Occasionally a death may occur for which the attending doctor cannot legally complete a medical certificate of causes of death (MCCD). This article concentrates on how to recognise and deal with such cases.
After reading this article you should be able to:
- Understand your administrative responsibilities following the death of a patient in your care.
- Demonstrate competence in the full completion of an MCCD.
- Recognise when the need to refer a death to the coroner arises and know how to do this.
- Discuss the possible outcomes of referral.
FRCEM Curriculum 2015 Coverage
CC13 – Breaking Bad News: “Recall that a post mortem examination may be required and understand what this involves”.
CC17 – Principles of Medical Ethics & Confidentiality: “Recall the obligations for confidentiality following a patient’s death”.
CC19 – Legal Framework for Practice: “Understand the legislative framework… [of] death certification and the role of the Coroner/Procurator Fiscal…”.
Completing a Medical Certificate of Cause of Death (MCCD)
- It is a statutory legal duty for Registered Medical Practitioners to provide an MCCD without delay if, to the best of their knowledge, that person died of natural causes for which they had treated them in the last 28 days.
- Legally, a death must be registered by the deceased’s family within 5 days – although to accommodate traditional timescales of burial, timely MCCD completion is required.
- A body will not be released by the Hospital Mortuary until either an MCCD has been issued or the Coroner provides their consent.
- Write legibly; include GMC number, no abbreviations (except HIV, AIDS and MRSA).
- Remember to populate the relevant box with the patient’s HCN.
- Avoid undesirable/poorly detailed terms e.g. Cancer, Cardiac Arrest, Natural Causes, General Debility of Old Age (although the latter term may be defended in some cases of patients over 80 years of age where you are confident the death was expected following a gradual decline in health due to natural causes, but not to any identifiable disease).
- On occasions it may be wise to discuss contents of the MCCD with the deceased’s family to prevent any misunderstandings.
- Remember the back page:
- In the event there are outstanding investigations (e.g. culture results), which will add detail to the cause of death, an indication should be clearly made on the MCCD highlighting this fact.
- Complete the questions relating to recent pregnancy if applicable.
- As well as duplicating the record made on the certificate’s counterfoil, it is prudent to list the details in the patient’s notes.
Role of the Coroner
The coroners’ core function is to investigate sudden and unexplained death (sudden, unexpected, violent or unnatural), so that a death certificate can be issued.
Police assists the local coroner. They arrange the formal identification of the person who has died, and where, how and when their death occurred.
When to Report a Death to the Coroner
If a medical practitioner has reason to believe that the deceased dies directly or indirectly:
- As a result of violence, misadventure or by unfair means.
- As a result of negligence, misconduct or malpractice (e.g. deaths from the effects of hypothermia or where a medical mishap is alleged).
- From any cause other than natural illness or disease e.g.:
- Homicidal deaths or deaths following assault
- Road traffic accidents or accidents at work
- Deaths associated with the misuse of drugs (whether accidental or deliberate)
- Any apparently suicidal death
- All deaths from industrial diseases e.g. asbestosis
- From natural illness or disease where the deceased had not been seen and treated by a registered medical practitioner within 28 days of death.
- Before a provisional diagnosis can be made and the General Practitioner is not willing to certify the cause.
- As the result of the administration of an anaesthetic (there is no statutory requirement to report a death occurring within 24 hours of an operation – though it may be prudent to do).
- In any circumstances that require investigation;
- The death, although apparently natural, was unexpected
- Sudden Unexpected Death in Infancy (SUDI)
- All deaths of patients who are in custody (which includes those under police arrest in an ED) or detained under Mental Health Act should be reported for investigation, regardless of cause.
- It is also advisable to report a death to the coroner if the patient’s family is unhappy with the care and treatment the deceased received. The specific concerns should always be documented and stored with the medical records.
- Death occurring in the ED, or death occurs within 24 hours of admission to the hospital
- Doctors should refer to the extra-statutory list of causes of death that are referable to the coroner – see pages 8 – 14 ‘Guidance on Death, Stillbirth and Cremation Certification’, DoH 2012 (Link to Dept. of Health Document). This is summarised below.
Summarised Extra-Statutory List of Diagnoses for Referral to Coroner
- Direct or indirect injury e.g. aspiration pneumonia (unless MCCD indicates underlying natural cause e.g. ischaemic stroke), fracture (except pathological), hypothermia/sunstroke, subdural haemorrhage (unless MCCD indicates natural cause), malnutrition (unless MCCD indicates natural cause e.g. anorexia nervosa).
- Industrial lung diseases e.g. asbestosis, berylliosis, chemical pneumonitis, extrinsic allergic alveolitis, penumoconiosis, silicosis.
- Lung diseases with noted occupational cause or exposureg. asthma, COPD, pulmonary fibrosis, tuberculosis.
- Other industrial diseases e.g. decompression sickness, mesothelioma, leptospirosis (from animal urine).
- Cancers with noted occupational cause or exposureg. skin, nasopharynx, bladder.
- Industrial poisoning e.g. lead, heavy metals, chemicals.
- Other poisonings e.g. alcohol, tetanus, septicaemia if following an operation, hepatitis if due to occupation or drug abuse.
- Birth injuries.
- Deaths occurring during an operation or before recovery from the effect of an anaesthetic.
- Deaths following an operation necessitated by injury.
- Deaths, which follow an operation necessitated by natural illness if the cause of death is attributable to an unrelated incident during the operation or because of the anaesthetic.
In both of the below cases an MCCD can still be issued after senior discussion, regardless of the condition’s deemed contribution, but the details need shared with the medical director for database/governance reasons.
- Difficile – Any patient who is toxin positive or has had CDAD in last 4 weeks needs consideration as to whether this has contributed to the death.
- MRSA – Any patient known to be colonised and have had an active MRSA infection (or positive MRSA blood culture in the last 30 days) needs consideration as to whether this has contributed to the death.
Reporting a Death to Coroner
- A doctor who is familiar with the medical history and can give an explanation of why death occurred should speak to the relatives first. Explain why the death is being referred sensitively.
- The doctor assuming responsibility for dealing with the death should view the body.
- If a death occurs at night it usually need not be reported to the Coroner until morning. Body can be moved to mortuary for overnight storage but all lines/tubes in situ must be left undisturbed.
- Report (regardless of time) if death follows a criminal assault.
- Report (regardless of time) if family have agreed for organ donation and Coroner’s consent is needed before removal of organs.
Coroner’s Service for Northern Ireland
May’s Chambers, 73 May Street, Belfast, BT1 3JL
Tel: 028 9044 6800, Fax: 028 9044 6801
Possible Outcomes of Referral
- Coroner agrees cause of death does not need investigated and MCCD can be completed. Document this discussion in patient’s notes.
- ‘Pro-Forma’ system – This involves completing a special form for stating cause of death and providing brief particulars of background circumstances. It is for use only after discussion with the Coroner and should be sent immediately by fax, then followed by the hard copy. Alternatively an unsigned MCCD with an accompanying letter detailing the background circumstances may be requested if pro-forma unavailable. Neither should be given to the family as it may cause confusion. Normally used where:
- Natural cause of death but doctor has not seen and treated the deceased for condition from which they died within 28 days of death.
- Not a natural cause but no suspicious circumstances e.g. simple elderly fall.
- Not a natural cause but no post-mortem required as definite diagnosis has already been made.
- Post-mortem required – The doctor who reported the death should prepare a clinical summary for the pathologist, which should accompany the body to the mortuary. Where the medical history is complex the consultant who led the care should assume personal responsibility for the content of this summary.
If it was not possible to find out the cause of death from the post-mortem examination, or the death is found to be unnatural (or occurred in state detention) or the coroner thinks there is a good reason to continue the investigation, a coroner has to hold an inquest to be able to finish his or her investigation. In the event someone is charged with an offence directly leading to the cause of death, the inquest will be postponed until conclusion of criminal proceedings.
An inquest is a public court hearing held by the coroner in order to establish who died and how, when and where the death occurred. The inquest may be held with or without a jury, depending on the circumstances of the death. It is not a trial and will not apportion blame.
If police contact you as part of their investigation you must assist by responding to all inquiries and offer all relevant information. Only where your evidence may lead to criminal proceedings against you are you entitled to remain silent (GMC’s Good Medical Practice).
- If the deceased is to be cremated, it is usual for the doctor completing the MCCD to be requested to complete Form B. You should only complete cremation forms if you have been trained to do so. Details on how to complete are outside the scope of this article.
- Any ‘child’ expelled or issued forth from its mother after the 24th week of pregnancy that did not breathe or show any other signs of life is required to be registered as a stillbirth. These forms can be completed by a medical practitioner or midwife present at birth, or who examined the body, and therefore need not necessarily be an ED doctor. Details on how to complete are outside the scope of this article.
- A child who breathed or showed signs of life is considered live-born for registration purposes and thus both birth certificate and MCCD are required (or referral to Coroner).
- Fetuses born dead before 24 weeks of pregnancy require no statutory forms.
- Fetuses delivered after 24 weeks but which are dead by the 24th week – seek O&G expert advice.
- When in doubt over the completion of an MCCD and/or referral to the Coroner, discuss it with a senior colleague.
- While discussion is sometimes required, causes of death should be treated confidentially as with all other patient information, and the relevant records held appropriately.
- Remember to clarify preceding causes of diagnoses which may be interpreted as unnatural e.g. aspiration pneumonia.
- Give a little extra consideration to MRSA or C. Diff positive patients.
- Always discuss a reason for referral to the Coroner sensitively with the family – they will want to know how they now register the death and so advise them to contact the Coroner’s Office. Basically once the Coroner approves burial/cremation a form to allow this will be issued along with a Registration of Death Certificate.
- Guidance on Death, Stillbirth and Cremation Certification, Department of Health 2012 (Link to Dept. of Health Document)
- Medical Certificate of Cause of Death (MCCD) – (Completion Of), NHSCT Official Policy 2012 (Link to NHSCT Policy Document)
- Reporting Deaths to the Coroner, MPS 2015 (Link to MPS Factsheet)
- Coroners Service for Northern Ireland, Department of Justice 2011 (Link to Dept. of Justice Document)
- Guidance for doctors completing Medical certificate of Cause of Death in England and Wales (www.gro.gov.uk/images/medcert_july_2010.pdf)
Information correct at time of writing, November 2016.
Edited by Dr Richard McQuillan, Dr Termizi Hassan