The skull beneath the skin

Much of the responsibility for dealing with dead patients falls on new doctors. Jonathan Haslam details the top tips to keep you safe

Any death is distressing. Ensuring that the formalities that follow a patient’s death are dealt with professionally is the last service you will provide for your patient, and an important support for relatives dealing with their loss. There are a number of forms and duties to perform, and it is important that these are completed correctly. A failure to do so can lead to a delay in funeral arrangements, causing embarrassment and inconvenience. It can also cause professional problems for you.

One of the consequences of the murders committed by Harold Shipman was a thorough inquiry into what happens after a patient dies. There was much criticism of the way that doctors were completing death and cremation certificates. In some hospitals, a relaxed culture had developed in the way these forms were completed. New doctors who had gone along with this approach found themselves caught in the crossfire, and some were investigated and punished by the GMC.

A new Coroners Act is in the offing, but until then here are the key points that you need to be aware of.

Medical Certificate of the Cause of Death (MCD)

Usually completed by the attending doctor, but some nurses are nowadays allowed to complete them too. If you are completing the MCCD you must be a qualified and registered doctor and you must have treated the deceased within the last 14 days. There is no obligation for you to have seen the body, but it is good practice to do so. The most important aspect is completing the cause of death. There are two parts to this: Part 1 is the actual cause of death, and Part 2 is any contributing factor. Failure to complete Part 1 correctly is a common cause of delay in the funeral arrangements. The cause must be a proper cause, not a mode of dying. So heart failure or liver failure are not acceptable on their own as an underlying pathological process must always be included. Complete proximate or immediate causes first under 1a, followed by underlying causes in parts 1b and 1c. There must be a logical sequence to the certification. In part 2, list only other significant conditions contributing to the death but not related to the disease or condition causing it.

Reporting a death to the coroner

Deaths are reported to the coroner for a number of reasons:

  • Unknown cause.
  • Violent, suspicious or unnatural (including accidents, suicides, neglect, related to industrial disease or employment), in custody.
  • Deaths after an abortion.
  • Deaths during an operation or before recovery from anaesthetic.
  • If there was no attending doctor during the final illness, or the attending doctor had not seen the patient within the last 14 days.

There will normally be local protocols in place for reporting deaths to the coroner. Find out what these are. In particular, local coroners will have their own list of deaths that they regard as unnatural. It is a good idea to have the phone number for the local coroner’s officer(s) in your mobile or on quick dial if you need to ask them for clarification. A call sooner rather than later can avoid embarrassment.

Cremation certificate

Because of the Shipman Inquiry it is now even more crucial that these are completed correctly. There are a number of forms to complete. The most likely to affect you are:

  • Form B – Completed by the attending doctor who has seen the body after death. A fee is payable for completing this form and there is no obligation on you to complete it.
  • Form C – Completed by doctor who has been registered for at least five years. This doctor must not have been involved in the care of the patient, related to the patient, or in partnership or related to the doctor who completed Form B. The doctor completing Form C should see the body and discuss the death with the doctor who completed Form B. Again there is a fee for completing this form, and no professional obligation to do so.

In the past, some doctors cut corners, particularly with Form C, eg, by not discussing the death with the doctor who had completed Form B. Employers and the GMC now take a dim view of such behaviour, so if you agree to complete these forms, it is important to complete them correctly. Recent guidance from the Crown Prosecution Service has also indicated that they will no longer leave the matter to the GMC, but will regard it as a criminal offence.

Blown away

Remember to record whether or not the patient was fitted with any medical devices. There have been cases of pacemakers exploding in crematoria. Apart from the emotional distress this causes, they can explode with enough force to damage the ovens, prompting a claim for the costs of the repair.

Feeling vulnerable?

If you are concerned about a death, either because of your own actions or the actions of others, and are worried about writing a report or appearing in court, then do not hesitate to contact MPS for advice.

Further reading

  • Palmer R, Signing Off, Casebook 14(2);8 (2006)
  • Salmon R, Filling in Cremation Forms, Casebook 15(1);14 (2007).

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