Completing a death certificate is a station in many-a final year OSCE, and more importantly is something that will need to be done in day-to-day life as a junior doctor. Knowing what to write where will speed this process up – great for the family and for you!
This guide will go through:
- What to do when a patient has died and you are asked to do the death certificate
- Some helpful tips and pointers
- A copy of a blank Medical Certificate of Cause of Death form for you to print off and practice with
- A few worked examples
What to do when a patient has died
- Assess patient and confirm death, clearly documenting in the notes (see our guide here)
- Discuss the death with the consultant in charge of the patient’s care (or a senior registrar) – this will help to clarify the cause to be written on the certificate.
- Liaise with bereavement office to organise an appropriate time to attend with the patient’s medical notes to complete the death certificate and any other paperwork.
- Complete Medical Certificate of Cause of Death form.
- Perform a full external examination of the patient’s body in the mortuary (ensure no implantable devices present, check for bruising/pressure sores/any suspicious findings).
The Death Certificate
Completing the death certificate
Personal details of the deceased
- Age – you should record the age of the deceased in completed years or, if under one year, in completed months
- Place of death – you should record to the best of your knowledge the precise place of death (e.g. the name of the hospital, or a private address)
Circumstances of certification
- Last seen alive by me – record the date you last saw the deceased alive
- Information from post-mortem – indicate if the cause of death takes into account information gained from a post-mortem or not
- Seen after death – indicate who saw the deceased after death
Part I – Cause of death
- Consider the main causal sequence of conditions that lead to death.
- The disease or condition that led directly to death should be documented on the 1a line.
- You should then work your way back through the other diseases that led to the eventual cause of death until you reach the underlying cause of death which initiated this chain of events. The lowest completed line in part 1 should therefore contain the underlying cause of death.
- Some deaths may have only one condition that lead directly to death, such as a sub-arachnoid haemorrhage. In these cases it’s acceptable to complete only line 1a.
- When stating the cause of death, be as specific as you are able to given the information you have. An example might be stating “Adenocarcinoma of the right main bronchus” rather than “Lung cancer”.
- In some circumstances there can be 2 separate conditions that led directly to death and in these cases you should enter them both on the same line and then in brackets state that these are joint causes of death.
A few things that you CAN NOT write as a 1a:
- “Failures” as a sole 1a – heart / kidney / liver / respiratory (Congestive Cardiac Failure is ok)
- Cardiac arrest
- Old Age/frailty as a sole cause of death (and this can only be used in those over 75)
Part II – Conditions that may have contributed to the death
- Part II allows you to document other conditions that were not part of the main causal sequence of death, but likely played a role in hastening the death.
- An example might be ischaemic heart disease in a patient who died of pneumonia.
- It is NOT somewhere where you should list the patient’s entire past medical history.
Other details at the bottom of the certificate
- You should sign the death certificate and print your name in block capital letters beside it.
- You should document your GMC number beside or under your name too
- You should write down your GMC approved qualifications (often something like MBBS Medicine & Surgery)
- Most commonly the residence is filled in as the hospital’s address (not your own personal address).
- If the patient died in hospital, document the consultant’s name on the little line at the bottom of the certificate (easily missed).
- There is a counterfoil on the left hand side which gets left in the death certificate book
- You need to document the patient’s name, the cause of death (Part 1) and conditions potentially contributing to death (Part 2).
- You also need to document your personal details again.
- _____ day of ______ refers to the “Fifth” day of “April 2015” (sounds simple, but I know someone who wrote “Tuesday” in an OSCE…).
- Numbers should be written out in words
- 1a should be the disease, illness or complication which led to death and not a mode of dying.
- Circle the 1/2/3 & a/b/c with regards to post-mortem.
The back of the death certificate
There are two boxes on the back of the death certificate that you may need to complete in certain circumstances:
- Box A – If you have referred a death to the coroner put your initial here. It should be noted however that if you have simply discussed the case with the coroner and they have said no referral is required then you DO NOT need to complete this box.
- Box B – If you may be in a position to provide more information about the cause of death in the future then you need to initial this box. This is the case when there are pending investigations not yet back or performed (e.g. histology, microbiology culture results, genetic analysis, post-mortem information). A request for this information will be sent to the consultant responsible for the patient.
Reasons to refer to the Coroner…
- Unknown cause of death
- Sudden or unexpected death (inclusive of all deaths <24hours after admission to hospital)
- Deceased person not seen by a doctor within 14 days before death
- The death is considered suspicious/unnatural/violent
- The death may be due to an accident, self-neglect or neglect on the behalf of others
- The death is/could be due to the deceased’s prior employment (including industrial disease)
- The death may be due to an abortion
- The death occurred during an operation or before recovery from anaesthetic
- The death occurred during or shortly after a period of police custody
- The death may be suicide
These are (helpfully!) written on the back of the MCCD form.
How to refer to the Coroner
Coroners are often lawyers (and occasionally doctors, or dual-qualified). Talk to the Bereavement Team within the hospital with regards to getting in touch with the Coroner’s Office local to you.
Following on from this are some cases to work through with questions. You may want to print out a copy of the blank death certificate to fill out and treat it as a mock OSCE. Hidden in the tabs are the suggested answers.
Mrs June Morbid was an 87 year old lady, whom you last attended to yesterday, on the ward round with the consultant (Dr Spot). She had suffered with advanced Parkinson’s disease and had been admitted 4 days previously with an aspiration pneumonia. This did not respond to antibiotic treatment, and the decision to palliate was made by the consultant after discussion with the family. Mrs Morbid peacefully passed away last night with her family around her, and her death was verified by your colleague on the night shift. You have been asked to fill in the death certificate after your ward round.
Mr Clive Matchstick (86 years old) was admitted to the ward a week ago from a local nursing home having vomited. Whilst in hospital he developed urinary incontinence and sepsis. He was treated for urosepsis, but unfortunately passed away. You confirmed his death this morning and had reviewed him last night before going home with his consultant Dr Johnson . He has a past history of: ischaemic heart disease, type 2 diabetes mellitus, Charcot’s deformity on the left foot and an amputation of the big toe on the right.
Mr Samuel Clock (75 years old) had been an in-patient on the ward you are working on for 2 weeks. He was being treated for a community-acquired pneumonia which was a CURB-65 score of 4. His condition had progressively worsened when you reviewed him with his consultant Dr Tyvand last night and the decision was made to switch to a palliative approach of management. He passed away this morning, with his wife by his side. You confirmed his death on the ward. He has a past medical history of ischemic heart disease, hypertension, mesothelioma, type 2 diabetes and benign prostate hypertrophy.
This is a trick question (cheeky, I know)…
This is a situation where the medical practitioner should have a conversation with the Coroner prior to issuing any certificate of cause of death as a post-mortem will most likely be required. Mesothelioma is a is almost always attributed to asbestos exposure and therefore falls into category of disease related to occupation which may have contributed to the death. The damage most often occurs 20 – 60 years after asbestos exposure. It would be very unlikely that you would issue a certificate, but if the Coroner instructed that you could do so, it might look a bit like this.
- Southampton University Hospitals NHS Trust – Medical Certificate of Cause of Death – Notes for doctors – LINK