A death not unexpected, but who completes the death certificate?

You’ve been paged to attend the orthopaedic ward late in your shift, where you’re asked to verify the death of 97-year-old Mr Charles. He was due to have surgery for a fractured neck of femur following a fall at his residential care facility. His medical history included vascular dementia, CVA and unstable angina. After the fall, his general practitioner had examined him and sent him to hospital where it was agreed that surgical intervention was appropriate. However before the surgery could proceed, his condition deteriorated to the point that, in consultation with Mr Charles’ family, it was agreed to cease active treatment and provide palliative care only. Can you complete the death certificate?*

Completing a death certificate, or a Medical Certificate of Cause of Death (MCCD), frequently generates calls to Avant’s Medico-legal Advisory Service.

When a patient dies in hospital, it’s not uncommon for the doctor called to attend to be unsure of their responsibilities, particularly if they have had limited involvement in the patient’s care.

The death certificate is an important document because it forms the record of death for the Registry of Births Deaths and Marriages. It also forms a key part of the process for funeral arrangements. Doctors tell us they can feel pressure to sign the form from families, other health practitioners, funeral directors, or police. They often call looking for guidance or reassurance.

This scenario illustrates some of the common questions we hear.

What are you required to do?

In most states and territories, the legal starting point is that you will be responsible for completing the death certificate if you:

• were responsible for the patient’s medical care immediately before death, or
• examined the body.

The death certificate needs to be completed within 48 hours. The exceptions are if:

• the death has been reported to the coroner (whether you or someone else has reported it), or
• someone else has completed the death certificate.

In many jurisdictions, if you have been called to verify death, you will generally need to take some steps to either complete the death certificate or arrange for it to be completed. Consider contacting the hospital doctor(s) involved in the patient’s care at the time of death to check whether they will be completing a death certificate, and to ensure you can form an accurate opinion. If the death certificate is unable to be completed in time (for example because there is uncertainty about the cause of death), you may need to report the death to the coroner.

There are several factors that determine what steps to take, including where in Australia the scenario takes place. In this article we discuss the issues generally. See the references at the end of this article for more specific guidance for your state or territory.

Could you complete the death certificate even if you were not the treating practitioner?

Even if you have not been caring for Mr Charles while he was in hospital, in most cases, you will be able to complete the death certificate if you are satisfied both:

• that there is no reason the death needs to be reported to the coroner, and
• of the probable cause of death.

Might Mr Charles’s death need to be reported to the coroner?

The law in each state and territory has a list of reasons why a death would need to be reported to the coroner in that jurisdiction.

While the requirements are broadly similar, the provisions in each jurisdiction do vary, so it is important to check the current requirements where you practise (see the list of resources below).

Where a death is violent or unnatural or occurs in unusual or suspicious circumstances, it needs to be reported to the coroner and you must not sign the death certificate.

Deaths related to healthcare procedures may also need to be reported. If Mr Charles had undergone surgery or received an anaesthetic, it is likely his death would need to be reported, even though there were other contributing factors. However different states and territories have different provisions. Depending on where you are located, a reportable death might be:

• any death that appears completely or partly attributable to an operation or procedure, or
• any death within 24 hours of surgery or anaesthetic (with some specified exceptions), or
• a death that was not the reasonably expected outcome of a health-related procedure.

Health department policies may include additional requirements, so make sure you check the policies for the hospitals you are working in.

Deaths resulting from an accident or injury would also usually need to be reported to the coroner. However, again, the provisions vary. For example, if you are in NSW an accidental death may not need to be reported where the patient is 72 or older and you are confident the accident is attributable to age, and that it was not caused by any other person’s act or omission.

How sure do you need to be about the cause of death?

Even if you do not believe the death is reportable, you should only complete the death certificate if you are satisfied about the cause of death.

In the case of a patient where there are multiple contributing factors and you are not sure which condition actually caused the death, it is always appropriate to seek advice.

In most states you can contact the local coroner’s office who will generally be able to assist with reviewing the patient’s medical history and reaching a consensus on the most probable cause of death. The coroner should then be able to confirm that you can complete the cause of death certificate, recording the cause of death as agreed. Keep a record of your discussion and the rationale for reaching the conclusion as to the cause of death.

The Australian Bureau of Statistics Information Paper on Cause of Death Certification  also provides guidance on recording deaths due to complex or non-specific causes such as frailty, natural causes and now COVID.

What are the options if you are unable to determine the cause of death?

Until you are satisfied as to the cause of death, you should not complete the death certificate.

Your first step would always be to review the patient’s medical record or speak to colleagues who have been involved the patient’s care.

If a patient has been recently admitted and you are unsure of their clinical history, it is appropriate to contact the patient’s general practitioner or other carers.

In the hospital you may be able to contact a duty forensic pathologist. Or, as noted, you can contact the local coroner’s office. You can also contact Avant for advice.

If the death certificate cannot be completed because there is no medical practitioner who can be satisfied of the cause of death, even after consultation, the death needs to be reported to the coroner.

Resources and further reading

The rules around certifying death are different in each state and territory, and they are contained in a range of legislation and regulations. There may also be guides and policies which are not always consistent.

All states and territories also require permits to be issued before the body of a deceased person can be cremated. These requirements vary considerably between jurisdictions.

It is complicated and often confusing.

To assist members, Avant has produced some new resources – factsheets and decision guides for each jurisdiction – to help clarify some of the most common issues.

For more information or immediate medico-legal advice, call us on 1800 128 268, 24/7 in emergencies.

*This scenario is based on Avant claims experience to date. Details have been amended for privacy reasons and issues have been summarised for the sake of discussion.