Death Certificate

Question 1

(2) pathognomonics of death

Answer 1

• hypostasis → accumulation of fluid or blood in the lower parts of the body or organs under the influence of gravity, as occurs in cases of poor circulation or after death
• rigor mortis → stiffening/rigidity of the limbs of the corpse caused by chemical changes in the muscles postmortem

Question 2

In what case should the death be reported to the coroner?

Answer 2

• cause of death unknown
• unnatural causes of death
• unknown identity of the deceased
• no attending doctor to complete MCCD
• poisoning (even by normally benign substance e.g. salt) → both accidental or deliberate
• exposure to toxic substance
• use of medical product, controlled drug, psychoactive substance, herbal/legal highs
• death due to a person undergoing treatment or medical procedure
• violence, trauma inury (includes also self-inflicted)
• self-harm
• neglect and self-neglect
• occupational injury/disease
• death in custody or detention
• if attending doctor has not seen a patient for more than 14 days

Question 3

Within what timeframe a verification of death should be done in:

A. Hospital

B. Community

Answer 3

A. Hospital → 1 hour

B. Community → 4 hours

Question 4

When can nurses & paramedics verify death?

Answer 4

Nurses and paramedics can verify death if it is:

• expected
• no suspicious circumstances
• occurs in a private residence, hospice, residential home, nursing home or hospital
• DNACPR is in place
• does not require reporting to coroner

*but they can refuse to verify and a doctor/ police would need to do this

Question 5

(2) elements of death verification

Answer 5

• confirm cardiopulmonary arrest
• confirm brainstem death

Question 6

How long for do we observe the patient during death verification?

Answer 6

• minimum of 5 minutes
• spontaneous return of cardiac or respiratory activity during this period → further 5 minutes observation

Question 7

How to establish irreversible cardiorespiratory arrest during verification of death? (3)

Answer 7

Observe for 5 minutes:

• absence of a central pulse on palpation (minimum 1-2 minutes)
• absence of heart sounds on auscultation (minimum 1-2 minutes)
• absence of breath sounds on auscultation (minimum 1-2 minutes)

*maybe supplemented by other monitoring (e.g. ECG, echo, intra arterial pressure monitoring)

Question 8

Death verification

What to do after 5 minutes of cardiopulmonary arrest observation?

Answer 8

Confirm brainstem death

Question 9

How to confirm brainstem death? (3)

Answer 9

(after 5 minutes of irreversible cardiopulmonary arrest observation and confirmation)

• absence of pupillary responses to light
• absence of corneal reflexes
• absence of motor response to supra-orbital pressure

Question 10

When to record a time of death?

Answer 10

The time of death is recorded as the time when we verify death (when we confirm cardio-pulmonary arrest and brainstem death)

Question 11

Who verify expected deaths in the community?

Answer 11

• GP or district/nursing home nurses/paramedics
• GP to issue MCCD (must have seen patient within 14 days)

Question 12

Who verifies unexpected deaths in the community?

Answer 12

• GP to verify + report to coroner
• If police/ambulance service in attendance → Forensic Medical Examiner to examine and verify

Question 13

Elements of referral of the death to the coroner? (2)

Answer 13

• inform family of the referral and that coroner’s office will contact them
• inform coroner’s office in writing → online portal

Question 14

Possible outcomes of coroner referral (3)

Answer 14

• coroner’s office will ring referring doctor back to discuss the case and ask for further information (if needed)
• referral may lead to:
• post-mortem +/- inquest OR
• inquest without post-mortem OR
• no investigation required (=permission to issue MCCD)

Question 15

The role of Medical Examiner (ME)

Answer 15

ME will be introduced in autumn 2020

• all deaths not referred to coroner to be discussed with ME by a doctor before MCCD
• ME will then:
• agree what a doctor wants to put on MCCD
• suggest something different to put on MCCD
• suggest coroner referral

Question 16

What’s MCCD and what’s its role?

Answer 16

MCCD = Medical Certificate of Cause of Death

• notifies the Registrar of births and deaths of the cause of death
• it is given to patient’s next of kin, who take it to register the death (within 5 days) → the registrar will then issue a certificate for burial/cremation and certificate of registration of death

*if Registrar has any concerns they can discuss them with a coroner

Question 17

How to complete MCCD in the following example

Patient had diagnosis of:

• bowel Ca 2010
• liver metastasis 2012
• disease progression (leading to death) 2014

Answer 17

I a Metastatic carcinoma (to liver) 2012

b Ca Bowel 2010

c

OR

I a carcinomatosis 2014

b metastatic

c Ca bowel

*carcinomatosis = effects of cancer

Question 18

What’s cause 1 and cause 2 on MCCD?

Answer 18

Cause 1 → reverse order (immediate cause first, followed by underlying conditions) 1a 1b 1c

Cause 2 → Conditions unrelated to 1 but contributing to death (not all conditions but the ones that contributed to death)

Question 19

Can we put frailty or old age as the cause of death on MCCD?

Answer 19

No - we need to be specific

Question 20

Can we put organ failure alone as a cause of death on MCCD?

Answer 20

No - we need to be specific

e.g. 1a chronic renal failure

1b diabetic nephropathy

1c diabetes mellitus

Question 21

Who completes Cremation Form 4?

Answer 21

Doctor looking after the deceased at the time of death

Question 22

Who can complete Cremation From 5? (3)

Answer 22

Cremation Form 5 → corroborates the medical circumstances of death as stated by the doctor in Form 4

• doctor of no less than five years’ experience
• not a relative of deceased, or a partner of the doctor who have done Form 4
• should not complete Cremation Form 5 for the GP practices where the doctor regularly / recently worked

Question 23

Fill in the following MCCD

• Mr GS 64 y old with a history of poorly controlled HTN and cholesterol
• Diagnosed with angina in 2018
• Patient presented to Blackpool Victoria Hospital with chest pain and had ST elevation on ECG
• Patient went into cardiac arrest with an unsuccessful resuscitation

Answer 23

1a ST elevation myocardial infraction

1b Cardiovascular disease

1c Hyperlipidaemia and hypertension

OR

(instead of 1c)

II hyperlipidaemia and hypertension

Question 24

Fill in the following MCCD

• 93 y old patient with type 2 diabetes, HTN, osteoarthritis, polymyalgia rheumatica and cataracts
• frail and poor mobility
• patient became drowsy, confused and unwell and was admitted to the hospital → sepsis diagnosed → urine sample grew E.Coli
• failure to respond to medical treatment → deterioration and death

Answer 24

1a Sepsis

1b Urinary tract infection (E.coli)

1c ———–

2 type 2 diabetes

Question 25

Fill in MCCD for:

• 78 y old patient with extensive smoking history
• COPD diagnosed in 2014 and gradually worsening
• frail and poor mobility
• patient developed productive cough and fever
• patient deteriorated despite treatment and died

Answer 25

1a Lower respiratory tract infection OR Exacerbation of COPD

1b COPD

1c ——-

2 Tabacco misuse

Question 26

Issue MCCD for:

• 87 y old patient
• retired builder with history of asbestos exposure
• presented with worsening SIB and haemoptysis
• found to have pleural thickening and a biopsy confirmed mesothelioma
• admitted to hospice for symptom control where deteriorated further and died

Answer 26

We can’t issue MCCD as death linked to condition due to occupational exposure

*refer to coroner