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