The scene

During an on-call shift, an FY1 doctor was called by a nurse from an acute medical ward. An elderly patient had died, and the nurse asked if the FY1 could come and verify the death.

The following day she was contacted by the bereavement office, who asked her to come down and complete a death certificate for the patient. She was unsure if she was able to complete this, and was anxious about getting it right. She called the MDU for advice.

MDU advice

The FY1 explained to the adviser that she had been able to watch doctors verifying deaths when she was on her final medical school placement and felt confident to do so herself. However, she hadn't seen a death certificate being completed before.

The MDU adviser explained that the FY1 was right to make sure she fully understood her responsibilities when it came to completing the medical certificate of cause of death (the MCCD - commonly referred to as the death certificate), as she was likely to spend a lot of time on the wards or on call in her first years as a doctor and could often be the person asked to verify and certify a patient's death.

The adviser explained that because it is a statutory document, there were legal penalties for falsely completing the MCCD. It was therefore important to make sure it was completed fully and accurately, in line with the FY1's GMC obligations to be honest and trustworthy, and to ensure that the information provided was accurate and not misleading by way of omitting relevant information.

"Can I sign the MCCD?"

The FY1 said she was aware there might have been changes to the process since she qualified. The advisor explained that in September 2024, a statutory medical examiner system was introduced in England and Wales, which means all deaths must be either reviewed by a medical examiner or through a coroner's inquiry. The medical examiner is a senior doctor who provides independent scrutiny of deaths that don't require referral to the coroner.

The adviser explained the changes also increased the number of doctors eligible to sign the MCCD by removing the previous requirements for the person completing the certificate to have attended the patient in their last illness, and to have seen the patient in the 28 days prior to the death or after death.

Now, any doctor who attended the patient during their lifetime can complete the MCCD. However, they would still need to feel able to establish the cause of death to the best of their knowledge and belief to be able to do so, and should only complete the form if the death does not need to be reported to the coroner.

The FY1 explained that she had been part of the team that looked after the patient and understood that they had been admitted with a pneumonia on a background of lung cancer and had a history of COPD.

However, she was anxious to make sure she was not missing anything. The adviser suggested the FY1 review the patient's records to make sure she was familiar with their medical history and the events leading up to their death, and then discussing the request she had received to complete the certificate with the consultant in charge of the patient's care, to confirm their view of the cause of death.

The medical examiner

The adviser explained that in cases where there was no requirement to notify the coroner of the death, the MCCD would need to be discussed with the medical examiner once completed. The medical examiner would then scrutinise the death and work with the attending doctor to agree the cause of death. Once agreed, it would be the medical examiner who would submit the MCCD to the registrar.

The medical examiner will also speak to the patient's bereaved family, and give them a chance to ask any questions they might have about their loved one's passing. However, doctors caring for the patient should still take steps to check if the family have any concerns or would like to speak to one of the treating doctors.

The MDU adviser acknowledged that while the FY1 may have witnessed death as a medical student, it can still be distressing. They asked the FY1 if there was anyone she felt able to speak to about this. The FY1 explained that the consultant in charge of the patient's care was also their clinical supervisor, and so she would be able to speak to them at the same time as discussing the cause of death.

The FY1 spoke to her clinical supervisor, who was supportive and acknowledged that this could be a stressful situation. He suggested that, as she hadn't completed an MCCD before, they could go to the bereavement office together and he would complete the form, while showing the FY1 what was involved and how to make sure the form was completed properly and accurately.

Completing the MCCD

The consultant explained that the MCCD for non-neonatal deaths is set out in two parts: part 1 where the sequence of events which led to the death are set out, and part 2 where you should record any other conditions or events that contributed to the death but were not part of the direct sequence.

The consultant explained that because the bronchopneumonia was the immediate and direct cause of death, this should be recorded 1a and should include the organism that caused it. He explained that they should then work back through the sequence of events that led to the death, until they reached the condition that started the sequence.

In this case, he recorded 1b as adenocarcinoma of the right lung and then 1c as cigarette smoking. In part 2, he recorded chronic obstructive pulmonary disease, ischaemic heart disease and type 2 diabetes. He explained to the FY1 that abbreviations shouldn't be used on MCCDs, so to always write out the conditions in full.

He also showed the FY1 where the presence of any medical devices or implants should be recorded on the MCCD. He explained this information would then be transferred to the certificate for burial or cremation, which is completed by the registrar.

The outcome

The FY1 felt more confident about their obligations when completing MCCDs and interacting with the medical examiner. A few weeks later, when another patient passed away on the ward, she completed her first MCCD after discussing it with the consultant.

The medical examiner spoke to the family, who had no concerns about their relative's death and even said that the FY1 had been very supportive and sympathetic.

I’ve been asked to certify a death – and I don’t know what to do

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