- 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 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 their last illness. There are separate provisions in Scotland allowing another practitioner to issue a certificate (more below).
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 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 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 that 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.
Deaths in England and Wales
Who can complete the MCCD?
In England and Wales, the attending doctor is someone who saw the patient either in a face-to-face or a video consultation in the last 28 days of their death or viewed the body in person after their death.
You can find guidance on completing MCCDs in England and Wales here.
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 28 days before death nor after death. It may be possible for a doctor to complete an MCCD, but the death should be notified to the coroner ideally before the death is registered
- 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
New format MCCDs were introduced in Scotland 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 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 provisions allowing a cremation to proceed on the basis of a single medical certificate (ie, without the confirmatory medical certificate 'form C') have been extended until 24 September 2022.
The Department of Health in Northern Ireland has also published guidance on notifying deaths to the coroner.
Where a patient has died in England, Wales or Northern Ireland and is to be cremated, separate forms need to be completed.
Who can sign cremation forms?
There are strict requirements concerning a doctor's eligibility to sign cremation medical certificate (known as form 4 in England).
Guidance on how to complete a form 4 in England and Wales was updated and published in 2022. In summary, the cremation form should be completed by a doctor who looked after the patient during their last illness. That doctor should have attended the patient either through a video consultation or face-to-face within the last 28 days, or seen the body after death.
It may also be possible in some circumstances for a GP partner who attended the patient more than 28 days before the death to complete a form 4 after discussion with the coroner.
The previously used 'confirmatory medical certificate (form 5)' was suspended during the pandemic through the Coronavirus Act 2020 provisions and the government's stated intention is that this will not be reintroduced after the pandemic.
- 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.
- 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 26/04/2022. 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.