Why a death certificate is vital

An accurate certificate is the last right to be fulfilled for patients and families.

For the sake of relatives, GPs must be accurate, prompt and professional when filling out death certificates
For the sake of relatives, GPs must be accurate, prompt and professional when filling out death certificates

Registration of a death is required for lawful disposal of the remains, for matters of inheritance, and for government administrative purposes. The medical certificate of cause of death (MCCD) is a prerequisite for death registration.

Once a death has been registered, the facts concerning it are in the public domain.

Accurate postmortem diagnosis is educational for doctors, as well as reassuring for relatives.

It is also important for public health, management of health services, forensic purposes and medical science. Much research into factors affecting the health of the nation, including the study of hazardous occupations, is based on death registration information.

According to the GMC it is 'not improper' to disclose information to national and regional NHS disease registers, such as cancer registries, 'where patients have been informed about the disclosure',1 and usually patients would be told in advance of the notification.

However, the disclosure of a postmortem diagnosis of cancer to the authorised registry could be defended as being in the public interest.

Books of blank MCCDs, issued by local registrars, must be kept securely. The completed MCCD is put in a sealed envelope for hand delivery to the registrar. The counterfoil must also be completed as a permanent record of certificates issued.

What to write on the certificate
Doctors must act responsibly; there is no legal obligation to see the corpse in every case but it is advisable to do so, not least to verify the identity of the deceased and to assure oneself that there are no grounds to doubt it was a natural death.

Before writing a certificate, ensure you have access to all relevant information, including your own observations, those obtained by consulting colleagues, conversation with those present at the death and perusal of medical records.

It is desirable to enter on the MCCD 'all those diseases, morbid conditions, or injuries which either resulted in or contributed to death'.2 In practice, the difficulty is clarifying which is the underlying cause, because this is the one that will be coded.

This decision is clearly the responsibility of the medical practitioner signing the death certificate (see box, below). Guidance is available from the General Register Office.3

Even if a patient is known to have a life-threatening illness, death may occur for another reason, such as an intercurrent illness. It is important for public health purposes to mention any communicable disease that could have contributed to the death (even if not stated as the 'underlying cause').

When to involve the coroner
In 75 per cent of cases, one of the doctors attending during the patient's last illness is able to provide the MCCD. If the cause of death is uncertain or unnatural, a coroner must be involved.4

Coroners use their discretion to decide whether to arrange a postmortem or inquest. A doctor who is unsure whether formal referral to the coroner is appropriate may contact the coroner's office to discuss the case.

For any patient who had surgery, an injury, or adverse effects of pharmacological treatment in the period preceding death, a coroner's inquiry is usually needed because these are 'unnatural causes' that might have contributed to the death.

Even where a death is expected, a coroner may be contacted if nobody eligible is available to carry out certification in the capacity of 'attending doctor'.

For example, when a patient dies at home (especially at the weekend), the GP dealing with the case, despite having seen the patient within the past 14 days, may not be immediately available to see the body or to provide an MCCD.3

Unnecessary referrals to the coroner create additional distress for relatives and extra expense and work for professionals. This situation can often be avoided if the GP involved speaks to the coroner or coroner's officer as soon as possible after learning of the death.

Causes contributing to death
Any possibility that an occupational hazard contributed to the death must be mentioned to the coroner and indicated on the MCCD.

It is important to consider all of the patient's past occupations, not just the last one. Correctly identifying industrial diseases might financially benefit the patient's dependants, as well as affecting national statistics.

There is a helpful but not exhaustive list of conditions thought to be associated with industrial disease or poisoning printed in the back of the book of MCCDs.

Occasionally, doctors must consider whether the person died by their own hand (or, rarely, whether another's actions contributed to the death). Such cases are initially handled by coroners, who may then pass them to the police.

EXAMPLE OF LEVELS OF CAUSE OF DEATH6

1a. Disease or condition directly leading to death: bronchopneumonia.

1b. Other disease or condition, if any, leading to 1a: carcinomatosis.

1c. Other disease or condition, if any, leading to 1b: carcinoma of bronchus.

2. Other significant conditions contributing to the death but not related to the disease or condition causing it: chronic bronchitis.

Occupational cause The death might have been due to, or contributed to by, the employment followed at some time by the deceased - Please tick where applicable.

Note 1: In this example, it would be desirable to specify the histological type of cancer if known.

Note 2: If the patient had at some time been a miner, it would be necessary to tick the 'occupational cause' box.

Requirements for cremation
When the deceased or relatives request a cremation rather than a burial, extra care is necessary because any evidence relating to the cause of death will be destroyed.

The cremation procedures do change and doctors should familiarise themselves with the forms to collect all of the information required.

One new provision in the regulations appears to breach a patient's right to confidentiality - the applicant (usually but not always a relative of the deceased) has a right to inspect the forms, which contain far more information than a regular MCCD (including sensitive facts, such as where the person died and who was present at the moment of death), and to question those who complete them.

The GMC cautions doctors to 'do your best to make sure any documents you sign or write are not false or misleading'.5 Professional judgment and discretion should be exercised in the wording of statements, considering who will have the opportunity to read them.

The last kindness that doctors can do for a patient may be to certify the cause of death accurately, promptly and as required by law, but also in a humane professional manner that alleviates and does not contribute to the sorrow of their friends and family. Patients have a right to expect this from us.

  • Dr Butlin is a salaried assistant in general practice in Alfriston, East Sussex

This article was originally published in MIMS Oncology and Palliative Care

REFERENCES

1. GMC. Confidentiality. London, GMC, 2009.

2. WHO. International Classification of Diseases and Related Health Problems, 10th revision. Geneva, WHO, 1993.

3. Office for National Statistics. Guidance Notes for Doctors Completing Medical Certificates of Cause of Death in England and Wales. Newport, ONS, 2008.

4. Office for National Statistics. Mortality Statistics: Deaths Registered in 2007, Review of National Statistician on Death in England and Wales 2007. Newport, ONS, 2008.

5. GMC. Good Medical Practice. London, GMC, 2006.

6. DoH. Modernising Medical Careers - the New Curriculum for the Foundation Years in Postgraduate Education And training. London, DoH, 2005.

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