The scene

A GP member called the MDU advice line to discuss a patient's recent death.

The patient was a 75-year old woman who lived alone and still ran her small farm single-handedly, although she had a number of significant chronic health problems including ischaemic heart disease and osteoarthritis. The member had recently seen her at the practice for a consultation about a cough she'd had for a week, which was now productive of green sputum.

The patient was no more breathless than usual and had walked to the surgery. Her temperature was 38.1 with an O2 saturation of 93%, other vital signs were normal. A negative COVID-19 PCR test was on her records from a few days earlier, and her chest was clear.

The GP knew the patient to be a stoical character who rarely attended and so, despite the reassuring examination findings, he prescribed antibiotics. He gave safety netting advice to call back if she got worse or was not improving over the next few days.

Sadly, the patient was found dead in bed three days later at home by her son, who visited when she did not answer his phone calls.

Our member was concerned because this was an unexpected death, and he was not sure of the cause. He felt it most was likely to have been due to a chest infection, but other diagnoses such as myocardial infarction or pulmonary embolism were also possible.

Given his uncertainty, our member had quite rightly discussed the case with the coroner, who was satisfied that this was a natural death and did not wish to investigate it. The coroner had advised the GP to issue a medical certificate of cause of death (MCCD) stating pneumonia in 1a.

Our advice

Our member sought the MDU's advice as he was disappointed that further clarification would not be possible because the coroner wasn't going to order a post-mortem.

The MDU adviser explained that when a patient dies, it is the statutory duty of the doctor attending them in their last illness to issue the MCCD. During the COVID pandemic, the requirements were relaxed to mitigate some of the pressures on medical staff - but as the attending doctor, our member would still be expected to provide the MCCD if practicable.

The coroner can only legally certify a death if they have investigated it by autopsy, inquest or both. The Coroners and Justice Act 2009 did away with the previous requirement for the coroner to investigate 'sudden' deaths, and doctors are required to certify causes of death "to the best of their knowledge and belief", using their clinical judgement.

The outcome

The adviser was able to reassure the member that the government guidance on completing the MCCD states that doctors "are not expected to be infallible". In this case the member had correctly discussed the case with the coroner, who had agreed an MCCD could be issued.

The member was of the view that, although other processes could not be totally excluded, pneumonia was the most likely cause of death here. After discussing the case with the MDU adviser, he was satisfied he could complete the MCCD to the best of his ability, along the lines he had agreed with the coroner.

This dilemma is fictional but based on members' experiences and the types of calls we receive to our advice line.

Cause of death

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