MCCD FORMS 4 4A

1. MEDICAL CERTIFICATION
OF
CAUSE OF DEATH(MCCD)
DRVARUNMODGIL,ASST PROF
DEPTTOFFORENSICMEDICINE
DAYANANDMEDICALCOLLGE

2. DEATH…
“Complete, permanent and irreversible stoppage of
respiration, circulation and brain functions”
Legal definition: (under section 46 IPC=s. 2(6) B.N.S
2023)
“Permanent disappearance of all Evidence of life at any time after
live-birth has taken place”
(Section 2(b) of “The registration of births and deaths act, 1969”)

3. DEATH-PROCESS/PHASES
Somatic death
Molecular death

4. Brain Death:
Beating heart,
Breathing by artificial means,
absence of encephalic electrical activity.
criteria for brain death..
Philadelphia protocol(1969)
Minnesota criteria(1971)
Harvard Criteria(1968)

5. CIRCULATION TESTS
•Magnus test
•Diaphanous test
•I card's test
•Finger nail test
•Application of heat
•Cutting a small artery
•ECG

6. RESPIRATION STOPPAGE TEST
Apnoea test
Winslow test
Stethoscope
Mirror test

7. BRAIN-STEM DEATH
CERTIFICATION
Pupillary reflex
Oculocephalic reflex
Vestibulo ocular reflex(caloric response)
Corneal reflex
Grimace reflex
Gag reflex

9. REGISTRATION OF BIRTH &
DEATHS ACT (RBD), 1969
Death certification
IMP PROVISIONS
•Section 10(3)
•Section 17(1)

10. WHAT IS DEATH CERTIFICATION?
•Death is not a moment
•Medical Certification of Cause of Death Scheme is
an important tool of obtaining authentic and
scientific information regarding causes of mortality

11. SHOULD KNOW…
• Cause of death
• Underlying cause of death
• Mechanism of death
• Manner of death
• Mode of death

12. CAUSE OF DEATH
• The cause of death is a disease, abnormality, injury or poisoning
that contributed directly or indirectly to death
• Any circumstances of the accident or violence which produced
any such injuries which is directly leading cause of Death
Chronic Ischemic Heart Disease Acute Myocardial Infarction Pulmonary Embolism
CHAIN OF EVENTS

13. UNDERLYING CAUSE OF DEATH
• The disease or injury that initiated the chain of morbid
events leading directly to death.
• The circumstances of the accident or violence which
produced the fatal injury
Pedestrian Hit By Truck Multiple Fracture fat embolism

14. MECHANISM OF DEATH
•Physiological or biochemical derangement
produced by the cause of death that results in
death
•Hemorrhage, Septicemia, And Cardiac Arrhythmia

15. MANNER OF DEATH
It is way, fashion or circumstances of death.
Natural– when due to disease
• Cardiovascular condition e.g. MI
• Respiratory condition e.g. Asthma, COPD
• Tumor of brain with sudden hemorrhage
• Tumor of brain producing pressure
• Metabolic disorders e.g. uremia

16. Unnatural
• Accidental head injuries e.g. RTA
• Homicidal head injuries e.g. stab, lacerated, incised, firearm
• Suicidal head injuries e.g. firearm injury
• Poisoning e.g. Opium, alcohol

17. MODE OF DEATH
It is stoppage or failure of vital system
• Coma :- failure of function of brain
• Syncope :- failure of function of heart
• Asphyxia :- failure of function of respiratory system

21. --KEY STEPS--
STEP 1:
ALWAYS read the case history and note the key events and conditions. Don’t
forget to consider signs and symptoms as well as negative symptoms
STEP 2:
ALWAYS establish a chronology of conditions which will list out the all
disease and events in the order in which they occurred before death

22. STEP 3:
ALWAYS determine the underlying cause of death(COD) which is the disease or
injury that started the chains of the events the lead to death of the individual
Remember to always check which disease, injury or event came first
STEP 4:
ALWAYS try to use ICD- 10 terminology, which is clear and universally accepted,
when recording the underlying COD
This also help avoid confusion between similar terms and abbreviations

23. A DIABETIC MAN WHO HAD BEEN UNDER INSULIN CONTROL FOR MANY YEARS
DEVELOPED ISCHEMIC HEART DISEASE AND DIED SUDDENLY FROM A MYOCARDIAL
INFARCTION. DEPENDING ON THE PHYSICIAN’S DOCUMENTED MEDICAL DIAGNOSIS,
THE FOLLOWING CERTIFICATIONS ARE POSSIBLE AND WOULD BE ACCEPTABLE: :
1. If the physician considered that the heart condition resulted from the long-
standing diabetes,
the sequence would be:
• Part I (a) Myocardial infarction..........................1 hour
due to
• (b) Chronic ischemic heart disease..........5 years
due to
• (c) Diabetes mellitus..............................12 years

24. 2. If the physician considered that the heart condition developed
independently of the diabetes,
the certification would be:
• Part I (a) Myocardial infarction................................................1 hour
due to
• (b) Chronic ischemic heart disease..............................5 years
• Part II Diabetes mellitus….............................................12 years

25. A LADY WAS ADMITTED WITH 80% SUICIDAL BURNS INJURIES DIED
OF SEPTICEMIA AFTER 3 DAYS OF ADMISSION.
Part I(a) Septicemic shock ------------------3 days
(b) Burn(80% superficial & deep)- 3 days
(c) Intentional self harm by fire & flames-3 days
back
Part II ..............Nil
Manner of death
1. Natural 2. Accident 3. Suicide 4. Homicide 5. pending investigation
Self Harm By Fire Burns Septicemic Shock

26. CASE
A 59 Years old male was admitted to the hospital with shock & with
signs of septicemia along with gangrene of (Lt) foot. Patient had
swelling of Lt foot and fever since 3 days. He had H/O COPD due
to chronic bronchitis and had Diabetes since 5 years. Patient had
diagnosed as C/O carcinoma of pancreas and operated for the
same 5 years back. Patient died 2 days after admission due to
septicemic shock.

29. CASE
A 59 Years old male was admitted to the hospital with shock & with
signs of septicemia along with gangrene of (Lt) foot. Patient had
swelling of lt foot and fever since 3 days. He had H/O COPD due to
chronic bronchitis and had Diabetes since 5 years. Patient had
diagnosed as C/O carcinoma of pancreas and operated for the
same 5 years back. Patient died 2 days after admission due to
septicemic shock.

31. CASE
70 years old female was admitted to the hospital for
fracture neck femur 6 hours back due to fall in a
bathroom. She was known diabetic since 10 years and
hypertensive since 15 years. Open reduction of the
fracture was advised but operation was delayed for
fitness, as BSL was not within normal limits. On 6th day,
patient deteriorated becoming severely breathless and
had sudden collapse showing signs of pulmonary
embolism. Patient died after 5 hours

33. CASE
• 70 years old female was admitted to the hospital for
fracture neck femur 6 days back due to fall in a bathroom
2 days back. She was known diabetic since 10 years and
hypertensive since 15 years. Open reduction of the
fracture was advised but operation was delayed for
fitness, as BSL was not within normal limits. On 6th day
patient deteriorated becoming severe breathless and had
sudden collapse showing signs of pulmonary embolism.
Patient died within hours

34. 6

35. BE AWARE OF COMMON ERRORS
• Inverted COD sequence with Underlying Cause of Death on top
• Recording Contributory Cause of Death in part I
• Leaving the time intervals column blank
• Not using ICD-IO terminology to record the Underlying Cause of
Death
• Recording Underlying Cause of Death in part II
• Wrong COD sequence with intermediate causes of death mixed
up

36. BE AWARE OF COMMON ERRORS
• Recording the mode of death instead of the immediate cause of death
• Recording Contributory cause of death as the Underlying cause of
death
• Mistakes in entering the name, age, sex, date and time of death and
socio-demographic information on the form
• Use of abbreviations
• Unclear handwriting
• Multiple cause of death entries on one line in the cause of death
sequence

37. IMPORTANCE OF DEATH
CERTIFICATE
Mortality statistics and
surveillance of specific
disease
An indicator for a serious outbreak.
Legal record of fact of
death

38. LEGAL AND PROTECTIVE
USES
• For claiming family allowance
• Hospital reimbursement
• Life insurance claims
• Obtaining a probate or succession certificate
• Settling inheritance/property claims
• Releasing provident fund claims
• Deleting the deceased name from the Government and official documents.
• For public safety, accident prevention and eradication programs.

39. DUTY OF THE DOCTOR
• Who attended the person in last 7 days.
• Fill the prescribed format form 4.
• should not sign medical certificate of cause of death in advance
• No refusal / no delay.
• No fee.
• Forward to the registering authority.
• The death report (Form 2) and MCCD (Form 4/4A) should reach the registrar with in
14 days of occurrence of death.
• Symptomatology or modes of death should not be recorded as cause of death
without mentioning the underlying pathological cause

40. WHEN NOT TO ISSUE
1. The injured is brought dead
2. A crime has already been registering by the police.
3. The police has already been informed about the case.
4. The cause of death is unknown.
5. When the brought dead is not examined or seen by doctor within
14 days.

41. Thank you