process. This does tend to detect sloppy certification and 30 to 60 minutes of your time might be involved.

Legal time of death

The time of death, in the eyes of the law, for the purposes of death certification and cremation forms, is the time when the patient is pronounced dead by a qualified person (usually a doctor or a nurse), even if the actual time of death was hours or days earlier.[18] (This may be confusing to relatives.)

Related articles

History in UK

  • 1874 Registered medical practitioners first required to provide a written statement of the medical cause of death unless they know that an inquest is to be held (doctors forms for registering deaths had been introduced from the 1840's)
  • 1903 Medical Referee position legally recognised and Cremation Forms created
  • 1926 Attending doctor required to give medical certificates of cause of death to registrar before a certificate for disposal can be issued and must have seen the deceased person in the 14 days prior to death or seen the body after death
  • 1935 Reform of the Cremation Regulations and no further reform due to controversy
  • 2009 The Coroners and Justice Act creates the possibility of the independent Medical Examiner due to be implemented in April 2018.

External Links

References

  1. Department of Health and Social Care. Consultation outcome: Death certification reforms. 2018; Updated 11 Jun 2018; Accessed: 2018 (22 Jun): (https://www.gov.uk/government/consultations/death-certification-reforms).
  2. Luce T, Smith J. Death certification reform in England. BMJ 2018;361, DOI: 10.1136/bmj.k2668 (https://www.bmj.com/content/361/bmj.k2668).
  3. General Register Office website
  4. Office for National Statistics, Home Office, Office for National Statistics’ Death Certification Advisory Group. Guidance for doctors completing Medical Certificates of Cause of Death in England and Wales (F66 Guidance). 2010 (July)
  5. Luce T. Reform of the coroner system and death certification (editorial). BMJ 2007;335(7622):680-681 (http://www.bmj.com ). doi:10.1136/bmj.39350.426389.80 (subscription may be required)
  6. Toby Helm and James Kirkup. New plan to keep school-leavers in training. Telegraph web site, last updated 2:54am GMT 07/11/2007
  7. Letter: Improving the process of death certification DoH August 2012
  8. Luce T, Smith J. Death certification reform in England. BMJ 2018;361, DOI: 10.1136/bmj.k2668 (https://www.bmj.com/content/361/bmj.k2668).
  9. Office for National Statistics’ Death Certification Advisory Group. Guidance for doctors completing Medical Certificates of Cause of Death in England and Wales. 2008
  10. BMA. Confirmation and certification of death. 2012; Updated 20 September 2016; Accessed: 2016 (7 December)
  11. Crown Office and Procurator Fiscal Service. Death and the Procurator Fiscal: guidance for medical practitioners 2008. (1998 guidance here.)
  12. Doctors Net UK "Corpse found, advice please" thread (for DNUK members only)
  13. [http://www.kentlmc.org/kentlmc/website10.nsf/0/535e31affa303be3802575da0040a927/$FILE/Confirmation%20and%20certification%20of%20death%20-%20June%202009%20Final.pdf BMA GPC guidance]
  14. Kent LMC advice on regarding "A request from the police, or ambulance service that the GP attend upon a body found in a public place, a deserted building or as the result of a road or other form of accident or other situation".
  15. Care Quality Commission (CQC). Nigel's surgery 13: Who can confirm death? Nigel's surgery 2015; Updated 23 December 2015; Accessed: 2016 (23 November)
  16. DNUK Forum discussion. Death Certificate - advice please. (DNUK members only)
  17. BMA. Confirmation and certification of death 2013 (11 Oct) last updated 2016 (20 September)
  18. What's the time of death? 2010 (last viewed 28/4/10). DNUK thread (members only)