Certifying death can refer to two separate, but often linked procedures
- Confirmation of death, i.e. lack of vital signs and neurological response
- In England this does not need a doctor !
- Administrative side, e.g. medical certificate of the cause of death, the legal and formal "death certificate"
- Good idea to view the body
- Formal death certificate
- Cremation forms
When to Involve the Coroner
- Any suspicious or unexplained cirumstances, including deaths which may be due to
- Neglect (by self or others)
- Industrial disease and deaths for
- Death during or following surgery or an anaesthetic
- 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 aquired infections referred to them.
The Procurator Fiscal is the Scottish equivalent of the coroner.
Statutory Duties relevant to Death
- Report to the coroner as above
- Disclosure to a coroner's court - this information includes personal health information on the patient.
- Complete death certificate on the offical form
- Complete appropriate part of cremation form
- Notification of certain infectious diseases on the offical 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 committment to the living. Coroners also have restricted availability (and must be treated with due precedence).
- They 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 registar of births and deaths and the coroner invites you to the court
- 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 who she never got a CT scan for (Right frontal lobe MRSA cerebral abcess)
- 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 (there will be a local procedure). 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 etc.
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 practicing 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
- Never ever say to relatives that you wish a post mortem as you don't know why the patient died. In this case you should have referred the case to the coroner.
- They are under requested for all sorts of cultural reasons. Every study done on the issue has shown that advances in technology have had little impact on accurate death certification. Patients continue to die riddled with undiagnosed malignacy despite an obvious stroke and bronchopneumonia and unsuspected pyleonephritis, ruptured abdominal organ, major blood vessel, tuberculosis, pulmonary embolism and subacute bacterial endocarditis.
- Requesting them involves a unwelcome chore and potentially difficult interactions with relatives
- Certain cultures do not believe that the body should be disturbed after death. You need to know the belief systems of the major cultures and religions.
- You will be expected to attend the examination - its an excellent and as alluded to often humbling learning experience. The reduced exposure to real anatomy of modern medical courses can also be identified as an issue needing further addressing before those challenging higher examinations in any speciality.
- They are not costed into the system for the frequency that would be consistant with a high standard of internal clinical governance
- Certain infectious diseases are relative contra-indications and others such as suspected prion disease will require special post mortem and disposal arrangements (eg lead lined coffins).
- 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) .
Death during a pandemic
During e.g. an influenza pandemic there might be a higher than usual death rate, at a time when there is also a much greater prevalence of illness, and when fewer staff are available (as they are off sick). This will affect healthcare and other public services - including the coroner and the register office. As a result of cost-cutting in public services, these services run with sufficient resources to just cope with a normal workload. Funeral directors, crematoria, and other services will also be overloaded and short-staffed.
At present NO ALLOWANCES have been made for relaxation of normal rules of death certification. It is just possible that changes might be made under emergency legislation, but we cannot assume that this will be the case.
As a consequence there might be long delays, with bodies having to be kept where they die - in hospitals, care homes, and at homes. Guidance for relatives might be made available before the next pandemic occurs.
dokane - a doctor