Student BMJ February 1997: Education
medical student
St Mary's Medical School
Procedures for dealing with dead patients are poorly taught. Michael Fertleman describes how to complete the death certificate and when to tell the coroner
The golden rule is to complete the process as quickly as possible. No grieving relative wishes the funeral to be delayed by bureaucracy. However, failure to go through the entire process by the book may lead to even greater delays.
Confirming that death has occurred
Sick patients take priority over dead patients, but nursing staff cannot prepare the body until death is certified so you should respond to a request for certification as quickly as possible, especially if relatives are present. The box gives the procedure you should follow when confirming death. Do not rush the examination. Write your confirmation clearly in the notes along with the date, time, and legible signature.
Informing the necessary parties
You must tell senior colleagues that a patient has died as they may want to order a postmortem examination. Everyone fears talking to bereaved relatives, and it is natural to want to put it off. However, relatives really appreciate words of sympathy and often respond with thanks and praise for all that was done. A comforting chat in private will often smooth over any bitterness felt towards medical staff. If you haven't had any training ask to sit in with senior staff when they are breaking bad news.
Before a necropsy is requested you need to get consent from the next of kin or the executor of the will. This examination has a different purpose from that requested by a coroner. Necropsies in hospital are conducted to discover the extent of the disease whereas those requested by the coroner are to discover the nature of the disease. Relatives are often frightened by the idea of a necropsy, and it can be difficult to obtain consent. But they can provide valuable information about disease and you should try hard to reassure relatives.1 Watch how senior staff raise the subject with relatives. Mitchell and Teale offer three hints for success:
 | Stress that it is in the interests of family to know the exact cause of death |
| Point out that postmortem examinations are common and do not disfigure the body or face |
| Dispel any misconception that the body will be used for experiments or teaching anatomy. |
Tell the family the results of the necropsy when you get the results. You must also tell the patient's general practitioner of the death. There is nothing more embarrassing for a general practitioner than meeting the relatives and not knowing a patient has died.
Reporting death to the coroner
The office of coroner dates from the 12th century. It is a royal appointment, and the salary is paid by the local authority. Coroners are either doctors (in London) or lawyers (outside London) with at least five years' experience in either law or medicine. Their role is to ascertain the cause of death. In Scotland this role is carried out by the procurator fiscal.
Deaths which should be reported to the coroner
| Sudden death for which the cause is unclear |
| Any death for which the cause is unknown |
| Accidents in any way contributing to the death |
| Any death in custody |
| Acute or chronic alcoholism |
| When an anaesthetic or surgical procedure seems to have contributed to the death, or where an operation was performed after an injury |
| Drug related death whether therapeutic or recreational |
| Death of a foster child |
| Death that may be related to any industrial disease |
| Death of someone receiving a disability pension |
| Deaths related to any forms of poisoning whether deliberate or unintentional |
| Stillbirths where there was any possibility of the child being born alive |
| Any death connected with a crime or suspected crime |
| The deceased was not seen professionally by a doctor during his last illness, or within 14 days of death, or after death |
When is a death reported?
The registrar of births and deaths is responsible for keeping an accurate record of everyone who has been born or died
in Britain. This is achieved by the two official documents, the birth and death certificates. The death certificate has a box for cause of death. If the cause is unknown or falls into one of the categories requiring a postmortem examination the registrar has a duty to report this death to the coroner.
There is no legal duty for a doctor to inform the coroner of a death, but in practice many deaths are reported by the doctor filling out the death certificate. Knight points out that the coroner may object to any delay in reporting a case and that it is ethically unacceptable to cause further delay in funeral arrangements by sending a death certificate to the registrar that will inevitably be passed to the coroner.3 The box gives the categories which will be of interest to the coroner.4 Doctors are poor at recognising which deaths to report,5 and there have been repeated calls for proper medicolegal education at medical school.
What can the coroner do?
The coroner may be satisfied that the cause of death can be ascertained without a necropsy and will request that the doctor certify the death in the usual way. More often, the cause of death cannot be ascertained and the coroner will request a necropsy. Usually this will be carried out by a pathologist at the hospital concerned. If there is an indication that conduct of a member of staff is to be criticised, or the relatives request it, another pathologist will be found. The necropsy result may show that death was due to natural causes without categories listed in the table. Under these circumstances the registrar of deaths will be asked to continue with the certification process. If the necropsy shows that the death was not due to natural causes, or there are complicating circumstances, then an inquest will be called.
An inquest is a fact finding inquiry and not a trial. It is held by the coroner when he or she decides that a death may not be due to a natural cause. The coroner's court is not concerned with matters of civil liability; its purpose is to determine who died, where, when, and how.6
The doctor caring for the patient may be required to give evidence so if you are reporting a death to the coroner it is in your interest to write down details as soon as possible. A written report may suffice, or the coroner may wish evidence to be given in person. Either way, a contemporaneous, accurate, clear, signed, and dated record is advisable.
Issuing a death certificate
Legislation regulating burial was introduced in the 19th century in response to panic caused by exaggerated claims of the number of people succumbing to epidemics and the killing of babies for insurance money.7 This legislation, still in force today, requires that a death certificate be issued before burial. Most death certificates are completed by the least experienced staff with many errors,8 but an Australian survey showed that the certification skills could be improved with written advice.9
Who should fill the certificate in? The law requires that a doctor in attendance during the last illness complete the death certificate.10 In attendance means that you should have seen the patient at least twice and the mode of death should be one that could reasonably be expected from the illness for which the doctor was attending. The mode of death is a process brought about by the cause of death - an illness. The cause of death must go down on the form.
To fill out the certificate you must have seen the patient within 14 days of death. Officially, if you see the patient outside this period but view the body after death you can still sign the certificate, but this should be strongly discouraged. Although it is not a legal requirement, you should always view the body before signing the death certificate even if you have seen the patient professionally within a fortnight of death. Cases exist where certificates have been issued for living people, either by accident or fraud.
Completing the form
If you or your senior colleagues have no idea of the cause of death the case must be referred to the coroner. To report the case to the coroner you must fill in box A on the reverse of the form and telephone the coroner to inform him or her that the case is being referred. Do not rely on other people to do this for you.
Most of the form is clear and straight forward. The most important part of the form is the box for the actual cause of death, where inappropriate use of language has resulted in delays leading to much unneeded stress for families.
Part I is for conditions leading to the death which are linked. You usually need to fill in only part Ia; being overzealous often leads to a coroner referral.
Part II is for conditions contributing to the death but not relating to the disease given in part I.
Sometimes you may not be able to give the cause of death straight away - for example, you may need to wait for laboratory results for confirmation. In this case you should complete box B on the reverse of the form and send the certificate for registration. This allows the relatives to start preparations for burial. Strictly speaking all completed forms should be sent to the registrar by post, but they can be entrusted to the relatives if they wish.
Cremation forms
To qualify for the fee for completing form B for cremation the doctor must have both attended the patient professionally within 14 days of death and viewed the body after death. The coroner does not have to be informed unless the death falls into one of the categories listed. If a necropsy is carried out you cannot complete the cremation form until the results are available.
References
2 Mitchell I A, Teale G R. The practical house officer. Oxford: Blackwell Scientific, 1994:24-8.
3 Knight B. The coroners autopsy. Edinburgh: Churchill Livingstone, 1983:5.
4 BMA. Rights and responsibilities of doctors. 2nd ed. London: BMA, 1992:8.1
5 O'Donovan C. Inquests - a practical medico-legal guide. London: Medical Defence Union, 1994:2.
6 Start R D, Delargy-Aziz Y, Dorries C P, Silcocks P B, Cotton D W K. Clinicians and the coronial system: ability of clinicians to recognise reportable deaths. BMJ 1993;306:1038-41.
7 BMA. Deaths in the community. London: BMA,
1980:2.
8 Leadbeatter S, Knight B. Anomalies and ambiguities in the disposal of the dead. J R Coll Phys 1986;20:273-5.
1 O'Sullivan J P. Doctors abuse the coronial system. BMJ 1993;306:1539.