- 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 do not have a statutory duty to establish the fact of death, but do need to certify the medical cause of death.
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 in their last illness should certify the death. This is not legally defined, but is generally taken to be a doctor who cared for the patient during the last 14 days of their life.
When completing a MCCD, you should:
- complete the death certificate promptly
- write legibly
- be honest and trustworthy
- check that what you are submitting is factually correct and doesn't omit relevant information
- be aware of when to report a death to the coroner (see below) or procurator fiscal (in Scotland). If in doubt, you can ask advice of the coroner/procurator fiscal or the MDU.
- be aware of your ethical obligations. The GMC's guidance End of life care (2010) says that if there is any information on the death certificate those close to the patient may not know about or understand, or find distressing, you should explain it to them sensitively and answer their questions, taking account of the patient's wishes if they are known.
Cause of death
You should start with the direct immediate cause of death in section 1a, and 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 which caused all the conditions in the lines above. That is, the conditions mentioned in sections 1b and 1c 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.
- Avoid putting 'old age' or 'natural causes' as the only cause of death.
- Similarly, terms such as 'organ failure' or 'cardiac arrest' are too non-specific.
- Avoid using abbreviations, which might mean different things to different people.
Reporting to the coroner
The registrar, a doctor or the police can report deaths to the coroner in certain circumstances, such as where:
- no doctor attended the deceased during their last illness
- although a doctor attended during the last illness, the deceased was not seen either within 14 days before death nor after death
- 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.
Death certification in Scotland
New format MCCDs were introduced in Scotland in 2015, eliminating the need for doctors to complete separate cremation forms.
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, in order to identify problems and make improvements to the death certification system if necessary.
More information is available on the Healthcare Improvement Scotland website.
Where a patient has died in England, Wales or Northern Ireland and is to be cremated, separate forms need to be completed.
The death certification system is currently under review, with changes expected to be in place in 2018. For now, however, the current system requiring a doctor’s signature on two separate cremation forms is still in place.
Who can sign cremation forms?
There are strict requirements concerning a doctor's eligibility to sign cremation forms, set out in the guidance The Cremation (England and Wales) Regulations 2008 – guidance to medical practitioners.
The requirements for the doctor signing form Cremation 4 include:
- You must be registered (provisional or temporary is acceptable) with a licence to practise from the GMC.
- You should also have treated the deceased during their last illness and have seen the deceased within 14 days of death.
- You should have cared for the patient before death or be present at the death. If that GP is unavailable, the coroner may agree to authorise a partner to sign the form.
- You must also have examined the body after death.
The requirements for the doctor filling in form Cremation 5 include:
- You are responsible for checking form Cremation 4 and querying any inconsistencies.
- You must be fully registered for at least five years with a licence to practise.
- You must be fully independent of the doctor signing Cremation 4, and not involved in the care of the deceased, or be a relative of the deceased. You cannot be a partner of the GP signing form Cremation 4 or work in the same surgery, even as a locum.
- You are expected to speak to the doctor who signed form 4, except in exceptional circumstances (for example, if that doctor is seriously ill).
Similar requirements exist in relation to signing the cremation forms B and C in Northern Ireland, set out in the Statutory Rules and Orders (NI) 1961, No.61 Cremation, Northern Ireland.
- Be honest when signing forms, and do not provide misleading information. You must take reasonable steps to check the information is correct, and not deliberately omit relevant details.
- Include the identity and contact details of people questioned about the cremation.
- The applicant for cremation, usually a relative, has the right to inspect the forms. If you believe that the deceased provided information to you in confidence, and would not wish it to be disclosed to the relatives, you can provide this information to the medical referee on a separate sheet of paper, explaining the reason for doing so.
- Medical referees review the forms, and can only authorise a cremation if they have been completed in accordance with the regulations. Inaccurate completion of the forms could result in a criminal conviction or, more commonly, a GMC investigation.
This page was correct at publication on 14/08/2018. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.