The cause of death: When GPs need to write a death certificate

Neelima Choahan

28/08/2018 4:14:58 PM

newsGP spoke to medico-legal expert Dr Sara Bird about what to keep in mind while issuing a death certificate.

Completion of a death certificate by a medical practitioner is a vital part of the notification process to the Registrar of Births, Deaths and Marriages.
Completion of a death certificate by a medical practitioner is a vital part of the notification process to the Registrar of Births, Deaths and Marriages.

The GP received a call from the police asking if she could write a death certificate for a patient who had attended the practice. The 83-year-old man had been found dead in bed by his wife that morning.
One of the GP’s colleagues had looked after the patient for about 10 years, but the colleague was overseas and not contactable. On review of the medical records, the GP noted that the patient had a history of ischaemic heart disease, having suffered a myocardial infarction eight years earlier. The patient had undergone coronary artery stenting three years ago.
Medical records showed the GP’s colleague had last seen the patient about two months before his death. At this time, the patient was well and he had attended for repeat prescriptions of his cardiac medications.
According to the police officer, the patient’s wife reported that her husband had been well since his visit to the GP and he had not seen any other doctors or attended hospital in the intervening time.
On the night before his death, the patient said he felt unwell and had some chest pain for which he had taken Anginine.
The GP was not sure if she could write a death certificate for the patient in this situation and contacted her medical defence organisation for advice. The medico-legal adviser informed the GP that if she was ‘comfortably satisfied’ as to the probable cause of the patient’s death, then on the basis that she was responsible for the management of her colleague’s patients in his absence, she was authorised to provide a death certificate.
If the GP wanted to discuss the situation further, she could also obtain telephone advice from the coroner’s office about whether she should write the death certificate.
Dr Sara Bird, Manager of Medico-legal and Advisory Services at MDA National, told newsGP the most common reason GPs would contact their medical defence organisation about death certification is when they receive a request from the police for a completed death certificate after their patient has been found dead at home.
Dr Bird said the completion of a death certificate by a medical practitioner is a vital part of the notification process to the Registrar of Births, Deaths and Marriages in the state or territory in which the death occurred, and enables an authority to be provided to the funeral director to arrange disposal of the body.
How does the GP determine whether they can issue a death certificate? 
The GP needs to consider whether the death should be reported to the coroner before issuing a death certificate.
‘The most common reason why GPs aren’t able to complete a death certificate is where the cause of death is unknown,’ Dr Bird said.
‘By definition, to be able to write a death certificate you have to be able to write on the certificate what the cause of death was. So GPs need to turn their mind to whether they can write a death certificate or not. 
‘If they can’t write a death certificate, then the death will need to be referred to the coroner. It’s important to be aware that writing a death certificate and reporting a patient’s death to a coroner are mutually exclusive exercises.’
When is a death referred to a coroner?
Police will refer a death to the coroner for an investigation if they believe a death occurred under suspicious, violent, unusual or unnatural circumstances; for example, a death by suicide.
‘In circumstances where the GP is getting a call from the police, it is generally where the police have already undertaken a consideration about the nature of the death,’ Dr Bird said.
‘Where they haven’t formed the view – that the cause of death is unnatural or violent or suspicious or unusual – then the next step is generally to contact the GP or the last doctor whom the patient has seen.
‘Sometimes the police have found a box of medication in the patient’s home and they will contact that GP and say, “This person has been found dead at home. Are you in a position to write a death certificate for this patient?”’
Dr Bird said other circumstances where a death is referred to a coroner include when the person was in police or other lawful custody, or where the person was held in care; for example, in a mental health facility or residential service.
A death also has to be reported if it resulted directly or indirectly from an accident or injury. However, in NSW it is only if the person was younger than 72 years of age.
‘For example, the patient had a fractured hip and had just been discharged home from a rehabilitation facility and dies the next day, then it is likely that the death resulted directly or indirectly from that injury,’ Dr Bird said.
‘Or if the death was within 24 hours – in the ACT within 72 hours – of a surgical procedure, or invasive medical or diagnostic procedure, or under or as a result of an anaesthetic.’
In NSW, Queensland and Victoria, a death is referred to a coroner if it was not a reasonably expected outcome of a health related/medical procedure, or healthcare caused/contributed to the death and the death was not expected by an independent person.
‘Only in ACT and NSW, if the person was not attended by a medical practitioner within three months [ACT] or six months [NSW] immediately before death then it has to be referred to the coroner,’ Dr Bird said.
Threshold for determining the cause of death
‘It is an interesting discussion as to what the threshold is for determining the cause of death,’ Dr Bird said.
‘You don’t have to know with absolute certainty what the cause of death was; however, the GP needs to be able to determine the probable cause of death, or be comfortably satisfied as to the cause of death.’
Is the death certificate ever queried?
Though uncommon, Dr Bird said the cause of death is occasionally queried and referred on to a coroner after a death certificate has been issued.
What if the GP is in doubt?
If the GP is uncertain about writing a death certificate, Dr Bird said they can contact the coroner’s office directly.
‘They can certainly ring their medical defence organisation and, in some circumstances, we encourage GPs to contact the coroner’s office and discuss with them whether based on the information they know, that the coroner’s office feels it is appropriate for the GP to complete a death certificate,’ she said.
Why is an accurate death certificate important?
Information from death certificates informs a lot of public policy decisions.
‘The statistics from the causes of death are used to form decisions as a community as to where resources should be spent,’ Dr Bird said.
‘But the most direct one is that it is an important legal document and there are specific reasons why accurate death certificates can be very important.
‘For example, it can be important information to test the validity of somebody’s will, particularly if someone has dementia.’
When filling out the death certificate, Dr Bird said GPs have to specify the approximate interval between onset of a disease and the death of the patient. If the GP does not have this information, they should write down ‘unknown’, rather than leaving it blank.
‘If a patient died in their 80s and had had dementia for 10 years, but their will was written when they were in their 40s, then people would be quite comfortable that the will was valid,’ Dr Bird said.
‘But in circumstances where they have had dementia for 10 years and their will was only written 12 months before their death, then that would trigger requirements for the validity of the will to be examined.’
The death certificate could also inform any investigation or payout of a life insurance policy.
‘There may be issues in terms of when that life insurance policy was taken out,’ Dr Bird said.
‘If a patient had metastatic cancer and the life insurance policy was only taken out six months before their death, depending on what’s written on the death certificate, that may trigger some implications for the life insurance policy that the patient had.’
What is the format of the death certificate and what information do GPs need to complete the form?
Medical Certificate of Cause of Death forms contain demographic details of the deceased person, including:

  • full name
  • gender
  • date of death
  • place of death
  • age at death
  • Aboriginal or Torres Strait Islander origin
  • cause of death.
Is coroner’s legislation different from state to state?
Dr Bird said every Australian state and territory has specific coronial legislation, and there are some variations in the reporting requirements throughout Australia.
‘GPs need be aware of what the reporting requirements are in their jurisdiction,’ she said.

death certificate medico-legal

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