19b Death certification and referral to the coroner

Every death occurring in the UK has to be registered in the Register of Deaths local to the place of death. This chapter relates to procedures in England and Wales, although other jurisdictions e.g. Scotland have very similar procedures.

The information recorded in the Register comprises personal details of the deceased person and medical information as to the cause of death.The death must be formally registered (within 5 days) at the Register Office for Births, Deaths and Marriages local to the place of death, although it is now possible to provide the personal details needed to register at any registry.

The relevant personal details (including the deceased’s full name, home address, dates and places of birth and death, occupation, matrimonial/partner status, etc.) will be provided by the ‘informant’ (normally a close relative who has personal knowledge of the deceased) who attends the Register office, and is able to respond to the various questions asked by the registrar.

The medical details will be provided by the registered medical practitioner who has been in attendance on the deceased during his/her last illness. He/she is required to furnish a certificate in the prescribed form (‘Medical Certificate of Cause of Death’ or MCCD). It should be completed, by the certifying doctor, with the cause of death to the best of the doctor’s information, knowledge and belief.

The MCCD should be completed promptly, giving clear statements that set out the sequence of the disease process that led to death. It should not give a ‘mode’ of death as the only entry nor should abbreviations be used. The doctor is legally responsible for the delivering the MCCD to the registrar, although normally the informant acts as the doctor’s agent and hands it to the registrar.

The registrar will copy all the medical details from the MCCD (using the identical words and spelling) into the register.

Deaths that cannot be readily certified as due to natural causes should be referred to the coroner. Once a death has been reported to the coroner, he/she has a duty to investigate the cause of death. This may be done by way of informal inquiry carried out by the coroner or a coroner’s officer, by a post-mortem examination made to establish a cause of death or by an inquest. If the family objects to the post-mortem, whether for religious or other reasons, an appeal can be made, but this may delay the funeral.

The registrar (but no one else) has a statutory duty to report any death to the coroner if, on the basis of information coming to the registrar’s notice, it may be one that, by law, the coroner is required to investigate (see below). Nevertheless, doctors are encouraged to report voluntarily any death that the registrar may subsequently refer to the coroner. This will save time and reduce uncertainty for the family. Coroners and their officers are always prepared to discuss individual cases and, in this way, ensure that families are neither inconvenienced nor troubled unnecessarily.

The coroner will address the duties of investigating a death by informal inquiry carried out by the coroner or a coroner’s officer, by a post-mortem examination made to establish a cause of death or by an inquest.

If the case is one where an inquest is held, the registration in the Register of Deaths is completed by the coroner when the inquest is finally concluded.

A coroner’s inquest is a limited public inquiry, convened by the coroner, to find factual answers to who the deceased person was and how, when and where the death occurred. The coroner does not address matters of blame (i.e. liability).

The registrar is required to report the death to the coroner if:

In addition, it is sometimes argued that if the deceased was only under the care of the doctor for less than 24 hours before death ensued, that doctor may not have sufficient knowledge as to the cause of death for him/her to complete the MCCD. The coroner’s office will always advise informally about this.

In a hospice setting it is not uncommon for a patient to die with a pathological fracture or to die within a short time of arrival at the hospice. The local coroner will be very pleased to discuss these cases.

Doctors have a legal duty to state all they know. However, it is relatively easy for any member of the public to obtain a copy of the death register entry that will include the cause of death. There is, therefore, the potential for a breach of confidence. The Office of Population Census and Surveys (OPCS) accepts that the present system is unsatisfactory.

The current practice of stating a superficial cause of death rather than the underlying disease process in such cases is widespread. Although it is technically illegal, it is condoned by the OPCS—provided the box on the reverse side of the certificate is ticked stating that additional information may be forthcoming. This point has yet to be tested in the courts. These comments often apply to patients dying with AIDS-related illnesses.

The registration process also provides authorization for burial or cremation. The authorization issued by the registrar should be handed to the funeral director to be used by the family. If the case is one where an inquest is held, the authorization of the burial or cremation is given by the coroner.

New regulations apply to cremation in the UK from 2009.

If a body is to be cremated a certificate of medical attendant (Form 4) and a confirmatory medical certificate (Form 5) should be completed.In Form B, if the doctor has not attended the deceased within 14 days of death, the coroner should be notified. The doctor must see the body after death.

Form C must be completed by a registered medical practitioner of not less than five years standing, who shall not be a relative of the deceased or a relative or partner of the doctor who has given the certificate in Form B. The doctor must see and examine the body after death. In addition, the doctor must have seen and questioned the medical practitioner who completed Form B.

The applicant for cremation has a new right to inspect form Cremation 4 or 5. Some of the information may have been given to the doctor by the deceased in confidence. If it is included in the form, it may be disclosed to the applicant for cremation if they choose to inspect the form. If this would be a breach of confidence information may be given to the medical referee on a separate sheet of paper attached to the Form with explanatory reasons.

When completed, the entries in the Register of Deaths will form ‘the death certificate’, the proof of death required for the various legal and social processes as well as overall statistics of causes of death. Copies of the death certificate can be obtained from the registrar.

If there is a will, the executors named in the will (or if there is no will, the deceased’s personal representative) is responsible for arranging the funeral and looking after (and subsequently disposing of) the person’s assets and property.

If there is a will, the executor should ‘prove’ this to obtain probate of the will.

If there is no will, the deceased’s personal representative should apply for letters of administration.

The funeral director will need to know whether the body is to be buried or cremated (over 75% of deaths in the UK are now followed by cremation).

They will need to know of any religious customs or rituals that might be necessary.

Bodies may be ‘partially’ embalmed routinely or this might be discussed with the family. Traditionally, embalming involves draining blood from the body and replacing it with formaldehyde plus a pinkish dye pumped under pressure, which has a hardening and disinfecting effect. Nowadays, the blood is not drained, but a small amount of embalming fluid is infused to help prevent the body smelling and to make the face more presentable; This is particularly relevant either for hygienic reasons or if the families wish to view.