The aim of this three-part series is to provide a helpful resource for general practitioners (GPs) to understand the legislative requirements of the Medical Certificate of Cause of Death (hereafter ‘death certificate’), enhance the accuracy and quality of death certificate completion and facilitate timely completion.
The Medical Certificate of Cause of Death series, introduced in an editorial in this issue of Australian Journal of General Practice,1 will include the following:
- Part 1 (the present article) – Introduction and the decision to complete
- Part 2 – Accurate completion2
- Part 3 – Special situations and considerations3
The completion of a death certificate is a fundamental medical duty with significant legal, medical, economic and social responsibilities. It is important for GPs to know how to certify the death of a patient and when to notify the police or the coroner. Despite the importance of this duty, there is a lack of formal training and minimal regulation of the process. For some GPs this may be an infrequent task. For others who work principally in aged or palliative care, it may be frequent. This is a challenging time: you are managing your own experience of the death of a patient and remaining aware of the needs of your patient’s family (Table 1).4,5
There is legal authority determining the conditions that must be met before a death certificate may be issued and time frames for completion of the certificate. The certificate must be registered with the local death registry office before the decedent may be buried or cremated. It is important for GPs to know which deaths in their regions must be reported to the coroner, as the circumstances may mandate investigation prior to certification.
Australia is a nation where the tyranny of distance presents challenges. In circumstances where a forensic pathologist needs to be involved, the deceased person may need to be transported thousands of kilometres to access this service. This adds considerable stress to families experiencing bereavement. One such reason for a forensic pathologist to be involved is when the treating doctor is not able to complete a death certificate. It is important that these services are used appropriately and that GPs and other doctors have the skills and confidence to complete a certificate when appropriate and spare families this additional stress.
Background
According to the Coroners Court of Queensland 2022–23 annual report, of the 38,160 deaths that occurred in the state, only 6590 deaths were considered by the coroner during the 12-month period. This means 83% of death certificates were completed by clinicians: GPs and hospital-based doctors rather than pathologists.6 Those certificates completed by forensic pathologists focus on deaths reported to the coroner. Significantly, 2987 (45%) of deaths reported to the coroner were classified as ‘Death certificate not issued and not likely to issue’. This number may decrease with increased training among clinicians. The report noted:6
“There is a clear need for medical teaching and training institutions, peak medical professional representative bodies and medical defence organisations to provide more effective training and ongoing clinical support to doctors regarding cause of death certificates.”
The importance of death certificates
The accurate completion of a death certificate is important for many reasons including: informing surviving family, legislative compliance, data collection and health economics (Box 1).
| Box 1. Importance of the Medical Certificate of Cause of Death |
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Accurate and timely completion of the Medical Certificate of Cause of Death is important for:
- surviving family members – provides closure; assists with managing health risk and awareness of inheritable conditions
- legislative compliance – allows initiation of burial and cremation procedures; is a milestone in deceased estate management
- data collection – for epidemiologists and to inform health and safety agencies and practices
- preventive health investment – individual and population level
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Surviving family
The deceased person’s health and cause of death may be directly relevant to members of their family because of risk factor management, inheritable conditions and further family planning. Beyond these considerations is the positive contribution a clear and understood cause of death has in resolving concerns about a family member’s death and providing closure.7
A family in grief must navigate the logistics of funeral planning, estate management and care of their immediate loved ones. This is one reason why time constraints in certificate completion are noted in legislative guidance (Table 2). In Queensland, a doctor has two working days from a person’s death to complete the certificate. In Victoria, the doctor has 48 hours to complete the form and notify the registrar or face the possibility of a fine of over $2000.
| Table 2. Timing of Medical Certificate of Cause of Death completion as per local Births, Deaths and Marriages ActsA |
| Queensland |
Two working days from a person’s death or when the body is discovered |
| All other states and territories |
Within 48 hours after the death |
| ASpecific religious observances may further drive the need for swift provision of a certificate. |
Legislative compliance
The certificate begins the chain of events that satisfy the legislative provisions relating to a death. The completed certificate is required to allow a funeral home to initiate a burial or cremation and must be sighted by several individuals, including an independent doctor if cremation is to occur.
A death must be registered by the relevant Registry of Births, Deaths and Marriages in the appropriate jurisdiction, and the certificate is the formal notification and represents a milestone in the management of the deceased’s estate.
Data collection
Once registered with the Registry of Births, Deaths and Marriages in each state, the data are then shared with the Australian Bureau of Statistics and may in turn be shared internationally.
Preventive health investment
Investing in disease prevention on the basis of causes of death is essential for effective health strategy planning and health economics. Cause of death data inform national health initiatives, including prevention, screening and research funding. The accuracy of death certificates is important, and poor-quality death certification can have a negative impact on healthcare delivery.8
Considerations before completing a death certificate
A death certificate can only be completed by a medical doctor if the requirements outlined in Table 3 are satisfied,9 providing the death is not a reportable death (Box 2).
In all states except Tasmania, there are forms or subsections for perinatal deaths as distinct from any other age group. ‘Perinatal’ refers to at least 20 weeks gestation or 400 g birthweight and includes live births and stillbirths. There is no cause of death certificate to complete for births less than 20 weeks gestation or less than 400 g birthweight: cremation or funeral services do not require forms in this instance.
There are important considerations for the GP prior to completing a death certificate and situations when the death certificate should not be completed (Box 2).
When a GP or other doctor is not able to complete the death certificate, the cause of death may only be determined by a coroner after investigation.
| Table 3. Conditions to be satisfied before completion of a Medical Certificate of Cause of Death |
| Queensland, Australian Capital Territory and New South Wales |
All other states |
- Attended the deceased when alive, or
- Examined the deceased person’s body, or
- Considered the deceased’s medical history and circumstances of the death,A and
- Can form opinion as to probable cause of death
Please note that a stillbirth requires a) and b) only
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- Attended the deceased when alive, or
- Examined the deceased person’s body, and
- Can form opinion as to probable cause of death
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| AIn Queensland and the Australian Capital Territory, a doctor may consider information about the deceased person’s medical history by examining medical records or speaking to another doctor who attended to the deceased person when alive. A doctor may be able to consider information about the circumstances of the deceased person’s death by speaking to someone who was with the deceased when they died or who discovered the deceased person’s body. In New South Wales, the legislation does not state consideration of medical records is sufficient, but the Medical Certificate of Cause of Death does in Part Four. |
| Box 2. Situations in which a Medical Certificate of Cause of Death should not be completed |
A Medical Certificate of Cause of Death should not be completed if:
- the death is reportable to the coroner
- you have an interest in the estate of the person
- you cannot determine the probable cause of death
- in ACT: a doctor has not attended the person for 6 months or more
- in states other than Qld, ACT or NSW: you have not treated the person or examined them
- in Qld, ACT or NSW: you have not treated the person, examined them or been able to review their medical records.
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Role of the coroner
In Australia, a coroner is a legally qualified Magistrate who investigates reportable deaths, approves their causes, may make recommendations and authorises burial or cremation. Each state and territory has its own Coroners Act and Regulation,9 outlining the coroner’s powers and defining reportable deaths within that jurisdiction (Table 4).
Certain deaths must be reported to the coroner, who will determine whether further investigation is required.9 Investigation may include requesting a forensic pathologist or another doctor to conduct an autopsy.
Jurisdictions differ on healthcare-related deaths. In Queensland, these are defined as deaths where healthcare significantly contributed to the death because of an omission (failing to do something expected)or a commission (doing something that should not have been done). In NSW, if a person dies following a health-related procedure and this was unexpected, the death is a reportable death. In other jurisdictions,the coronial authority is relevant in the limited circumstance that an anaesthetic or medical procedure was involved. If a cause of death certificate is not issued, the death must be reported to the coroner. A number of helpful, state-based resources are provided in Appendix 1.
| Table 4. Reportable deaths |
| Cause of death |
- Unknown – the general practitioner is not able to opine as to the cause of death.
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- Violent, suspicious, unnatural or unusual – this includes suicide, choking, poisoning.
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- Death due to accident or injury (eg motor vehicle accident). A fall leading to death is reportable in some but not all jurisdictions.
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- Death related to healthcare – varies for different jurisdictions.
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| Location of death |
- Deaths occurring within certain facilities, such as death in police or lawful custody or where a person is held in care (eg mental health facility or residential service other than a private dwelling or aged care facility).
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| Characteristics of the person who died |
- The person’s identity is unknown.
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- Person in custody or in care; for example, the decedent may have been the responsibility of the state through legislation: generally, a person ‘in custody’ or ‘in care’. These terms vary across jurisdictions and are defined in legislation. Different legislative instruments may reduce an individual’s choices and freedom because of mental health conditions or infectious states.
These terms vary across jurisdictions and are defined inlegislation. Different legislative instruments may reduce an individual’s choices and freedom because of mental health conditions or infectious states. |
| Death certificate not issued or not likely to be issued |
- There may be no treating doctor, or the treating doctor is unable or unwilling to provide a certificate for various reasons.
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When the police contact the GP
When a patient dies in the community, ambulance and police services are often called. Police may contact the person’s GP to determine the cause of death and complete the certificate. Police input on these occasions can be valuable, as they typically rule out suspicious causes through their procedures; however, they are not medical experts and may not be aware of certain risks, for example, when a new or high-risk medication has been prescribed. In such situations, it is important to verify medication was taken as directed.
Discussions with police are typically factual, focusing on whether the doctor will complete a death certificate and any questions about the circumstances, scene or drug history. Generally, the police provide information to assist the GP in their decision.
After-hours calls from police often seek to confirm if a doctor can complete a death certificate. If access to medical records is needed to make this decision, advise the police of this requirement. If you expect to issue the certificate after reviewing medical records, the family’s undertaker can be engaged but must wait for the certificate before starting preparations. If you later determine a certificate cannot be completed, the government undertaker will transfer the body to a government mortuary. If, from the outset, you advise that you cannot complete a certificate, the government undertaker will transport the body to the nearest government mortuary. The latter may be a journey of several hundred kilometres. For this reason, it is important that when it is appropriate for a death certificate to be completed, GPs feel confident that they can do so.
Obtaining death certificate forms
Physical copies of death certificate forms are available from the Registry of Births, Deaths and Marriages in your jurisdiction (Table 5).8 Some will offer online ordering; for example, NSW allows doctors and private hospitals to order blank forms by emailing their practice details and Australian Health Practitioner Regulation Agency registration details. Public hospital facilities order via a state printer.
In part 2 of the Medical Certificate comprehensive completion of death certificates will be discussed.2
Key points
- Accurate completion of a death certificate is important for public health records, family closure and legal matters.
- Be aware of your local jurisdiction’s legislative obligations with regard to timing, completion of certificates and when you must report a death to the coroner.