Dr Toni Hazell offers top tips on important changes to death certification procedures in England and Wales that have arisen during the coronavirus pandemic

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Dr Toni Hazell

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Read this article to learn more about:

  • who can verify deaths in care homes and in the community during the COVID-19 pandemic
  • which criteria must be met for any doctor to sign a medical certificate of cause of death
  • which circumstances merit referral of a death to a coroner
  • how to apply for cremation and where to access the relevant guidance.

The coronavirus pandemic has been the catalyst for many changes in the way that we work in the NHS; those of us familiar with the usual slow pace of change have been amazed at the speed at which video calls, hot hubs, visiting services, and secondary care phone reviews have materialised. It has also prompted legislative change with the passing through Parliament of the Coronavirus Act 2020,1 a change to the law that significantly simplifies the process of registering a death and doing the necessary paperwork for cremation. At the time of writing, several aspects of this legislation are clear and unambiguous, but there remains some confusion about verification of death. This article outlines the changes to procedures relating to death certification in England and Wales, with references at the end for those working in Scotland or Northern Ireland.

1. Understand who can verify death

GPs who look after care homes will be familiar with the visit request to verify a death, because the funeral director will not remove the body until this has been done. There is actually no legal requirement for a doctor to verify death—it can be done by any appropriately trained healthcare professional.2,3 Many nursing homes will have nurses who can do this and for those who do not, training can be accessed online;3 some residential homes will also have staff who can access this training. Care homes should ideally not insist that doctors visit solely to verify death because this poses a clear infection risk with no benefit to the patient.

Verification is trickier when a patient dies at home, as there may be no healthcare professional on hand. To help under these circumstances, the British Medical Association and Royal College of General Practitioners have jointly produced guidance for remote verification of death when there is someone in the house who is willing and able to help.4 The Department of Health and Social Care (DHSC) have also endorsed this approach.5 This may be a relative, friend, or carer with no formal training in this area, but who feels comfortable with verifying a death under remote supervision. No one should be pressurised into taking part in this process. Verification is not normally the remit of coroners in deaths from natural causes, but in a significant number of areas, coroners have made statements concerning this matter.6 There appears to be no consistency across England and Wales, with some coroners advising that, in their area, verification should only be performed by doctors, trained nurses, paramedics and, in very rare instances, police, but others stating that funeral directors and family are acceptable. Pressure continues to be applied at a high level to try to effect change to find a universal process; one that increases the range of people able to verify death while reducing the current risk of cross-infection and delay. 

2. Know who can sign a medical certificate

Previously, the Medical Certificate of Cause of Death (MCCD) could only be signed without referral to the coroner if the patient had been seen within the last 14 days of life, although in practice, coroners would usually accept a longer time period if the death was expected. That 14-day period has now been extended to 28 days.7

In normal times, the doctor issuing the MCCD has to have seen the patient in life; however, it has been recognised that this may cause unnecessary delay, particularly if the only doctor to have seen the patient in life is unwell or self-isolating because of illness in their family. Any General Medical Council (GMC)-registered doctor can now therefore sign the MCCD if the doctor who attended the patient in life is unable to sign or it is impractical for them to do so. For this to happen, three criteria must be met:

  • the doctor signing the MCCD can state the cause of death to the best of their knowledge and belief
  • the usual doctor is unavailable
  • a medical practitioner has seen the patient in the 28 days before death (in person or by video) or after death (in person only).7

When signing for a patient who the GP has not seen in life, the name and GMC number of the doctor who did see them in life should be recorded on the certificate, in the place where they would usually write when they had seen the patient before death.7

3. Involve the coroner where necessary

Some patients will die in the community without having seen a doctor in the preceding 28 days. In this case, the certificate can still be issued (if the GP is happy to state a cause of death), but the coroner needs to be involved.7 The situation can be explained by contacting the local coroner’s officer by the usual means. The coroner will usually give authorisation to fill in the MCCD, which the GP then sends to them. The coroner then fills in a form 100A and passes the MCCD and form 100A to the registrar; this allows the death to be registered even though the patient was not seen within 28 days of death.8

4. State COVID-19 as cause of death even without a swab

At the moment, only healthcare professionals and those patients who are admitted to hospital are being tested for COVID-19, and the test has a significant false negative rate.9,10 COVID-19 can be used as a cause of death on clinical suspicion.11 If a test has been done but the result is not available, box B on the back of the death certificate should be used to indicate that more information (that is, the test result) will be available at a later date.11 COVID-19 is a notifiable disease, but this does not mean that every COVID-19 death needs to be referred to the coroner,8 unless there are other reasons for the death to be referred. Reasons for referral include death:12

  • where the GP cannot state a cause
  • due to violence
  • which has occurred in prison
  • which has been contributed to by industrial disease.

5. Communicate with registrars by email

Many registrars are now working from home, so the usual practice of the relatives making an appointment to go and register the death has changed. Practices can scan the signed MCCD and email it to the local registrar; registration can take place without the family needing to physically attend.7,13 Funeral directors are now also authorised to register a death on behalf of the family.13 The original MCCD is an important legal document and the local registrar will advise what to do with it—some are asking for them to be posted individually, whereas others recommend that they are kept safe at practices to be collected in one go once the pandemic has passed. Cremation forms can also be filled in electronically,14 and the act of them being sent by secure email negates the need for a wet signature.

6. Know how to complete cremation paperwork

Before the coronavirus pandemic, a patient’s GP would fill in the cremation form 4 (colloquially known as a ‘part 1’), and a few days later they would get a call from another GP who had been charged with filling in the form 5 (‘part 2’). With immediate effect, there is no need for the form 5 and a body can be cremated with just a form 4 and the crematorium medical referee’s authorisation.7 Similarly to the MCCD, if the doctor who saw the patient in life is not available, then the form 4 can be completed by any doctor, as long as a doctor saw the patient in life within 28 days (in person or by video) or after death (in person only).7 If this is not the case, then the procedure outlined under heading 3, above, should be followed, whereby the coroner completes a form 100A; this will allow cremation of a patient who has not been seen in the 28 days before death, or after death. Things have moved very quickly in this area—if a local crematorium referee is not aware of the new regulations, they can be directed to the recent guidance from the chief coroner’s office.15

Summary

The passing of the Coronavirus Act 2020 has simplified the process of death certification during the COVID-19 pandemic. In certain circumstances, the MCCD and cremation form can now be completed by a doctor who had not met the patient in life. This change will obviate the need for doctors to visit solely to verify a death, potentially exposing them to infection. It will also avoid delays in issuing MCCDs related to illness or self-isolation among healthcare professionals.

Dr Toni Hazell

Part-time GP, Greater London

Acknowledgement

The author of this article would like to thank and acknowledge Dr Frances Cranfield, GP and Assistant Coroner for Hertfordshire, for her help with writing this article

Key points

  • The Coronavirus Act 2020, most provisions of which will currently remain in force for 2 years but with regular review by Parliament, has significantly simplified the process and paperwork relating to certification of death
  • Both the death certificate and cremation form can now be filled in by a doctor who had not met the patient in life, if certain conditions are met
  • Death and cremation paperwork is more straightforward if the patient has been seen in the last 28 days of life; it is therefore worth ensuring that all patients in care homes are reviewed at least once a month
  • All paperwork is now electronic
  • The cremation form 5 (colloquially known as the part 2) is not currently required.

Information about death certification and COVID-19 for doctors working in Scotland or Northern Ireland

Medical Defence Union. Certifying deaths during COVID-19 outbreak—Northern Ireland. Available at: www.themdu.com/guidance-and-advice/latest-updates-and-advice/certifying-deaths-during-covid-19-outbreak?Region=Northern+Ireland

Health Improvement Scotland. Death certification. Available at: www.healthcareimprovementscotland.org/our_work/governance_and_assurance/death_certification/questions_and_answers.aspx

Implementation actions for STPs and ICSs

written by Dr David Jenner, GP, Cullompton, Devon

The following implementation actions are designed to support STPs and ICSs with the challenges involved with implementing new guidance at a system level. Our aim is to help you consider how to deliver improvements to healthcare within the available resources. 

  • Discuss with your local coroner their interpretation and guidance on the new flexibilities offered under the Coronavirus Act 2020:
    • Agree and disseminate a joint statement setting out local interpretation and be aware that more than one coroner’s office may be responsible for your area
    • Publish local pathways for referral to coroners and local death registration arrangements, with appropriate guidance
  • Pay special regard to the needs of care homes and facilitate their staff to verify death
  • Consider video review every 28 days of patients in care homes who are likely to die, as this counts as being ‘seen’ for death certification purposes
  • Ensure local funeral directors are included in any correspondence relating to the above and are empowered to help prompt and guide GPs and relatives of the deceased at this difficult time.

STP=sustainability and transformation partnership; ICS=integrated care system

References

  1. HM Government. Coronavirus Act 2020. London: HM Government, 2020. Available at: www.legislation.gov.uk/ukpga/2020/7/contents/enacted/data.htm
  2. Care Quality Commission. Nigel’s surgery 13: who can confirm death? www.cqc.org.uk/guidance-providers/gps/nigels-surgery-13-who-can-confirm-death (accessed 6 May 2020).
  3. Royal College of Nursing. Confirmation or verification of death by registered nurses. www.rcn.org.uk/get-help/rcn-advice/confirmation-of-death (accessed 6 May 2020).
  4. Royal College of General Practitioners, British Medical Association. Guidance for remote verification of expected death (VoED) out of hospital. London: BMA, 2020. Available at: www.rcgp.org.uk/-/media/Files/Policy/A-Z-policy/2020/covid19/RCGP-guidance/BMA-RCGP-Guidelines-For-Remote210420.ashx?la=en
  5. Department of Health and Social Care. Coronavirus (COVID-19): verifying death in times of emergency. DHSC, May 2020. www.gov.uk/government/publications/coronavirus-covid-19-verification-of-death-in-times-of-emergency/coronavirus-covid-19-verifying-death-in-times-of-emergency#verification-of-death-in-this-period-of-emergency-standard-operating-procedure-sop (accessed 6 May 2020).
  6. Merrifield N. Coroners clash with BMA over death verification during coronavirus pandemic. Pulse, 29 April 2020. www.pulsetoday.co.uk/news/coroners-clash-with-bma-over-death-verification-during-coronavirus-pandemic/20040679.article (accessed 6 May 2020).
  7. NHS England and NHS Improvement. Coronavirus Act—excess death provisions: information and guidance for medical practitioners. London: NHS England and NHS Improvement, 31 March 2020. Available at: improvement.nhs.uk/documents/6590/COVID-19-act-excess-death-provisions-info-and-guidance-31-march.pdf
  8. Lucraft M. Chief coroner guidance—COVID-19. London: Courts and Tribunals Judiciary, 26 March 2020. Available at: www.judiciary.uk/wp-content/uploads/2020/03/Chief-Coroner-Guidance-No.-34-COVID-19_26_March_2020-.pdf
  9. Merrifield N. GPs with Covid-19 symptoms should stay off work even if test is negative, says NHS. Pulse, 1 May 2020. www.pulsetoday.co.uk/clinical/clinical-specialties/respiratory-/gps-with-covid-19-symptoms-should-stay-off-work-even-if-test-is-negative-says-nhs/20040750.article (accessed 6 May 2020).
  10. Grassly N, Pons-Salort M, Parker E et al. Role of testing in COVID-19 control. London: Imperial College London, 23 April 2020. Available at: www.imperial.ac.uk/media/imperial-college/medicine/mrc-gida/2020-04-23-COVID19-Report-16.pdf
  11. Office for National Statistics, HM Passport Office. Guidance for doctors completing Medical Certificates of Cause of Death in England and Wales. London: ONS, 2020. Available at: assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/877302/guidance-for-doctors-completing-medical-certificates-of-cause-of-death-covid-19.pdf
  12. Ministry of Justice. Revised notification of deaths regulations 2019 guidance. London: Ministry of Justice, 2020. Available at: www.gov.uk/government/publications/notification-of-deaths-regulations-2019-guidance
  13. Dent A. General Register Office circular No. 5/2020. Southport: HM Passport Office, 27 March 2020. Available at: www.iccm-uk.com/iccm/wp-content/library/GROCircular-5-2020.pdf
  14. Ministry of Justice. Cremation medical certificate—medical certificate (Cremation 4). London: Ministry of Justice, 2020. Available at: www.gov.uk/government/publications/cremation-medical-certificate
  15. Chief Coroner. Summary of the Coronavirus Act 2020—provisions relevant to coroners. London: Chief Coroner, 2020. Available at: www.judiciary.uk/wp-content/uploads/2020/03/Chief-Coroners-Office-Summary-of-the-Coronavirus-Act-2020-30.03.20.pdf