Certification - Deaths
The LMC receives many queries on the subject of death certification, cremation and Coronial regulations. The Covid-19 pandemic and associated emergency legislation have added a further level of confusion.
We have summarised guidance relating to Death Certification and Cremation during the Covid-19 Pandemic in a booklet that can be found here: https://www.wessexlmcs.com/covid19deathcertificationandcremation .
It is incumbent on those working with the bereaved to recognise that these processes can cause significant distress to them. All participants in the system must be ever conscious of this and conduct themselves in a manner that does not add to the emotional suffering of families.
The BMA promotes the following core principles in these matters:
- This subject matter is of significant distress to the bereaved. All participants in the system must be conscious of this and conduct themselves in a manner that does not add to the emotional suffering of families.
- All those involved respect the dignity, religious and cultural needs of the deceased and family members.
- The timely and efficient verification of death is highly important in the current crisis and those responsible should act accordingly. We encourage workers in the wider health and care system to work collaboratively with doctors to achieve this.
- The procedures for certification can provide a valuable safeguard against wrongdoing and everyone involved in this process should raise any concerns they have as a matter of urgency.
There are four separate processes to go through when a patient dies:
- Firstly, the death must be verified by a suitable qualified person pronouncing that life is extinct.
- Secondly, a decision must be made as to whether the death is referred to the coroner.
- Thirdly, the MCCD must be signed by a doctor.
- Finally, for those patients who will be cremated, the cremation form must be signed.
The law requires a doctor to notify the cause of death for any patient whom he or she has attended during that patient’s last illness, to the Registrar of Births and Deaths. Stating, to the best of his or her knowledge and belief, the doctor is required to notify the cause of death as a certificate, on a form prescribed.
It should be noted that the strict interpretation of the law is that the doctor shall notify the cause of death, not the fact. Thus, a doctor does not certify that death has occurred, only what in his or her opinion was the cause, assuming that death has taken place. Arising out of this interpretation there is no obligation on the doctor even to see, let alone examine the body before issuing the certificate. The Broderick report recommended that a doctor should be required to inspect the body of a deceased person before issuing the certificate, but this recommendation has never been implemented. Thus, there is no requirement in English law for a General Practitioner or any other registered medical practitioner to see or examine the body of a person who is said to be dead.
GPs, as a body would not and as individuals should not, seek to use this quirk of English law to avoid attending upon an apparently deceased patient for whom the GP is responsible.
However, the fact that there is no legal obligation upon a GP to attend the deceased should be remembered and, if necessary, quoted when organisations such as the emergency services ask GPs, either in or out of hours, to attend the deceased as a matter of urgency. If a patient is declared to be dead by a relative, a member of staff in a nursing home, ambulance personnel or the police, GPs would be acting correctly by prioritising the needs of their living patients.
On a parallel basis, case law exists to confirm that an NHS GP does not have a contractual obligation to attend upon the body of a patient declared to be dead. Once again, the fact that a contractual obligation does not exist should never be used by GPs to avoid the ethical and moral responsibility to make the experience of bereavement as gentle and easy as possible for relatives and friends.
Verification of death.
There is often confusion around this issue. It has never been necessary for a doctor to verify death – this task has always been something that can be done by a nurse or other competent person, a phrase which can be interpreted to include other professionals who have been trained to do this.
In these challenging times, we want to be able to allow staff to work efficiently to the top of their licence. We must support them to do so. We also want to avoid unnecessary visits to verify death in order to protect clinician capacity to deal with the likely significant patient load in the community.
Verification of the fact of death:
Verification of the fact of death documents this formally in line with national guidance and is associated with responsibilities of identification of deceased, notification of infectious illnesses, and implantable devices. This is recognised as the official time of death. Verification of death follows a set of steps and therefore requires some training.
Certification of death:
Certification of death is the process of completing the ‘Medical Certificate of the Cause of Death’ (MCCD) by a medical practitioner in accordance with The Births and Deaths Registration Act 1953, underpinning the legal requirements for recording a person’s death.
An expected death is the result of an acute or gradual deterioration in a patient’s health status, usually due to advanced progressive incurable disease. The death is anticipated, expected and predicted. It is anticipated in these circumstances that advance care planning and the consideration of DNACPR will have taken place. The death can be verified even if the doctor has not seen the patient in the previous fourteen days.
You may wish to work with your local care homes to ensure that they have staff members adequately trained to verify expected deaths. Ideally the Care homes, as the employers, have to agree to a policy, training and form of documentation – in the current climate this could be done very rapidly - and the RCGP suggests that all nursing homes should have a nurse trained in verification.
The RCN have just released guidance on the particular aspect around verification of death in COVID 19. https://www.rcn.org.uk/clinical-topics/end-of-life-care/covid-19-guidance-on-dnacpr-and-verification-of-death
It does partially recognise the current situation but also still insists that nurses receive training to be able to do this.
“In normal circumstances, we would expect there to be confirmation within the patient record that death is expected, or that medical staff would appreciate nurse verification of death or for there to be a DNACPR recommendation. However, there is no legal requirement for this and, given the current situation, we recognise that it is likely that there may not always be such records in place.”
“We expect nurses verifying death to be trained and supported in the procedure and in the aftercare required by families and staff.”
Guidance for Remote Verification of Expected Death (VoED) Out of Hospital
The BMA and RCGP have produced this guidance.
Medical Certificate of Cause of Death
The government have update their guidance around issuing MCCDs taking into account the emergency Covid legislation (April 2020):
The Royal College of Pathologists have published updated guidance on acceptable causes of death for MCCDs(June 2020)
Completing Form 5's (Part 2's)
(This is currently not required under the Covid emergency legislation)
Just a reminder on who can complete cremation Form 5’s (formerly Form C or Part 2). Regulation 9 of the Cremation Regulations states that in order to be eligible to complete cremation Form 5, you must be a “registered medical practitioner of not less than five years' standing.” The Department for Constitutional Affairs takes the view that this requires a continuous period of registration at the relevant time. As far as limited registration is concerned, periods of temporary or provisional registration would not seem to disqualify a registered doctor from completing a confirmatory certificate, but it will be a matter for the medical referee to decide whether an inadequate length of full registration may be a factor to be taken into account in any particular case.
The medical practitioner who completes the confirmatory medical certificate should not be a relative of the deceased, or a partner of the doctor who has given the cremation certificate in Form 4.
Locums and former partners are permitted to complete cremation Form 5, however, we would advise these doctors not to complete cremation Form 5 for practices where they regularly or have recently worked. Here you can access a Guidance for Medical Practitioners completing cremation 4 and 5.
GMC Numbers and Death Certificates
On signing the death certificate, the patient's next of kin takes the certificate to the Registrar. With the new GMC License to Practice some registrars have been asking for a list of doctors who are licensed.
It would therefore be helpful (although not obligatory) for GPs to sign the certificates and put their GMC number or some other clear identifier so that the Registrar can go online and identify the doctor and check their license.
Coroners Reports & Contact Details for Wessex Coroners
National guidance regarding notification of deaths to coroners is available here ( https://www.gov.uk/government/publications/notification-of-deaths-regulations-2019-guidance.)
We advise that providing basic medical information for a Coroner's Report is your duty. However, a more detailed report may be asked for. There is nothing in the Coroners Act that clearly stipulates a fee for reports where payment is not being offered. The BMA advises doctors to complete the report otherwise they may face being summonsed.
Working within an established legal framework it is the principal statutory duty of Coroners to investigate deaths which are reported to them and which appear to be
a. due to violence, or
b. are unnatural, or
c. are sudden and of unknown cause, or
d. which occur in legal custody.
They are entitled to request medical information that is relevant and necessary to their enquiries.
The GMC sets out clearly in Good Medical Practice that 'You must assist the coroner or procurator fiscal in an inquest or inquiry into a patient's death by responding to their enquiries and by offering all relevant information. You are entitled to remain silent only when your evidence may lead to criminal proceedings being taken against you.'
Coroner Contacts for Wessex Area
Wiltshire and Swindon
Her Majesty’s Senior Coroner for Wiltshire & Swindon - Mr David Ridley.
Coroner’s Service Office Manager – Mrs Ann Corcoran MBE
26 Endless Street, Salisbury
Address26 Endless Street
Telephone: 01722 438900
BaNES is covered by Avon Coroner
Senior Coroner – Maria Voisin
Area Coroner – Dr Peter Harrowing
Old Weston Road
Telephone: 01275 461920
Senior Coroner - Mrs Rachael Griffin.
Assistant Coroners - Mr Brendan Allen, Mr Richard Middleton, Mr Stephen Nicholls, Mr Grant Davies, Mrs Victoria Cook and Mrs Deborah Rookes.
Coroner's Office for the County of Dorset
Telephone: 01202 454910
Dedicated phone number for GPs reporting deaths: 0300 123 9867
Fax: 01202 454977
Hampshire, Portsmouth, Southampton
Senior Coroner - Christopher Wilkinson
Area Coroners - Jason Pegg and Rosamund Rhodes-Kemp
Assistant Coroners - Simon Burge, Karen Harrold, Samantha Marsh and Sarah Whitby
Winchester Office Address:
Hampshire, Portsmouth and Southampton Coroners Service
Castle Hill, The Castle, Winchester, SO23 8UL
Office Telephone Number: 01962 667884
Office Email: email@example.com
Secure Office Email: firstname.lastname@example.org
Isle of Wight
H.M Senior Coroner - Mrs Caroline Sumeray LL.B. (Hons), Dip FMS, Barrister.
Assistant Coroner - Mr John Matthews DL. B.A. (Law).
Isle of Wight
Telephone: 01983 823010
Viewing the Body
There have been instances of undertakers taking deceased patients into GP car parks to avoid inconveniencing the GP providing cremation certification. We would strongly advise against this on the grounds of the distress it would cause to the family and your other patients if they discover this practice happening.
We realise this may be a particular difficulty in some more rural areas but believe that the Undertakers could arrange to move the body to a more local undertaker to care for whilst waiting to be viewed.
Free from Infection Certificate / Information
If a patient passes away and the family would like to repatriate them to their country of birth, a ‘Free from Infection Certificate’ will be required from the Undertakers. The following provides information on what is required by the GPs in this instance:
- If the patient has had a postmortem the information needs to be provided by a Pathologist from the hospital where this took place.
- If the GP has issued the death certificate this will then need to be provided by the GP.
- There is, as such, no formal certificate. However a letter will need to be provided. This will need to include information regarding the infection status of the following:
- Hep B
- Hep C
- This is not core GMS work therefore you are able to charge for this
The Role of the GP when a Patient Dies in a Residential or Nursing Home
The attached letter provides guidance regarding the procedures relating to the death of a patient under a homes care.
With thanks to Bedfordshire & Hertfordshire LMC for providing this letter.
The Respective Roles of Coroners and Doctors in Certification of Death
The Coroner’s office is tasked with establishing who has died, as well as how, when, and where they died. However, they are not medical, and they need specialist medical input to advise them what the cause of death is. If it is not clear or unnatural then the Coroner will seek further specialist medical input i.e. postmortem or other expert opinion to advise them in making the decision.
The medical specialist who is most often in the position to be able to advise on the cause of death is the patient’s GP who manages the vast majority of a patient’s care. The statutory duty to fill out the death certificate rests with the doctor who has cared for the patient. Therefore, the Coroner will contact the patient’s GP.
In many cases a GP has sufficient knowledge of the patient’s disease or recent health and therefore can offer a cause of death. This applies even if the GP has not seen the patient within the last 14-28 days. For example, a patient may be known to in a terminal phase of cancer and being cared for at home. In this case, after referral to the Coroner, if the Coroner accepts the cause of death, the coroner’s office will issue paperwork to the Registrar to prove the cause of death has been authorised and the GP circles numbers 3 and 4 on the back of the MCCD.
The death certificate can only be issued by a doctor. The Coroner is not a medical professional and cannot issue death certificates.
The Coroner needs the input of the relevant doctor – either GP or hospital – as to whether they are able to determine a cause of death to put on the MCCD. Until a GP (or hospital doctor) has made this decision, the Coroner’s office is unable to progress with any investigations that might be needed if they cannot issue.
Conversations can be held between Coroner’s Officers and GPs in relation to the cause of death and whether they can issue a certificate, however this is only advice and neither Officers nor the Coroner can tell a GP or Doctor what to write. The GP will use their knowledge and that contained within the patient record to decide whether they can determine a cause of death.
If the GP feels happy to issue an MCCD – then do so
If the GP feels unable to determine a cause of death to write on the MCCD and/ or is not in a position to issue the certificate in line with the current regulations around attending the deceased– refer to the Coroner for advice
If the GP suspects the death is unnatural then refer to the Coroner
Sudden death policy - Across Hampshire and Isle of Wight Police area
Please refer to our webpage - https://www.wessexlmcs.com/suddendeathpolicyacrosshampshireiowonly