In England and Wales, the Coronavirus Act 2020 makes changes to the requirements for death certification to recognise that the doctor who saw the patient during their last illness may be unable to sign the certificate or it might be impractical for them to do so - for example, if they are self isolating.
Who can sign a death certificate?
If practicable, the practitioner who attended the deceased during their last illness should complete the medical certificate of cause of death (MCCD), as was the case previously.
The updated guidance for doctors on completing medical certificates of cause of death in England and Wales states: "There is no clear legal definition of attended", but it is generally accepted to mean a doctor who has cared for the patient during the illness that led to death and so is familiar with the patient's medical history, investigations and treatment. For the purposes of the emergency period, the attendance may be in person, via video/visual consultation, but not audio (e.g. via telephone). The certifying doctor should also have access to relevant medical records and the results of investigations.
The guidance goes on to state that where the certifying doctor has not seen the deceased before death, they should delete the words 'last seen by me'. If the patient was seen by another medical practitioner within the last 28 days, but not the certifying doctor, that doctor's name should be included on the MCCD.
The Ministry of Justice has updated its detailed guidance for doctors on how to complete cremation forms to take into account changes introduced by the Coronavirus Act.
What if I didn't see the patient before death?
The Act also allows an MCCD to be completed if a patient was not seen by any medical practitioner during their last illness. If that happens, a doctor would need to state to the best of their knowledge and belief the cause of death. Guidance from NHS England and NHS Improvement states that a doctor intending to complete the MCCD should obtain agreement from the coroner that they can do so. It remains the case that if there is no doctor at all who can give a cause of death then the death will still need to be referred to the coroner in the usual way.
COVID-19 is now an acceptable 'direct' or 'underlying' cause of death for the purposes of the MCCD and although COVID-19 is a notifiable disease, this does not mean that deaths from COVID must be reported to the coroner.
Registrars will now accept scanned or photographed copies of the MCCD forwarded from a secure email account (such as nhs.net). An original, signed MCCD should be securely retained for delivery to the registrar as soon as circumstances allow.
What does it mean for relatives trying to register a death?
MCCDs completed under the new arrangements will be accepted by the Registrar of births deaths and marriages. It means the death can be registered without automatically having to refer the death to the coroner (as was the case previously) provided the deceased has been seen by a doctor within the last 28 days. Even where the deceased has not been seen within the last 28 days, if the coroner agrees that a doctor can complete an MCCD then the relatives should be able to register the death.
What impact does this have on cremation forms?
The Act removes the need for a confirmatory medical certificate (form 5) for cremations. The existing form 4 (medical certificate) is still required and this should be completed as you would in normal circumstances.
If the doctor who attended the patient (either by remote video consultation or in person) within the last 28 days is unable to complete the form or it is impractical for them to do so, then any medical practitioner is able to complete a form 4. However they can only do so when the MCCD was completed on the basis that the deceased was attended within 28 days of the death or where a medical practitioner has viewed the body after death, even if only for the purpose of verification.
Examination of the body after death is not required if the deceased was either seen after death by a medical practitioner or attended (in person or by video consultation) within the last 28 days.
When completing form 4, if you did not attend the patient during their last illness, you can answer question 5 with 'certifying doctor' as an acceptable 'medical role'. Answer question 9 with the name, GMC number and role of the medical practitioner who attended the deceased.
It is acceptable to answer question 8 (which asks the date and time that you saw the body of the deceased and the examination that you made of the body) with 'not applicable' if another medical practitioner attended the patient within 28 days before death or saw the body of the deceased, even if only to verify the death. The date and time and nature of that examination should be set out in the answer to question 9 (which asks you to explain from the medical notes, your own observations and that of others how you came to make conclusions about the cause of death).
Changes introduced in 2008 already allowed cremation forms to be sent to the crematorium's registrar by email, and in the current circumstances it makes sense to do so.
Can a death be verified remotely?
During the COVID-19 period of emergency guidance from the Department of Health and Social Care states that in community settings verification of death can be performed by 'professionals trained to do so in line with their employers’ policies (for example medical practitioners, registered nurses or paramedics) or by others with remote clinical support. In the hospital setting there is no change to current practice, which is that death is verified by a medical practitioner or registered nurse.
Where remote verification of a death is necessary the guidance explains that the person physically attending the body of the deceased need not be a medical professional but that they should 'usually and normally' be independent of family members. However, if the non-medical person verifying the death is not content to verify death the guidance makes clear they 'should not experience any pressure to verify deaths' and should instead defer to clinically-trained professionals or NHS 111.
In the community setting the remote verification clinical support is provided by the deceased's NHS GP practice during core practice hours and out-of-hours support will be provided by a clinician after contacting NHS 111. The guidance sets out in detail the practicalities of providing remote clinical support for the purposes of verification.
Although you will know what is required to verify a death in person, the remote verification process is both detailed and structured and therefore you may wish to spend some time to read the guidance to familiarise yourself with it. There is also a procedure to be followed to confirm the identity of the deceased and the guidance recommends that an appropriate identity document (such as photo ID) is provided to you either during the video call or by secure email. Finally, bear in mind that the guidance does not affect what needs to be done if the death is unnatural. If it is suspicious you should report it to the police and if unexpected (but not suspicious) to the coroner.
The Registration of Births, Deaths and Marriages (Scotland) Act 1965 allows another medical practitioner to provide an MCCD in circumstances where no registered medical practitioner who attended the deceased during their last illness is available, or if the attending practitioner is unable to provide a certificate.
As is currently the case, an application for cremation can be made once the death has been registered using the MCCD. Concern that the process for review of some MCCDs might lead to delays in cremations and burials have led to Scottish ministers exercising their powers under the Coronavirus Act 2020 to suspend the current processes for review of MCCDs. This will also have the effect of pausing current reviews unless the reviewer considers that it may be appropriate to refer the death to the procurator fiscal.
In Scotland, guidance has clarified that for the purposes of completing an MCCD (form 11) related to COVID-19:
- the terms COVID-19 disease and SARS-CoV-2 infection are acceptable
- if the disease is suspected but not confirmed, you may write: 'Presumed COVID-19 disease' on the MCCD
- in both cases, the hazards box on the form must be ticked and the public health department informed.
Unlike the case with other notifiable diseases, deaths secondary to COVID 19 or SARS-CoV-2 infection do not need to be reported to the procurator fiscal. This suspension of the normal reporting requirement came into effect on 24 March and will be reviewed in July 2020.
Deaths from COVID-19 only need to be reported to the procurator fiscal if there is another reason for reporting the death based on their guidelines. Deaths due to other notifiable diseases must still be reported to the procurator fiscal in the usual way, as must deaths from COVID-19 where there are other factors which would normally mean that the death would be reportable to the procurator fiscal.
The Coronovirus Act 2020 changes death certification in Northern Ireland, enabling death certificates to be signed in cases where a patient has died of a natural illness and the doctor who cared for the patient in the last illness is not available (for example because the doctor is self-isolating).
A doctor who has not seen the patient can sign the certificate relying on their knowledge and belief of the cause of death.
A death certificate can also be signed for a person who has died of a natural illness but was not seen in the 28 days before death. The doctor can sign the death certificate, if they are able to state the cause of death to the best of their knowledge and belief - for example, after review of the medical records.
In both cases, the usual certificate can be used and will be interpreted as if the lines beginning, "Date on which was last seen alive and treated by me…" and the wording relating to the patient having been seen in the last 28 days were omitted.
If you are signing a death certificate, we recommend you review all the information available and keep a note about your reasoning for stating a particular cause of death.
The doctor who signs the death certificate must send a copy to the registrar electronically and is not required to give a copy to the family (but can still do so if they wish).
This guidance was correct at publication 11/05/2020. It 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.