Provision of death certification

Providing death certification is a legal obligation for doctors, as a Medical Certificate of Cause of Death (MCCD) must be produced before a death can be registered. An MCCD can only be completed by a registered medical practitioner and the cause of death must be certified to the best of the doctor’s knowledge and belief.

There are some deaths which must be reported to the coroner or procurator fiscal (PF). If there are any doubts about the cause of death, these can be discussed in the first instance with the medical examiner (in England and Wales) or medical reviewer (in Scotland).  The coroner or PF may also need to be informed.

The regulations vary within the UK jurisdictions and doctors should have a good working knowledge of those which apply to their work. Similarly, there can be local procedures to follow and doctors should be familiar with the standard practice in their area.

Basic considerations

The General Medical Council (GMC) guidance, Good medical practice, explains at paragraph 71:

“You must be honest and trustworthy when writing reports, and when completing or signing forms, reports and other documents. You must make sure that any documents you write or sign are not false or misleading.
a. You must take reasonable steps to check the information is correct.
b. You must not deliberately leave out relevant information”

This applies to all documentation, including death certification.

The GMC also offers guidance in Treatment and care towards the end of life: good practice in decision making, which states:

“85. You must be professional and compassionate when confirming and pronouncing death and must follow the law, and statutory codes of practice governing completion of death and cremation certificates. If it is your responsibility to sign a death or cremation certificate, you should do so without unnecessary delay. If there is any information on the death certificate that those close to the patient may not know about, may not understand or may find distressing, you should explain it to them sensitively and answer their questions, taking account of the patient’s wishes if they are known.

86. You must comply with the legal requirements where you work for reporting deaths to a coroner (England, Wales and Northern Ireland) or procurator fiscal (Scotland). You should be prepared to answer questions from those close to the patient about reporting procedures and post mortems, or to suggest other sources of information and advice.

87. You must treat the patient’s body with dignity and respect. You should make sure, wherever possible, that the body is handled in line with their personal religious or other beliefs.”

England and Wales

The death certification process in England and Wales has undergone reform with changes effective from 9th September 2024.

• Any doctor who has attended the patient in their lifetime can now complete the MCCD.
• There is no specific definition of ‘attended’, but it is generally accepted to mean a doctor who has cared for the patient and is familiar with the patient’s medical history.
• Abbreviations should not be used on the MCCD when certifying the cause of death.
• The MCCD now requires information on the patient’s ethnicity (if this information is not in the records, further details should not be sought from the patient’s family or assumed, and the ethnicity should be recorded as ‘unknown’) and whether they were pregnant in the last 12 months.
• The existence of implantable medical devices is now recorded on the MCCD so cremation forms are no longer required
• Once completed by the certifying doctor, the MCCD should be sent to the medical examiner  
• The medical examiner will review the proposed cause of death and MCCD. They will liaise with the certifying doctor to agree the MCCD
• Once agreed, the medical examiner is responsible for sending the MCCD to the registrar

Certain classes of death must be reported to the coroner, where the death was due to: 

• poisoning;
• exposure to or contact with a toxic substance;
• use of a medicinal product, controlled drug or psychoactive substance;
• violence, trauma or injury;
• self-harm;
• neglect, including self-neglect;
• undergoing a medical treatment or procedure;
• injury or disease from employment;
• unnatural death or cause unknown; and
• deaths in custody (or temporarily released or absconded).

A death should be categorised as “due to” one of these factors if there is reasonable cause to suspect that it was more than minimally, negligibly or trivially caused or contributed to thereby.

In addition, where there is no attending registered doctor or the attending doctor is not available within a reasonable time frame, the death must be reported.

Any uncertainty as to whether a death required notification to the coroner should be discussed with the medical examiner in the first instance.

Scotland

The doctor who attended the patient in their last illness should complete the MCCD. This is generally accepted to mean a doctor who cared for the patient during the illness or condition that led to death and so is familiar with the patients history, investigations and treatment.

If it is not possible for the attending doctor to provide the certificate, or no doctor was in attendance, another doctor in the team with knowledge of the deceased and/or access to the clinical records can complete the MCCD.

In addition to the standard information regarding the cause of death, the following information is required: the deceased’s community health index number, the name of the health board area where death occurred, the certifying doctor’s GMC number and the certifying doctor’s business contact telephone number.

The MCCD also requires “the certifying doctor to confirm, to the best of their knowledge and belief, whether there are any public health risks associated with the body of the deceased, and whether the body contains any potentially hazardous devices such as pacemakers or other implants to be removed and disposed of safely before cremation.” As a result, separate cremation forms are no longer required.

A proportion of MCCDs require review by the medical reviewer.

Certain deaths require to be notified to the procurator fiscal in Scotland, including:

• Any death which cannot be entirely attributed to natural causes (including suspicious deaths, drug related deaths, accidental deaths, deaths resulting from an accident in the course of employment, deaths of children from overlaying or suffocation, deaths where there is a possibility of suicide);

• Deaths due to natural causes, but in the following circumstances:
  o Unknown causes;
  o Neglect / fault (including where there is an allegation or possibility of fault on the part of another person, body or organisation);
  o Certain deaths of children (including infant deaths and deaths of ‘looked after’ children);
  o Notifiable industrial / infectious diseases;
  o Under medical or dental care;
  o Subject to compulsory treatment under mental health legislation;
  o in legal custody
  o Any death where the circumstances surrounding the death may cause public anxiety.

All reportable deaths must be notified to the PF as soon as possible and before any steps are taken to issue a death certificate. If a death certificate has been issued to the family and the PF declines to accept the cause of death, the certificate would have to be retrieved from the family.

Northern Ireland

It is a statutory requirement for the doctor who attended and provided care within 28 days of death to complete the MCCD to the best of their knowledge and belief.

Deaths that should be reported to the coroner include: misadventure/violence, any cause other than natural illness/disease, industrial disease, poisonings, and death from an injury.

Common pitfalls

• Delays in certification can lead to complaints. Try to avoid this and communicate sensitively with close relatives/friends of the deceased.
• Lack of understanding of who can and who cannot complete an MCCD can lead to delays. Check this carefully when asked to certify death.
• If there is uncertainty over acceptable causes of death for the purposes of the MCCD, this can be discussed with the medical examiner (in England and Wales) or the PF or medical reviewer (in Scotland).
• Do not use abbreviations and complete all forms legibly.

Key points

• Doctors have a statutory obligation to complete MCCDs.
• Ensure you are familiar with national and local guidance.
• If a death must be reported to the coroner or PF, it is important to discuss this openly and tactfully with relatives so they understand what is happening and why.
• Advice can also be obtained from MDDUS.

Further guidance

GMC: Treatment and care towards the end of life

England and Wales:

Guidance for doctors completing Medical Certificates of Cause of Death in England and Wales

Guidance for registered medical practitioners on the notification of death regulations 2019

Scotland:

Medical certificates of cause of death: guidance on completion - gov.scot (www.gov.scot)

Reporting deaths to the procurator fiscal

Northern Ireland:

Guidelines for death certification - issuing MCCD using NIECR

Guidance for matters relating to the coroner