How has the process for certifying deaths changed in England and Wales?
The Coronavirus Act 2020 makes changes to the requirements, for death certification in England and Wales. The Act recognises that the doctor who saw the patient during their last illness may be unable to sign the certificate or it might be impractical for them to do so - for example, if they are self-isolating.
However if possible, the medical certificate of cause of death (MCCD) should be completed by the practitioner who attended the deceased during their last illness as was the case before the COVID-19 outbreak.
According to guidance for doctors on completing MCCD in England and Wales: 'There is no clear legal definition of "attended"', but it is generally accepted to mean a doctor who has cared for the patient during the illness that led to their death and so is familiar with the patient's medical history, investigations and treatment.
For the duration of the COVID-19 outbreak, attendance may be in-person, via video consultations, but not via audio or telephone. The certifying doctor should also have access to relevant medical records and the results of investigations. Another doctor can complete the certificate if they believe they are able to give a cause of death (for example, by relying on the clinical records), if the doctor who has cared for the patient is unable to do this.
The new Act also enables an MCCD to be completed if the patient was not seen by any medical practitioner – the doctor would need to state the cause of death to the best of their knowledge. If there is no doctor at all who can give a cause of death then the death will need to be referred to the coroner in the usual way.
Registrars will now accept scanned or photographed copies of the MCCD forwarded from a secure email account (such as nhs.net) but original signed MCCD should be securely retained for delivery to the registrar as soon as circumstances allow.
What impact will this have on cremation forms?
Under the Act, cremation no longer requires the confirmatory medical certificate (cremation form 5), but still requires the completion of the medical certificate (cremation form 4).
Any medical practitioner is able to complete a form 4 if the doctor who attended to the patient within the last 28 days is unable to do so, or it is impractical for them complete the form. However, they can only do so when the MCCD was completed on the basis that the deceased was attended within 28 days of the death, or where a medical practitioner has viewed the body after death, even if only for the purpose of verification.
Examination of the body after death is not required if the deceased was either seen after death by a medical practitioner or attended (in person or by video consultation) within the last 28 days.
When completing form 4, if you did not attend the patient during their last illness, you can answer question 5 with 'certifying doctor' as an acceptable 'medical role', but you should put the name, GMC number and role of a medical practitioner who attended the deceased in your answer to question 9.
'Not applicable' is an acceptable answer to question 8 if another medical practitioner has seen the deceased after death in person, even if only for the fact of verification of the death. Additionally, the date and time and nature of that examination should be set out in question 9.
What should doctors in Scotland do?
The Registration of Births, Deaths and Marriages (Scotland) Act 1965 allows another medical practitioner to provide an MCCD in circumstances where no registered medical practitioner who attended the deceased during their last illness is available, or if the attending practitioner is unable to provide a certificate.
Scottish ministers have, under the Coronavirus Act 2020, suspended the current process for reviewing MCCDs. This will have the effect of pausing current reviews unless the reviewer considers that it may be appropriate to refer the death to the procurator fiscal.
In Scotland, guidance has clarified that for the purposes of completing an MCCD (Form 11) related to COVID-19:
- the terms COVID-19 disease and SARS-CoV-2 infection are acceptable
- if the disease is suspected but not confirmed, you may write: 'Presumed COVID-19 disease' on the MCCD
- in both cases the hazards box on the form must be ticked and the public health department informed
- Deaths from COVID-19 should only be reported to the procurator fiscal if there is another reason for reporting the death based on their guidelines. The procurator fiscal should still be notified of deaths due to other notifiable diseases.
What should doctors in Northern Ireland do?
The Coronavirus Act 2020 changes death certification in Northern Ireland, as death certificates can now be signed in cases where a patient has died of a natural illness and the doctor who cared for the patient in the last illness is unavailable.
A death certificate can also be signed for a person who has died of a natural illness but was not seen in the 28 days before death. The doctor can sign the death certificate, if they are able to state the cause of death to the best of their knowledge.
In both cases, the usual certificate can be used and will be interpreted as if the lines beginning, 'Date on which was last seen alive and treated by me…' and the wording relating to the patient having been seen in the last 28 days were omitted.
- Dr Ed Nandasoma is acting head of advisory at the MDU
Updated guidance on death certification is available here.