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Independents' Day

How to avoid common pitfalls when signing death certificates

Dr Frances Cranfield, GP and assistant coroner, advises

The death certification process is antiquated and a number of major reviews have advised modernisation and restructuring. A consultation concerning the proposed introduction of medical examiners to look over all death certificates that are not sent to the coroner has just been undertaken but it is still likely to be several years before implementation so it is important for all concerned, particularly the bereaved, that medical certificates of cause of death (MCCD) are accurately completed.

Here are some common mistakes GPs make and how to avoid them:

1. Giving the cause of dying as a mode of dying. Do not complete with modes of dying as the only cause of death in part 1 e.g. respiratory arrest, kidney failure, cardiac failure (congestive cardiac failure is allowed as a cause) as this will result in the death being referred to the coroner by the registrar and it is possible this will delay the funeral and add to the bereaved’s distress. The use of acute or chronic will not make the terms acceptable.

2. Using abbreviations. For example CVA, MI or medical symbols. Abbreviations are ambiguous. For instance does ‘MI’ mean mitral incompetence or myocardial infarction and will the family know what such abbreviations mean? Inclusion of such ambiguous terms may delay registration.

3. Signing the certificate when you have not seen the deceased. You should have seen them in the last 14 days prior to death, during the period of the last illness that was the certified cause of death or seen the deceased after death.

4. Not being specific about the underlying cause of death. Be as detailed as possible when considering the main casual sequence of conditions. When recording a neoplasm, wherever possible state the site of the tumour, whether it is primary or secondary and the histology. When there is infection try to be specific about the type and consider whether there is more that you can write, for example instead of recording the sole cause of death as pneumonia, also include any underlying conditions that could have led to this. Mortality statistics derived from the death certificates are vital for public health surveillance and other purposes such as insurance. As we learn more about genetics and lifestyle, the cause of death may impact on heath choices for family including lifestyle, screening and genetic determinations.

5. Applying proof ‘beyond reasonable doubt’ instead of ‘on the balance of probability’. The Births and Deaths Registration Act 1953 says that any registered medical practitioner who attends the deceased during his last illness shall sign a certificate stating the cause of death to the best of his knowledge and belief. This is not a criminal standard of proof, ie ‘beyond reasonable doubt’, but is generally considered to be the civil standard, so ‘on the balance of probability’. You are not expected to be infallible but the cause of death must be based on a conscientious appraisal of facts.

6. Signing what is not true or accurate at the time. This is the case even if you intend it to be true later. Do not sign to say you have seen the body if you have not but intend to go later in the day. The family may have registered the death before you have even finished morning surgery. The unintended consequence of this is potentially a GMC matter, so do not feel pressurised to sign too early. The certificate asks you to sign when you last saw the deceased alive so do not give a date when another medical practitioner saw the deceased alive.

7. Completing without due care and attention. If you misspell the cause of death, the registrar is required to copy exactly what you have written on to the death certificate which is the family’s permanent record. Please write legibly to assist the registrar (there has been a request for a self-populating electronic version of the MCCD for the future).

8. Not taking time to discuss with the family. You should discuss what you believe to be the cause of death with the family before handing them the envelope. Be compassionate and try to help to support the bereaved so they can gain understanding and comfort wherever possible. If the family arrive at the registrars and then learn about the alleged cause of death for the first time and have concerns about this, this causes further delay and stress.

9. Using old age or senility as the only cause of death in part 1. This is unless a more specific cause of death cannot be given and you have checked the situation in your coroner’s area. In Hertfordshire we expect the deceased to be over 80 and frailly of old age may then be acceptable. This is the Shipman legacy.

10. Using Part 11 (which asks for conditions that may have contributed to death) as a list of all conditions present at death. It should only be conditions that contributed to death but which were not part of the sequence leading directly to death.

11. Not referring to the coroner. GPs do not in fact have a statutory duty to report any death to the coroner but for the sake of all please do so where appropriate. It is easy to forget that you should refer to the coroner for industrial diseases and the relatively new issue of all patients under deprivation of liberty safeguards (DOLS).

Dr Frances Cranfield is a GP and assistant coroner in Hertfordshire

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Readers' comments (5)

  • interesting, I hadn't heard about the DOLS patients needing referral.

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  • Dear Dr Cranfield,
    I am afraid you are wrong with regard to the so called "14 day rule". I will briefly explain; the 1953 Births and Deaths Registrations Act requires any doctor caring for the deceased DURING their last illness (note no 14 day limit) to provide an MCCD. Its paragraph 22. Therefore on the MCCD the time last seen could be a minute, an hour, a day, a week, a month, a year. There is no stipulation of any time limit or deadline in the 1953 Act and it is the 1953 Act that creates the law that requires doctors to complete MCCDs.
    There is a 14 day limit but it is a responsibility on the Registrar not the doctor. It is the The Registration of Births and Deaths Regulations Act 1987 that sets the 14 day limit, its Part 10 regulation 41. That limit is a limit set by that Act on the registrar, if they are given an MCCD where the date last seen is greater than 14 days THEY must notify the Coroner. The 14 day limit does not apply to the doctor, it applies to the Registrar.

    This is a very common misconception and i have striven for years to get it corrected. Its the cause of nursing homes asking for visits because "they've not been seen for 14 days". I thought it had been put to bed when the BMA issued updated guidance and even the latest notes that accompany the book of MCCDs now make this clear.

    I realise it is common practice for the GP to smooth the passage of greater than 14 day MCCD but that is different to it being the law.

    It is very disappointing that this myth is being perpetuated by a GP Assistant Coroner.

    Of interest the 1953 Act requires EVERY doctor who cared for the deceased to provide an MCCD which means in theory you could have several; one from the GP, one from the OOH doctor and one from the Oncologist.

    Hopefully Dr Cranfield will issue a correction.

    Oh and by the way you don't have to see teh body after death either........

    Paul Cundy

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  • Dear Paul
    Thank you for your comments and actually I think we can technically both be considered to be right.
    Please note the article is entitled common pitfall and at point 3 it headed ‘Signing the certificate when you have not seen the deceased.’ In the word count I was given I regret it was not possible for me to quote the law but yes if you are a registered medical practitioner and were in attendance during the deceased’s last illness you are required under the Births and Deaths Registration Act 1953 to certify the cause of death to the best of your knowledge and belief. Please note that you are required to see the deceased during their last illness. This is defined as the illness from which the patient is considered to have died. Thus if you last saw the patient for an exacerbation of their chronic pulmonary disease but the cause of death was say an intracerebral haemorrhage which occurred after you last saw them and was considered to be the cause of death, then you should not sign the certificate. This is something that does unfortunately occur.
    I would draw your attention to the brown book containing the Medical Certificates of Cause of Death which on page two says ‘A death should be referred to the coroner if the deceased was not seen by the certifying doctor either after death or within the 14 days before death.’ You are correct that this guidance does indeed come as a result of the Registration of the Births and Deaths Regulations 1987. As I have said, a practitioner does not actually have a statutory duty to report a death to the coroner. If you as a practitioner complete the certificate when you have not seen the patient within 14 days in their last illness or afterwards and then give the certificate to the bereaved advising them to take it to the registrar’s office, then when the bereaved family arrives for their appointment with the registrar, they will be told that the registrar is unable to register the death with that certificate and the matter has to be referred to the coroner. This frequently causes enormous distress for the bereaved at what is often one of the darkest and most difficult times of their life. They have often booked the funeral date, sometimes to occur within days and it comes as an enormous shock especially if the funeral must be delayed as a result. Sadly this and other issues with death certificates that the bereaved take the registrar’s office without any warning is what we see, just as I have seen today, on an almost daily basis. It means that the coroner’s officers then have to phone the practitioner to gather details at a time when the practitioner himself may be in the middle of a very busy day rather than the practitioner initially himself choosing a time to speak to the coroner’s officer.
    Paul I note you have said that you have striven for years to correct what you consider to be a common misconception and myth. I am sure that it would be difficult to find anyone who does not believe that the current death certification and investigation process is antiquated and reform is long overdue. There have been a number of reviews strongly recommending reforms but of course the proposals cost money. Since the time I was instructed to examine Harold Shipman’s patients’ medical records and give evidence at the Shipman Inquiry, I have been a strong advocate for change. However, in the meantime I truly believe that whilst we may have no obligation to refer to the coroner, none of us would wish to purposely set out on a path that we understand is extremely likely to cause increased distress and delay for the bereaved.
    Frances Cranfield
    Assistant coroner and partner in general practice 26th July 2016

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  • 'The issue of seeing the patient after death and the "14 day rule" applies particularly where cremation is to be undertaken and this is where the coroner and medical referee have different guidelines. I have very frequently needed to explain this to GPs and sometimes to the coroners officer.
    As a busy medical referee (more than 50 cases per week) the elucidation to colleagues can be time consuming !

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  • Thanks. This is interesting, I was aware of seeing the deceased after death when death was expected, but was under the impression that the deceased must have been seen by the doctor signing the certificate at least 14 days prior to death or after death if the death was expected and had been seen by another health professional within 14 days

    Am I right to understand, even if I have not seen the deceased in the last 14 days, but see the deceased after death, I can sign the certificate without referring to the coronor

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