Be legible, honest, accurate and prompt.
Avoid non-specific terms.
Know when to refer a death to the coroner/procurator fiscal.
Understand your responsibilities and requirements when signing cremation forms.

Certifying cause of death

When a patient dies, doctors have a duty to certify the cause of the death (where possible) to the best of their knowledge and belief.

Anyone, such as a family member, can declare a person dead and note the date and time of death. The doctor's responsibility is to certify the cause of death by issuing a medical certificate of cause of death (MCCD).

A doctor who attended the patient during their lifetime should certify the death. Depending where you are in the UK, this may not need to be a doctor who cared for the patient during their last illness (more below).

The MCCD

Follow these advice points when completing an MCCD.

Complete the death certificate promptly.
Write legibly.
Be aware of when to report a death to the coroner (see below) or procurator fiscal (in Scotland). If in doubt, you can discuss the death with the medical examiner, ask the coroner/procurator fiscal for advice, or contact us at the MDU.
It's important to complete certificates accurately and not omit relevant information even if it might cause upset to the family. However, the GMC's guidance on treatment of care towards the end of life says that if the death certificate includes information that those close to the patient may not know, understand, or find distressing, you should sensitively explain it to them, answer their questions, and consider the patient's wishes if known.
In England and Wales, the medical examiner will also speak to bereaved relatives as part of their role in scrutinising the death. This offers relatives an opportunity to raise any concerns.
The attending practitioner should record the presence of any medical devices and implants on the MCCD. This information will be transferred to the certificate of burial or cremation by the registrar.

Cause of death

Start with the disease or condition leading directly to death in section 1a, then go back through the sequence of events that led to the death, so that the last line of section 1 is the underlying root cause. Each condition listed in sections 1b, 1c and 1d should have directly caused all of the conditions listed in 1a.

Section 2 of the 'cause of death' section is for any other conditions contributing to the death, but not related to the disease that caused it - for example, a chronic condition.

Never use 'natural causes' as the only cause of death.
Similarly, terms such as 'organ failure' or 'cardiac arrest' are too non-specific to be used alone without specifying the underlying condition.
Never use abbreviations or symbols.

'Old age' should only be given as the sole cause of death in very limited circumstances. The expectation is that the deceased would be over 80 years old, you must have personally cared for them over a long period of time, and you should have observed a gradual decline in their health and function.

Additionally, you should not be aware of any identifiable disease or injury that contributed to the death, and you should be certain there is no reason to report the death to the coroner. In most situations, it is more appropriate to provide a specific cause of death.

Deaths in England and Wales

Who can complete the MCCD?

There are now different MCCDs for anyone dying after the first 28 days of life and for live born children dying within the first 28 days of their life.

All deaths not referred to the coroner are now reviewed through the statutory medical examiner system. So once the MCCD has been completed, the death should be discussed with a medical examiner, whose role is to scrutinise the death. The medical examiner will then submit the MCCD to the registrar, rather than the attending practitioner.

Read our journal dilemma on medical examiners seeking records.

From 9 September 2024 in England and Wales, the attending practitioner is someone who attended the deceased during their lifetime. Although 'attended' is not defined in law, this generally means a medical practitioner who cared for the patient and who is familiar with the patient’s medical history, investigations and treatment. They must have access to the relevant medical records.

It remains the case that the doctor completing the MCCD can only do so if they can establish the cause of death to the best of their knowledge and belief, and if the death does not need to be reported to the coroner.
Read more guidance on completing MCCDs in England and Wales.

Cremation form 4

Although the cremation form 4 is no longer required for deaths in England and Wales, a cremation medical certificate does need to be completed by a registered medical practitioner to allow release of the body if the death occurred in Scotland, Northern Ireland, the Channel Islands, or the Isle of Man, and if the cremation will take place in England or Wales.

Implantable devices

For deaths in England and Wales, the MCCD includes a section about implantable devices, requiring details on whether the deceased had one during their lifetime, specifics about the device, and whether it has been removed. This information can then be transferred to the burial or cremation certificate completed by the registrar.

The guidance for medical practitioners completing MCCDs provides more details about the types of devices that could pose risks during cremation.

Reporting to the coroner

A registrar, doctor, medical examiner or the police can report deaths to the coroner in certain circumstances, such as when:

no doctor attended the deceased during their lifetime or no attending practitioner is available. In such cases, the medical examiner will complete a 'medical examiner MCCD'. Initially, the medical practitioner should refer the death to the senior coroner. If the coroner decides the death does not need investigating, they should refer the case back to the medical examiner to certify the death by completing the medical examiner MCCD
the cause of death appears to be unknown
the death occurred during an operation or before recovery from the effects of an anaesthetic
the death occurred at work or was due to industrial disease or poisoning
the death was sudden or unexpected
the death was unnatural
the death was due to violence or neglect
the death was in other suspicious circumstances
the death occurred in prison, police custody or other state detention.

Deaths in Scotland

In Scotland, new format MCCD were introduced in 2015, eliminating the need for doctors to complete separate cremation forms.

The guidance for doctors completing death certificates in Scotland explains that it is the duty of the doctor who attended the patient during their last illness. As in England, it is not clear what is meant by 'attended', but it is interpreted as meaning the doctor who cared for the patient during their last illness or for the condition bringing about their death.

Where it's not possible for the doctor who attended the patient to complete the certificate or where no doctor was in attendance, another doctor in the team or with knowledge of the deceased and with access to the relevant records may complete the MCCD.

Previously, a burial could take place before the death was registered. All deaths must now be registered before a body is buried or cremated.

Death certificates in Scotland are also subject to a national review system. A sample of MCCDs (approximately 10%) are randomly selected for independent review by Healthcare Improvement Scotland to identify problems and make improvements to the death certification system if necessary.

More information is available on the Healthcare Improvement Scotland website.
Deaths reported to the procurators fiscal are not reviewed by the Death Certification Review Service (DCRS).

Deaths in Northern Ireland

A doctor who attended the patient in the last 28 days of their life can complete an MCCD in Northern Ireland. The Department of Health in Northern Ireland has issued guidance for issuing a handwritten MCCD and issuing an MCCD using the Northern Ireland Electronic Care Record (NIECR).

The Department of Health in Northern Ireland has also published guidance on notifying deaths to the coroner.

MDU advice

Take care to be accurate when completing forms and do not provide misleading information. You must take reasonable steps to check the information is correct, and not deliberately omit relevant information.
While the need for the medical practitioner signing the MCCD in England, Wales and Scotland to have seen the deceased within the last 28 days before death no longer exists, this requirement continues in Northern Ireland.
All deaths in England or Wales (other than those referred to the coroner) should be discussed with a medical examiner, whose role is to scrutinise the death.
If the death has occurred in England or Wales, record any medical devices or implants on the MCCD so this information can be passed on to the registrar before cremation.

Signing death certificates

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