1. When a Patient Dies
Dr John Potter

2. When a Patient Dies Confirming death Talking to relatives
Reporting to the coroner
Death Certification
Cremation Forms
These are the 5 tasks that are described in this document.
You will inevitably encounter death if you are working in acute specialties in hospital. It is vital that you understand your role and that you are clear about your role and that you manage the deceased, the relatives and staff caring for the deceased professionally and in line with UK law.
You must understand the difference between Confirming death and certifying death. You must understand when you can Certify Death and when you cannot.
You must be clear when you must inform and discuss a death with the Coroner.
You must be able to complete Death Certificates and Cremation forms accurately and efficiently.
For relatives and loved ones death is often nearly impossible to bear, remarkably though people are able to rise to the occasion and deal efficiently with it. It is vitally important that you do not add to the burden by introducing unnecessary delays or by creating problems by inaccurate or erroneously completed certificates and forms.

3. Confirming Death No respiratory effort at least one minute
No Cardiac output
pulse
heart sounds
Fixed and dilated pupils - unreliable
Confirmation of death is on the face of it simple and in the main there should be no problems with the act of confirming death.
Remember that very occasionally errors occur with this simple process, do not hurry the examination.
Confirm the identification of the patient.
English law:
does not require a doctor to confirm death has occurred or that “life is extinct”; Though hospitals will usually ask the first on call doctor to confirm death.
does not require a doctor to view the body of a deceased person;
does not require a doctor to report the fact that death has occurred;
does require the doctor who attended the deceased during the last illness to issue a certificate detailing the cause of death.
So we are starting to develop a difference between Death Confirmation and Death Certification.
Confirmation of death can be by any person in a position to make the judgement of life extinct, you will however usually be asked to make that judgement whilst working in hospital. You can confirm death on any patient and do not need to have see and or cared for them before death.
In confirming death you are making the diagnosis of life extinct.

4. After Confirming Death
Record confirmation of death in the medical notes
List examination undertaking
Time and date of death
Signature (legible) and bleep number
This is an obvious requirement of accurate and contemporaneous notes.
This may be your last involvement with the patient if your are NOT in a position to CERTIFY death. You must make that judgement early. If you are not in a position to certify then you must inform the ward team of that so that they can be sure to make arrangements for certification. If it becomes clear that no one is in a position to issue a death certificate then you may need to start a discussion with the coroner’s officer. This will be discussed later.

5. After Confirming Death (2)
If you think the death should be reported to the Coroner ALWAYS speak to a consultant or SpR first.
Record in the notes when a death has been reported to the coroner

6. Talking to Relatives Usually advisable to be accompanied by a nurse
Be considerate and sympathetic
Explain clearly – avoid technical terms
Check that you have been understood
If the death is being reported to the Coroner the implications need to be conveyed with tact
This is a vital part of your role as a doctor.
Relatives will be distressed but need to know what has happened and what will happen next. The nursing team will be able to help you with some of the question (for example; where to collect personal belongings and where to collect the death certificate and when that will be possible).

7. Talking to Relatives (2)
Registering the death, collection of personal belongings etc.
Done best by the nursing staff
Leaflets available
Any questions answer honestly
Ask if they would like anything else
A drink
To speak to a priest

8. The Coroner Appointed by county authorities
To find the medical cause of death if unknown
To enquire into unnatural deaths
Registered lawyers / doctors
Assisted by a team of officers who investigate on their behalf.
Often former police officers, NHS managers or former members of the legal profession.
In the first instance you will contact the Coroner’s office and speak to one of the Coroner’s officers. He or she will take details of the deceased and the circumstances and will usually talk to the coroner themselves and relay the outcome of that discussion back to you.
You must know the circumstances where it is necessary for you to discuss a death with the Coroner’s office. They are listed on the following slides.

9. The Coroner (2)
Once a death is reported to the Coroner, the Registrar of deaths is unable to register the death until the Coroner’s inquiry is completed.
12% of deaths result in an inquest
Telephone number available on ward or from mortuary

10. When to refer to the Coroner
Patient not seen by a doctor within 14 days prior to death
Cause of death unknown
Violent, unnatural or suspicious death
Accident
Poisoning
Drug dependence, misuse or overdose
Suicide
Self Neglect

11. When to refer to the Coroner (2)
Deaths within 24 hours of admission
During an operation or before recovery from the effect of anaesthetics
Following any medical procedure due to an abortion
Industrial disease / related to employment
In police custody
Detained under the mental health act

12. Issuing a medical certificate of cause of death
Legal duty
A doctor must have made a diagnosis prior to death and be satisfied that no other condition or event, that is not a natural disease, has contributed significantly to the death. The doctor has expected the death to occur roughly when it did and be satisfied that the mode and circumstances of the death are compatible with the diagnosis.
You must know when you are in a position to provide a certificate of cause of Death.
You must have seen the deceased alive and have been involved in their heath care which of course means that you knew what illnesses they had before death and you are in a position to certify the cause of death.
You do not need to see them after death to complete the death certificate and of course you do not therefore have to have been the person who confirmed death.

13. Death Certification Complete all the boxes
(remember the second side of the form)
Use capital letters
No abbreviations
No vague phrases
Be as accurate as possible
Sign the certificate AND print your name / GMC number next to your signature
The law requires a doctor to notify the cause of death of any patient whom he/she has attended during that patient’s last illness to the Registrar of Births and Deaths. The doctor is required to notify the
cause of death as a certificate, on a form prescribed, stating to the best of his/her knowledge and belief, the cause of death. It should be noted that the strict interpretation of the law is that the doctor shall notify the cause of death, not the fact.
It is your duty to issue the certificate if you have attended the patient. The Registrar of Births Deaths and marriages with record the death. It is the duty of the patients relative to take the deceased person’s death certificate and register the death with the Registrar. The death certificate will be presented to the relative in an envelope which will have specific details of how the relative or responsible person should contact the Registrar and arrange to register the death.
One of the duties of the Registrar is to ensure that the doctor who has issued the certificate has the appropriate registration with the GMC to issue the certificate, hence the requirement to add your GMC number and to print your name to facilitate identification.
The Coroners and Justice Act 2009 makes provision for an entirely new service of a Specialist Medical Examiner, to ensure deaths are correctly and urgently referred to a Coroner when necessary. They will also ensure that deaths are medically certified as accurately as possible. Information regarding this new service is available on the eLearning for health website. The proposals for full implementation of the Medical Examiner Role have not been completed yet.

14. Useful Links
There is further information and guidance on death certification in the pages in the beginning of the Death certificate Book.
It is obvious that you should ensure that your writing is completely legible and unambiguous. You should ensure that you record in the notes the fact that you have written the certificate and your complete cause of death. You should sign and date your entry in the notes as always.
The reverse of the certificate is for information if you have referred to the coroner. You will find a list of industrial illnesses which may be important You will also see a list of those who may act as informant to the registrar. (the person who takes your death certificate to report the death to the Registrar.

15. Terms to use with care Septicaemia
Organ failure e.g. CCF, Renal failure
Old Age
Cardiac arrest
Cerebrovascular accident
Carcinomatosis
There is much more detail in the document “guidance for doctors completing medical certificates of cause of death” which is included in this pack.
Take care to read the specific instruction and examples of cause of death.
Why do you think “organ failure” on its own is inappropriate on a death certificate.
How about “cardiac arrest”?
It is of course that these are consequences of disease and therefore do not describe cause of death they simple describe how the disease caused death and therefore if you use these statements you must include the disease process e.g.
1a Cardiac arrest
1b Myocardial infarction
1c Ischaemic Heart Disease

16. George Lewis – DOB
PMH: COPD – ex smoker IHD – MI 2003 CCF DM Admitted to AAU 13th September at 4:15pm 3 day history of increasing dyspnoea, cough productive of purulent sputum.
Look at these slides and follow the process to cause of death

17. O/E: Temp 37. 7⁰ C RR 24 Central cyanosis + (O₂ sat
O/E: Temp 37.7⁰ C RR 24 Central cyanosis + (O₂ sat.87%) BP 110/70 PR Irregular JVP↑ (difficult to assess) Oedema to mid calf Chest emphysematous basal crackles R>L

18. Investigations A Blood gases pH 7. 26 pO₂ 5. 4 pCO₂ 8. 7 Hb 16
Investigations A Blood gases pH 7.26 pO₂ 5.4 pCO₂ 8.7 Hb 16.7 WBC 16 CRP 87 Urea 10.6 Creatinine 154 ECG AF, LBBB CXR over inflated lung fields bulky right hilum patchy shadowing right lower zone

19. Admitted to HDU for NIPPV + nebulisers + steroids + i/v antibiotics Died 14th September at 2:20pm

20. Death certificate for G Lewis
1a Bronchopneumonia
1b Chronic obstructive pulmonary disease
II Ischaemic heart disease
Diabetes mellitus
(after discussion with Coroners office)
Why was Mr Lewis discussed with the Coroner’s office?
It is ultimately the responsibility of the consultant who is leading the heath care of the patient to ensure that the certification process is completed. You should always ask if you are not sure whether you can certify or are unsure about the process.

21. Cremation Forms 70% of deaths are followed by cremation
1 in 4 forms are completed incorrectly
Part 3 – completed by the doctor who writes the death certificate
If any doubt refer to the Coroner for advice – speak to a consultant or SpR first
A fee is paid for this certification
30% of deaths are therefore burials and require no further certification beyond the production of the certificate of cause of death.
If the deceased is to be cremated the remains will usually have been kept in the hospital mortuary until the required forms are completed. Usually the doctor who has completed the Death certificate will be asked to complete the first part of:
The medical certificate or “cremation form” as it is usually known.
A copy of the cremation form is available here:
And a form is included in the pack

22. Cremation Forms (2) Part 3
Completed by a second independent doctor, full registration for at least 5 years
Must discuss case with first doctor
Examine the body and agree with the cause of death

23. Summary Confirming death Talking to relatives – being considerate
Reporting to the Coroner
Certifying death and issuing a death certificate
Cremation forms (sensible, accurate completion)
This is a quick run through the administrative part of the process of death in the UK.
Take some time to reflect on what you have learned:
Who can confirm death?
When can and should you certify death?
When will you discuss with senior colleagues?
When will you contact the coroner’s office?
When can you complete a cremation form? Who should you ask to complete Part 3 of the form and what should you tell them?