Death certification assistantship 2021 vp

Professor Vinod Patel
FRCP FHEA MD MRCGP DRCOG RCPath ME
Clinical Skills and Diabetes
Hon Consultant in Diabetes and Endocrinology,
Acute Medicine, Medical Obstetrics
With help from David Sarginson
(Coroner’s Officer)
Death Certification, Medical
Examiners, and Coroners
Assistantship Lecture Series 2021

Objectives
• Deaths in “UK”
• The Role of the Medical Examiner
• The Role of HM Coroner
• Legislation
• Coronial Actions and Inquests
• Verification of Death
• Death Certification Practicalities
?

Global Causes of Death
UK: 3rd Rank
Coronavirus Deaths
April 2021
125000 people
12 Months

Global Causes of Death
Global: 4th Rank
Coronavirus Deaths*
April 2020
3.1 million people
6 Months
*CNA Infographic 2021

Monthly number of deaths in England and Wales from January 2015 to February 2021
Monthly number of deaths in England and Wales 2015-2021
Note(s): United Kingdom (England, Wales)
Further information regarding this statistic can be found on page 8.
Source(s): Office for National Statistics (UK); ID 1115077
2
Deaths in England
and Wales

• A national network of medical examiners was recommended by the
Shipman, Mid-Staffordshire and Morecambe Bay public inquiries
• In October 2017, Parliament announced that a national system of
medical examiners will be introduced from April 2019.
National Medical Examiner, Dr Alan Fletcher (RCPath ME) said:
• "Medical examiners are the last piece of the jigsaw of ensuring
patient safety when someone dies; their role is not to investigate
but to detect and pass on."
Medical Examiners

• The regulations will require a doctor’s certification of
cause of death to be scrutinised and confirmed by an
independent medical examiner, taking into account
concerns raised by the bereaved, and could cover
the care the deceased received prior to death.
• Registration of the death will only be permitted
once the death has been scrutinised by a medical
examiner or a coroner
• Considerable input from the Medical Examiners’
Officers in the Bereavement Office
Medical Examiners

Why are Medical Examiners needed and what will they do?

The Coroner: A Short History
• After the Norman Conquest, to deter the local communities from a
continuing habit of killing Normans, a heavy fine was levied on any
village where a dead body was discovered, on the assumption that it
was presumed to be Norman (unless English proven)
• The fine was known as the 'Murdrum', from which the word
'murder' is derived
• 'Presumption of Normanry' which could only be rebutted by the local
community, and a fine thus avoided, by the 'Presentment of
Englishry‘
• 1836, the first Births and Deaths Registration Act was passed,
prompted by the public concern and panic caused by inaccurate
'parochial' recording of the actual numbers of deaths arising from
epidemics such as cholera.

1194……the original Coroner.
• Richard the Lionheart was king and
needed funds to pay for the crusades
• But, the county ‘Shire reeve’ or Sherriff
who collected taxes on behalf of the
Crown.. kept most of them!

Historically, his most important role, as it is the only
one to survive until today, was his central position
in the investigation of sudden death

• Later uncontrolled access to numerous poisons, and inadequate medical
investigation of the actual cause of death, many homicides were going
undetected.
• By then, the coroner's fiscal responsibility had diminished and the Coroners
Act of 1887 made significant changes
• Concerned with determining the circumstances and the actual medical
causes of sudden, violent and unnatural deaths for the benefit of the
community as a whole.
• Post Shipman’s conviction, 3 inquiries looked at ways in which sudden death
is investigated
• New legislation and subsequent changes to the way in which all deaths are
investigated and the manner in which coroners carry out their duties.

The autopsy became more common
during these times…

Legislation
• Coroner’s Act 1988
• Coroner’s Rules 1984
• Coroner’s and Justice act 2009
• PACE 1984
• Human Rights Act
• Health & Safety Legislation
• Other case specific
Legislation/Case law

Human Rights Act.
4 rights impinge on Coroners.
The right to life.
The right to a fair hearing.
The right to respect for privacy and family life.
The right to freedom of religion.
?

Human Rights Act.
States obligation is to have an enquiry under Article 2 to
answer 4 questions;-
Did the State take a life?
May it have taken a life?
Did a person die in custody?
Did the deceased die in the care of the State?

Role Of HM Coroner
• Inquire into Violent, Sudden, Unnatural
or Unexplained Death.
• Who
• Where
• When
• How

Coronial system:
an old institution
• Coroners investigate a body lying within a
jurisdiction area
• Hold inquests in public
• Approx 120 coronial jurisdictions in England,
Wales, & NI.

Table 1: Category of death (advisors' view) n= %
Natural cause of death in community 929 55
Natural cause of death in hospital 351 21
Intentional self harm (suicide) 50 3
Other 55 3
Unascertained 44 3
Associated with a road traffic collision 41 2
Associated with medical intervention 20 1
Alcohol related cause of death 23 1
Natural cause of death (location not stated) 38 2
Industrial related cause of death 31 2
Associated with illicit drug overdose/poisoning 16 1
Mishap in hospital (e.g. fall) 2 0.5
Associated with fire 5 0.5
Associated with immersion 4 0.5
Sudden infant death syndrome (SIDS) 4 0.5
Multiple causes of death (including epilepsy) 78 4
TOTAL 1691 100.0

What is a Coroner?
• To become a Coroner in England and Wales the applicant
must be a qualified solicitor, barrister, or a Fellow of the
Chartered Institute of Legal Executives (CILEx) with at least
five years' qualified experience.
• Can appoints deputies and assistants in order to
investigate deaths reported to them
• Deaths could be; sudden, violent, unnatural or natural
• He can allow doctors to issue medical certificates, order
post mortems and hold Inquests
• Who is your Coroner?
• NB: Case is usually discussed with the local
coroner’s officer- a police officer
?

Mr Cotter
Mr Allen
Mr Balmain
Mr Sean McGovern

Referral to the coroner - when
A doctor may report the death to a coroner if the:
• Cause of death is unknown
• Death was violent or unnatural
• Death was sudden and unexplained
• Person who died was not visited by a medical practitioner during their final illness
• Medical certificate is not available
• Person who died was not seen by the doctor who signed the medical certificate within
14 days before death or after they died
• Death occurred during an operation or before the person came out of anaesthetic
• Medical certificate suggests the death may have been caused by an industrial disease
or industrial poisoning
The coroner may decide that the cause of death is clear. In this case:
• The doctor signs a medical certificate.
• Family take the medical certificate to the registrar.
• The coroner issues a certificate to the registrar stating a post-mortem is not needed.
Basic coronial law
Coroners Act 1988: ss8, 19, 20

Reportable Deaths
• Unknown cause of death/unexpected death
• Suspicious circumstances
• Death linked to an accident
• Self neglect or neglect by others
• Death is linked to another Act
• Lack of medical care
• Not seen recently by Doctor
• Drug or alcohol abuse
• Prison or police custody
• Possible suicide
?

Sudden Death Reporting: details
If the death fits into the below categories it must be
reported to the Coroner.
• Unknown
• Unnatural
• Violent/Suspicious
• Industrial/Workplace
• Police/Prison Custody
• Sec 3 MHA
• Road/Railway
• Under 16
• Drug/Alcohol Abuse
?

Coroner’s Actions
Post-mortems
• Coroner may decide a PM is needed to find out how the person died. This can be done either in a
hospital or mortuary.
• No-one can object to a Coroner’s PM - but if you’ve asked the coroner must tell you (and the
person’s GP) when and where the examination will take place.
After the Post-Mortem
• Coroner will release the body for a funeral once they have completed the PM and no further
examinations are needed.
• If the body is released with no inquest, Coroner will send a form (‘Pink Form - form 100B’) to the
registrar stating cause of death.
• The coroner will also send a ‘Certificate of Coroner - form Cremation 6’ if the body is to be cremated.
If the Coroner decides to hold an inquest
Coroner must hold an inquest if the cause of death is still unknown, or if the person:
• Violent or unnatural death possible
• Died in prison or police custody
• No-one can register the death until after the inquest. The coroner is responsible for sending the
relevant paperwork to the registrar.
• Death cannot be registered until after the inquest, but the coroner can give you an interim death
certificate to prove the person is dead.
• When the inquest is over the Coroner will tell the registrar what to put in the register.

Coroner’s Actions: Usual
The coroner may decide that the cause of
death is clear. In this case:
1.The doctor signs a medical certificate.
2.You take the medical certificate to the
registrar.
3.The coroner issues a certificate to the
registrar stating a post-mortem is not needed.

What are coronial
autopsies for?
A1. Just to consider and
exclude homicide
A2. Just to consider and
exclude unnatural death
B1. To provide an acceptable – though not
necessarily correct – medical cause of
death for registration purposes
B2. To provide the correct medical cause of
death and accurate data for national
statistics
B3. To provide an account of sufficient
accurate detail to address any concerns
from the next of kin and to be useful to
them
B4. To provide detailed information for
medical audit and explanation of events
following medical interventions
B5. To provide the basis of a publishable
case report

•
Learn from the Post Mortem!

Purpose of an Inquest
To establish four facts about a death
1. Who?
2. When?
3. Where?
4. How came by death?
?

Inquests
• Witnesses
• Interested Parties
• Jury
• Media
• Other Agencies
• The General Public

Who are the interested parties?
• The coroner
• The pathologist
• The family
• The general practitioner
• The hospital and other care centres
• National statistics
• The Dept of Health
• The police and the CPS
?

Resumed Inquests – non suspicious
• When all information available, the Coroner will
resume the Inquest and all evidence will be heard in
open court.
• Hearsay evidence is acceptable and you may be
asked for your opinion on events
• At the conclusion, the Coroner will record his verdict
• He does have the right to instruct a Jury and always
will for Railway and Prison deaths

Identification
• Methods Of Identification include:
• Visual/Photograph
• Fingerprints
• DNA
• Dental
• National Intelligence systems
• Surgical scars/replacements (serial no)
• Marks, Scars and Tattoos
?

Specialist Areas
• Murder/Homicide
• Rail/Road
• Health & Safety
• Prison/Police Custody
• Sec 3 MHA
• Military
• Mass disasters/Multiple Victim Identification
• Infants and Children (SUDC)
?

THE INQUEST.
• Findings of civil liability or criminal responsibility
are simply not permitted.
• At the end of the evidence, advocates are not
allowed to address the Coroner on the facts,
merely, the law.
• The findings are recorded in an Inquisition Form.

Procedure.
•The average inquest is a simple affair.
•In a close community, its only real function is to officially
confirm what most knew and to inform the others.
•It does have the effect of allaying wrongful rumour.
•Documentary evidence may be admitted if it be non-
controversial and this will often save a family hearing the
details of an autopsy and other things that might cause
distress.
•Most Coroners use this power in the Coroners Rules
where a family so wishes for the family can refuse to
accept documentary evidence.

Jury.
It is mandatory to have a jury where death occurs in
custody – Police or Prison or perhaps a mental patient;
Where the death has to be reported to a government
department e.g.railway inspectorate, Health and Safety at
work, reportable disease
Any other case where the Coroner believes that a section of
the public may be at risk from the circumstances of this
death.

Jury.
There must be a minimum of 7 people and thus provided 7
can sign the Inquisition Form at the end of the Inquest,
those dissenting do not count.
In this way Coroners Courts have had “majority verdicts”
for a very long time.
The Coroner sums up the evidence and the law for the
Jury before they retire.

Verdict
• Not to proportion guilt/blame.
• Be within the remit of the Inquest.
• Common/Generic Verdicts
• Narrative Verdicts
• Unlawful Killing and Suicide must be proved
“beyond reasonable doubt.”
• All other verdicts are “on the balance of
probabilities.”
?

Conclusions or Verdicts.
Natural Causes.
Eg: patient is suffering from a potentially fatal condition,and medical
intervention fails, the verdict must still be Natural Causes.
Industrial Disease.
Disease process as a consequence of employment. Abuse of drugs either
dependent or non dependent.
Accidental Death.
Either Death from a procedure process or event or consequence of an
unintended occurrence or consequence of a deliberate human act which has
unexpectedly turned for the worse and death.

Suicide.
A voluntary act that results in death with that intention.
Standard of Proof. Beyond all reasonable doubt.
Unlawful killing.
Murder, Voluntary Manslaughter, Involuntary
Manslaughter or Gross Negligence Manslaughter. i.e.
a. Duty of care. b. Breach of that duty.
c. Breach caused death by being grossly negligent.
Lawful killing. Lawful self defence.

Open Verdict. Where the standard of proof is high and the
evidence does not support it or where it may be one type of
verdict or another and there is no evidence, then an open
verdict should be returned.
Neglect or self neglect.

Narrative Verdict.
New and of great use in those cases where the behaviour
complained of does not do justice to the facts.
• The deceased died from natural causes in part because
the risk of him doing so was not immediately recognised
and appropriate actions were not taken.
• The deceased died as a result of an unexpected
complication of a necessary therapeutic procedure.

Can I Issue A Death Certificate? 1
Have I treated the patient alive within the last 14 days?
Yes – continue
No – is there another doctor who can certify?
Am I confident of a probable/likely or confirmed natural
cause of death?
Yes – continue
No – contact the coroners officer to discuss
Has the patient undergone any recent surgery/accident
which has lead to the admission/during admission?
No – continue
Yes – contact Coroner’s officer to discuss/refer for PM

Can I Issue A Death Certificate? 2 Yes
When considering the causes of death for the MCCD, it is
important to ensure the following:
1a Must be the ultimate cause of death
1b Must be the mode of death causing 1a
1c Mode of death causing 1a and or 1b
2 Known Medical conditions which could
Contribute to 1a, 1b or 1c.

Can I Issue A Death Certificate? 3
Yes: but discuss with Medical Examiner and ? Coroner’s Officer
if you are considering any of the following certificate, discuss with
CO, this may avoid the family being refused registration:
hepititis b hypothermia
tuberculosis diarrhoea
dehydration any fracture/break
alcoholism anorexia
salmonella subdural (anything
frailty exhaustion
malnutrition neglect
intracerebral bleeding perforation
poisoning accident
any failure or accident– eg. Renal failure at 1a on its
own, CVA (use Stroke)
recent surgery or injury of any kind

Verification of Death
? CPR needed
Ask the ward staff about the circumstances surrounding the death as you will need
to document this in the notes.
Ask for the patient’s notes:
•Confirm the resuscitation status of the patient
•Read the patient’s notes for some background on the patient
If family or friends are present:
•Introduce yourself
•Offer your condolences
•Explain the need to confirm the death
•Offer the family the opportunity to wait outside – respect their preference
•Ask if the family have any concerns or questions
?

1. Wash hands
2. Confirm the identity of the patient – check the wrist band, notes
3. General inspection – any obvious signs of life
4. Look for signs of respiratory effort – any movement
5. Does the patient respond to verbal stimuli? – “Hello, can you hear me?”
6. Does the patient respond to pain? – press on fingernail / trapezius squeeze /
supraorbital pressure
7. Assess pupils using pen torch/light source – after death fixed and dilated
8. Feel for a central pulse – carotid artery- both sides
9. Auscultation:
Listen for heart sounds for at least 2 minutes
Listen for respiratory sounds for at least 3 minutes
(The recommended times for each of these vary, so adhere to your local hospital policy. General guidance advises a minimum of five
minutes total to establish that irreversible cardiorespiratory arrest has occurred)

8 April 2021 8.10 am
Called to Confirm the Death of Mr James Raffles
Pupils fixed and dilated, no response to light
No pulses
No breath sounds
No heart sounds
No response to pain
Mr James Raffles certified dead at 8.20 am 8 April 2021
Rest in Peace
Tertius Lydgate
Dr Tertius Lydgate MB ChB GMC 1234567

Guidance for doctors completing Medical Certificates
of Cause of Death in England and Wales
The death of a loved one is a difficult time that causes much pain and
sadness. To make a difficult period as easy as possible, procedures after
death should be hastened and carried out efficiently and correctly.
The clinician should express and display the highest professional standards
possible especially in relation to dealing with family members and friends of
the deceased patient.
The bereavement service will be invaluable to family members and friends.
Clinician may also need support from the bereavement with some patients
such as deaths in children and other close patients.

Confirmation of Death
It is a professional duty to examine the patient who has died to clinically confirm
death. There are many instances, anecdotally and in the medical literature, where
patients were revived in the mortuary! This can be avoided by verifying and
confirming death as follows:
 Fixed pupils that are unresponsive to a bright light.
 No respiratory effort or breath sounds (auscultation over trachea and
anterior upper chest).
 No pulses: check carotids, radials.
 No Heart sounds (listen over usual apex position, 30-60 seconds).
 No response to sternal rub/supra-orbital pressure (painful stimuli).
 Retinal Examination, occasionally undertaken, would reveal
discontinuous clots in retinal veins.
If a patient that is known to you and you are going to do the death certificate then
it will be useful to start establishing the Cause of Death. Also check for the
presence of a pacemaker, this is easier to check in a patient that has recently died
rather than in the mortuary.

The Purposes of Death Certification 1
• A medical certificate of cause of death (MCCD) enables the deceased’s family to
register the death. This provides a permanent legal record of the fact of death and
enables the family to arrange disposal of the body, and to settle the deceased’s
estate.
• A doctor who attended the deceased during their last illness has a legal
responsibility to complete a MCCD to be presented to the registrar of deaths as
soon as possible to enable the registration to take place
• This duty may be discharged through another doctor who may complete an MCCD
in an emergency period.
• Deaths are required by law to be registered within 5 days of their occurrence unless
there is to be a coroner’s post mortem or an inquest.
• After registering the death, the family is provided with a certified copy of the register
entry (“death certificate”), which includes an exact copy of the cause of death
information that you give.

The Purposes of Death Certification 2
• The MCCD provides them with an explanation of how and why their relative died.
• It also gives them a permanent record of information about their family medical
history, which may be important for their own health and that of future generations.
• Extremely important that you provide clear, accurate and complete information
about the diseases or conditions that caused your patient’s death in a timely
manner.
• Health Data: relative contributions of different diseases to mortality, monitoring the
health of the population, designing and evaluating public health interventions,
recognising priorities for medical research and health services, planning health
services, and assessing the effectiveness of those services.
• Death certificate data: extensively used in research into the health effects of
exposure to a wide range of risk factors through the environment, work, medical
and surgical care, and other sources.

Referring deaths to the coroner
Medical practitioners are required to certify causes of death “to the best of
their knowledge and belief”
Doctors and registrars of births and deaths have a legal obligation to report
certain categories of deaths to the coroner before they can be registered.
These include deaths where there is reason to suspect, the death was:
• Unnatural, unexplained, violent or where the death occurs in prison or
otherwise in state detention.
• Deaths occurring during an operation, or before full recovery from an
anaesthetic should also be referred
• Also: neglect concerns
• Deaths for which the cause is not known must be reported to the coroner.
In the emergency period, if no doctor has attended the deceased within 28
days of death (including video/visual consultation) or the deceased was not
seen after death by a doctor, the death must be referred to the coroner.

Referring deaths to the coroner
Medical practitioners are required to certify causes of death “to the best of
their knowledge and belief”
Omitting to mention on the certificate conditions or events that contributed to the
death in order to avoid referral to the coroner is unacceptable and a breach of the
doctor’s legal obligations.
If these come to light when the family registers the death, the registrar will be obliged
to refer it to the coroner. If the fact emerges after the death is registered, an inquest
may still be held.

Sequence leading to death, underlying cause and
contributory causes
MCCD, two parts, in accordance with WHO recommendations in the International
Statistical Classification of Diseases and Related Health Problems (ICD)
• Start with the immediate, direct cause of death on Line 1a, then to go back
through the sequence of events or conditions that led to death on subsequent
lines, until you reach the one that started the fatal sequence
• The condition on the lowest completed line of part I will have caused all of the
conditions on the lines above it. This initiating condition, on the lowest line of part I
will usually be selected as the underlying cause of death, following the ICD coding
rules.
WHO defines the underlying cause of death as:
• The disease or injury which initiated the train of morbid events leading directly to
death, or
• The circumstances of the accident or violence which produced the fatal injury”.

Sequence leading to death, underlying cause and
contributory causes
• From a public health point of view, preventing this first disease or injury will result
in the greatest health gain.
• Most routine mortality statistics are based on the underlying cause.
• Underlying cause statistics are widely used to determine priorities for health
service and public health programmes and for resource allocation.
• Remember that the underlying cause may be a longstanding, chronic disease or
disorder that predisposed the patient to later fatal complications.
• You should also enter any other diseases, injuries, conditions, or events that
contributed to the death, but were not part of the direct sequence, in part two of
the certificate. The conditions mentioned in part two must be known or suspected
to have contributed to the death, not merely be other conditions which were
present at the time.

Examples of Death Certification
Examples of cause of death section from MCCDs (including example of COVID-19 as underlying
cause of death):
Cause of death the disease or condition thought to be the underlying cause should appear in the
lowest completed line of part I
Disease or condition leading directly to death
I (a) Interstitial pneumonitis
Other disease or condition, if any, leading to I(a)
1 (b) COVID-19
Other disease or condition leading to 1(b)
1 (c) Primary adenocarcinoma of ascending colon
II Other significant conditions Contributing to death but not related to the
disease or condition causing it:
Diabetes mellitus

cause of death):
I (a) Intraperitoneal haemorrhage
1 (b) Ruptured metastatic deposit in liver
1 (c) Primary adenocarcinoma of ascending colon
Diabetes mellitus

cause of death):
I (a) Cerebral Infarction
1 (b) Thrombosis of the Left Middle Cerebral Artery
1 (c) Cerebrovascular atherosclerosis
Frailty, Sacral Ulcers

1(a) Frailty
1(b)
1(c)
2 Hypertension,
Old age, ‘senility’ or ‘frailty of old age’ should only be given as the sole cause of death
in very limited circumstances. These are that:
• You have personally cared for the deceased over a long period (years, many months)
• You have observed a gradual decline in your patient's general health and functioning
• You are not aware of any identifiable disease or injury that contributed to the death
• You are certain that there is no reason that the death should be reported to the
coroner

Avoid organ failure alone
Do not certify deaths as due to the failure of any organ without specifying the disease
or condition that led to the organ failure. Failure of most organs can be due to unnatural
causes, such as poisoning, injury or industrial disease. This means that the death will
have to be referred to the coroner if no natural disease responsible for organ failure is
specified. Examples:
Ia. Renal failure
Ib. Necrotising-proliferative nephropathy
Ic. Systemic lupus erythematosus
II. Raynaud's phenomenon and vasculitis
Ia. Liver failure
Ib. Hepatocellular carcinoma
Ic. Chronic Hepatitis B infection
II. Congestive cardiac failure Essential hypertension

The MCCD in use in England and Wales currently has 3 lines in part I for
the sequence leading directly to death. If you want to include more than 3
steps in the sequence, you can do so by writing more than one condition on
a line, indicating clearly that one is due to the next. Example:
Ia. Post-transplant lymphoma
Ib. Immunosuppression following renal transplant 15 years ago
Ic. Glomerulonephrosis due to Type 1 Diabetes mellitus
II. Recurrent urinary tract infections
Type 1 Diabetes mellitus with renal complications is the
underlying cause.

More than one disease may have led to death If you know that your patient
had more than one disease or condition that was compatible with the way in
which he or she died, but you cannot say which was the most likely cause of
death, you should include them all on the certificate.
They should be written on the same line and you can indicate that you think
they contributed equally by writing “joint causes of death” in brackets.
Examples:
Ia. Cardiorespiratory failure
Ib. Ischaemic heart disease and chronic obstructive airways disease
Ic.
II. Osteoarthritis
Ia. Hepatic failure
Ib. liver cirrhosis
Ic. Chronic hepatitis C infection and alcoholism (joint causes of death)
II.

Professional Principles
There are important aspects in relation to the removal of the body and its eventual final state dependent on the specific religion, if
any. The standard secular choice is a straightforward burial or cremation after the body has been removed to the mortuary and
funeral arrangements have been made. The following notes are for general guidance only and each death should be treated as
an individual case. Specific religious wishes are best discussed with the Multi-faith Chaplaincy service that now operates in most
hospitals in UK. It is also best to clarify wishes with regards post-mortem and or organ donation on an individual basis with the
next of kin.
 Christianity
o Several variations in relation to final moments and care after death depending on the denomination.
o A priest may be required to offer last rites if death imminent.
o Final State: Burial or cremation.
 Islam: If death imminent inform family.
o Family will wish to be with deceased to offer last rites and prepare body after death.
o Prompt burial imperative hence try to complete death certificate as soon as possible.
 Judaism
o Body prepared and washed prior to burial by family.
o If no family contact local hospital Rabbi or local Hebrew Burial Society or Jewish Community.
o Prompt burial imperative hence try to complete death certificate as soon as possible.
 Hinduism
o Various rituals according to specific denomination.
o Hindu priest to be contacted to perform last rites, Cremation usually.
 Sikhism
o Family may wish to perform last rites and prepare body.
o Cremation usual but stillborn / miscarriages are buried.
o Buddhism
o Advisable not to remove body before monk/sister arrives, Cremation common.
 Jehovah’s Witnesses
o No ceremonial rites.
o Usual preparation appropriate.

Referring to the Coroner
There are many reasons why a death needs to be discussed with the Coroner. In
reality the discussion takes place between the doctor and the coroner’s officer (a
police officer). The following should be discussed with the coroner.
 Death suspicious in any way: potential murder, recent assault.
 Unknown cause of death.
 Patient not seen by certifying doctor in the last 14 days.
 All deaths within 24 hours of admission to hospital.
 All deaths in relation to surgery or anaesthesia or any medical treatment.
 Death due to road traffic accident, other accidents, trauma, industrial injury.
 Death due to violence, neglect, abortion, suicide or poisoning (including alcohol).
 Deaths in Legal Custody.
 Death in any cases where issue of negligence has been raised.
 Death due to industrial injury or employment.
The coroner can decide on one of three options: allow the death certificate to be
issued concordant with the discussion, order a post mortem to be held or hold a
coroner’s inquest to establish cause of death.

The basic pathway
• If a registered medical practitioner:
a. knows the cause of death of the person ‘to the best of
his/her knowledge & belief’
b. and this cause is ‘natural’
c. and has seen the patient within the last 14 days
• Doctor discusses case with the Medical Examiner
• Completes a Medical Certificate of Cause of Death (MCCD)
• Relatives take MCCD to Registrar of Births & Deaths
• Relatives receive a form to permit burial or cremation

Professional Tips
 Discuss cause of death with the Medical Examiner: in almost all cases, the
junior clinician should discuss the cause of death of a patient with the responsible
senior clinician and then the Medical Examiner.
 Coroner’s officer: if there is any doubt as to the cause of death or there is a need
to consider a post-mortem, discuss the case with the Coroner’s Office as soon as
possible. E-referral form usually.
 The MCCD: Accurate, legible, No abbreviations, Sign off with GMC number, write
address as the Hospital.
 Sources of help: the bereavement team, social worker and nursing staff will be of
great help if needed.

Case study 1
• Elderly female, depressed, diabetes type 2
• Minimal history from coroner, no scene of death
information
• Autopsy: some coronary atheroma and
bronchopneumonia
• 1a. Bronchopneumonia
1b.
1c.
• 2. Type 2 Diabetes mellitus
• Later information detailed……..

Case study 1
• Elderly female, depressed
• Minimal history from coroner, no scene of death
information
• Autopsy: some coronary atheroma and
bronchopneumonia
• Later information detailed that the patient was found
with a plastic bag over the head
• Too late for other investigations e.g. toxicology

Case study 2
• An elderly resident of a nursing home, diabetes- fell from
bed
• Admitted to hospital with drowsiness and general
deterioration
• CT scan showed a large acute-on-chronic subdural
haematoma
• Not suitable for surgery and the patient died a week later

Case study 2
• Coroner specifically raised the question of whether the subdural
haematoma was contributory to the death?
• The autopsy found 54g of clotted blood and a chronic subdural
membrane present over the right side of the brain, with an intact skull
There was also a well described old infarct in the brain, along with
cerebral atrophy
• The lungs showed thromboembolism filling the pulmonary arteries; DVT
present
• Comment in the report that "Death was due to natural causes".
• The cause of death given was:
1a. Pulmonary embolism
1b. Lower limb phlebothrombus
2. Diabetes mellitus
• There was nothing in the report addressing the circumstances raised by
the coroner

Case study 3
• A middle-aged, known alcohol abuser
• Seen drunk and was found dead 24 hours later, in unkempt state
• At autopsy, the brain was normal. The heart was 320g, had no
coronary artery disease but the left ventricle was described as
hypertrophied at 2cm thick
• No further investigations were done
• The comment was "natural causes" and the cause of death
was given as:
1a. Acute left ventricular failure
1b. Left ventricular hypertrophy
• The advisor stated that the issue of alcohol was not addressed at all
and should have been pursued with estimation of blood and urine
alcohol or the measurement of beta-hydroxybutyrate in the blood, as
a marker of the keto-alcoholic syndrome that can cause sudden
unexpected death in chronic alcoholics

Why quality was unsatisfactory
• Alcohol abuse not mentioned (4 cases)
• Drug usage, both prescribed and non-prescribed (28 cases)
• Schizophrenia, dementia, epilepsy not mentioned (3 cases)
• Significant medical history not mentioned (50 cases)
• The occupation of the deceased, including asbestos exposure or
previous diagnosis of mesothelioma, not mentioned (13 cases)
• Not enough data on hanging or trauma related to death (15 cases)
• Information just too brief or muddled (59 cases)
• Information handwritten and illegible (4 cases)

Natural Death
• What makes a death natural?
• A death where the Doctor has seen a patient in the
last 14 days and certifies that the patient has died
from a natural illness running its full course.
• In these cases, the Coroner has no jurisdiction
provided the Coroner is satisfied if it has been
referred to him.
• About two third of deaths are not referred to the
Coroner.

Objectives
• The Role of the Medical Examiner
• The Role of HM Coroner
• Legislation
• Sudden Death Reporting
• Identification
• Inquests
• Specialist Areas
Any Questions?

Case study 4
• An elderly resident died in a nursing home. In the
history provided by the coroner was the following
statement and request:
• "It has been brought to my attention that the
Public Health Department (PHD) are investigating
this nursing home on the suspicion that residents
could be dying from viral meningitis... The PHD
has therefore requested that lung samples are
obtained and also that blood is taken in order to
grow cultures".
• No cultures were done
• Note also confusion over which cultures to be
done

Death certification assistantship 2021 vp

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