Body of evidence: lessons in writing death certificates

John Kamaras, Legal Team Manager - Professional Conduct, Avant

Monday, 30 January 2023

Close up of medical staff filling death certificate

A case involving a doctor who became embroiled in a coroner’s inquest into an elderly woman’s death after they were asked to sign her death certificate, highlights why you need to be clear on whether you can sign a death certificate or not.

The task of signing death certificates frequently falls to general practitioners and junior hospital doctors who are faced with the family of the deceased or the police putting pressure on the doctor to sign the death certificate.

Case study

In this case, the patient’s doctor was asked to sign a death certificate for Mrs L, who suffered dementia, after being told by the aged care facility where she resided, that she had been found lying in the grounds next to a fountain, deceased from a suspected heart attack.

After visiting the aged care facility where Mrs L was lying peacefully in her room, the doctor dutifully signed the death certificate. At the time, the doctor did not feel it was necessary to ask any questions and did not report the death to the coroner.

Subsequently, the doctor was furious to discover that some of the staff at the aged care facility had covered up the more sinister circumstances of Mrs L’s death and in fact, she fell into a fountain in the nursing home grounds and most likely drowned.

The coroner launched an investigation, and the doctor was involved in an inquest into Mrs L’s death in which their professional approach to writing death certificates was scrutinised.

The investigation uncovered CCTV footage which showed that Mrs L had tripped over the garden light and fallen headfirst into the fountain, possibly striking her head.

Evidence suggested that staff discovered her fifty minutes later and removed her from the fountain.

During the inquest into Mrs L’s death, the nurse in charge said the facility manager had threatened to sack her if she did not falsify progress notes to state that she had been found in the courtyard lying on the ground after suffering a suspected heart attack.

The nurse told the inquest that a carer had dried off Mrs L and re-clothed her in preparation for the family.

The coroner found the cause of death to be immersion with underlying cause undetermined in circumstances of a fall into a courtyard water feature.

When to report a death to the coroner

This case emphasises the importance for doctors when asked to provide a death certificate ensure they conduct a thorough examination of the body and to ask any relevant questions. The doctor conceded as the death had involved a fall, it should have been reported to the coroner and agreed that when in doubt about whether a death was reportable, it was better to err on the side of caution and report it.

A doctor responsible for a patient’s care immediately prior to death or who saw the deceased after death must sign such a certificate unless the death is reportable to the coroner.

“If the death is reportable or you cannot confidently certify the cause of death you should not sign the death certificate,” John Kamaras, Legal Team Manager - Professional Conduct, Avant , said.

‘Reportable deaths’ must be notified to the coroner or police, and no death certificate should be issued.”

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

Related resource

Avant’ fact sheet: Completing a death certificate

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