The term sudden death is usually taken as being synonymous with unexpected death. It is usually taken to exclude unnatural causes of death.
Sudden death can occur in infants and is described in the separate article Sudden Infant Death Syndrome (SIDS). Sudden death can also occur in adults, from a variety of causes, usually cardiac or with an underlying diagnosis of epilepsy. Whatever the age or cause of the sudden death, to some extent the circumstances of the death will have a bearing on whether primary care doctors become involved or not. A dramatic collapse from cardiac disease on the sports field will result in the ambulance and emergency services being called. The discovery of an elderly patient dead in bed one morning is less likely to initiate such a response from relatives, but they may well call their GP rather than the police or emergency services.
Unexpected death may occur at home or in a public place.
An unexpected death may be reported to the GP and it is important to ascertain quickly what response is appropriate. It is most important first to establish whether death has occurred, or is likely to have occurred beyond all reasonable doubt.
When informed of a sudden or unexpected death:
- Take a history:
- Confirm the grounds for believing that the person is dead. The caller is almost always correct but it is worth checking that there are indeed no signs of life.
- Confirm the identity of the deceased and the address.
- Check medical records for terminal illness, evidence of heart disease or of serious illness. There may be no history of illness. Check when the patient was last seen by a doctor.
- Try to get some background as to what happened.
- If there is any doubt about whether the patient is dead then an ambulance should be called. It may be necessary to guide the caller by asking direct questions about signs of life. Caution is called for when the caller may be unreliable (for whatever reason) or the patient has certain conditions (for example, diabetes).
- Ambulance personnel will not take a dead body to hospital but they may initiate resuscitation if appropriate.
- When death has obviously occurred and is unexpected the coroner's officer should be informed. They will then take over management of the situation and initiate investigation of the death and the cause of death.
- Is a visit required? A visit may be appropriate because:
- The patient collapses suddenly and the doctor and emergency services attend.
- Death has not definitely occurred. Where there is uncertainty, and a death would be unexpected, it would be normal to call an ambulance.
- Relatives may be particularly distressed and need medical attention.
- Be aware that:
- Anyone may confirm death. Only a doctor may certify death.
- A GP is not contractually obliged to attend the deceased (but this of course assumes that death has occurred).
- A sudden and unexpected death may be a death from an unnatural cause (and require police involvement and forensic examination).
- According to the British Medical Association (BMA), the Broderick report of 1971 recommends that a doctor should be required to inspect the body of a deceased person before issuing the certificate but this recommendation was not implemented.
- There have been some changes in procedure which affect completion of cremation papers following the Shipman Inquiry. Changes in certification of death are planned and will come into effect from April 2012.
This is distinct from certifying death. There has been updated guidance on the certification of death from the Home Office.
There is guidance on the diagnosis and confirmation of death from the Academy of Medical Royal Colleges and further detail can be found in the separate article Death (Recognition and Certification). The guidance is mainly concerned with confirmation of death in hospital and in circumstances where the diagnosis of death may be more difficult (patients on ventilators, for example).
If a visit is made in primary care it is important to follow a routine. Police or ambulance personnel may be present. They may be able to give you more history. Then conduct:
- A brief inspection and examination of the body to confirm death:
- Confirm that the body is lifeless with no spontaneous movement and no sign of respiratory effort.
- Confirm there is no pulse. The carotid may be a better place to feel than the radial pulse.
- Confirm there is no breathing effort. Look for signs, listen to the chest.
- After five minutes confirm the absence of pulse and respiratory effort as above.
- Whilst waiting, consider the following:
- If a body has been dead for a matter of hours, then gravity tends to pool blood and a dependent livido results. If this is not in the lowest parts, as expected, the body has been moved.
- A cherry red colour may suggest carbon monoxide poisoning and is seen only post mortem. It can also occur with organophosphate poisoning.
- It is appropriate to discreetly inspect the body on both sides to ensure that there are no concealed findings which may be relevant to death.
- It is much better to discover unexpected or unexplained wounds before the undertaker!
- Use of the ophthalmoscope to inspect the retina. The characteristic sign is called tracking. The usually continuous lines of the retinal vessels are interrupted like a string of sausages.
- Note the temperature. Is the body still warm or very cold? Low-reading thermometers are used to measure the temperature of the body and, noting the temperature of the environment, this will help indicate the time of death. Most doctors, even Forensic Physicians (formerly Police Surgeons) do not carry such an instrument. The job of measuring temperature is now done by Scene of Crime Officers (SOCOs).
- Look at the face. Is the face congested or swollen? Petechial haemorrhages suggest asphyxiation. Inspect the neck. Note any unexplained bruises, abrasions or marks.
- Whilst waiting, have a brief inspection/look around the room:
- Remember the possibility of death from unnatural causes when considering the history, the mode of death and possible causes of death.
- Be careful about moving more than is necessary, both as a mark of respect but also until it is clear that death was from natural causes. Whilst there is a possibility of death from unnatural causes, the room is a potential crime scene.
- The scene may have been radically changed if cardiopulmonary resuscitation (CPR) has been attempted. For example, the body may have been moved off the bed and on to the floor.
- There may be medicine bottles indicating a disease and possibly glyceryl trinitrate (GTN) immediately at hand, suggesting recent use.
- Emptied bottles of pills, suicide notes and emptied bottles of alcohol are also sometimes enlightening.
- Look again at the body.
Time of death
In detective fiction, any doctor can ascertain the time of death with consummate ease and with breathtaking accuracy. In real life, ascertaining the time of death is very much more difficult and, where the expert treads with great caution, those who are inexpert should be even more wary.
The doctor should note such simple matters as whether the body is warm or cold and if rigor mortis is present. A stony cold body has obviously been dead for several hours. The rate of loss of heat will depend upon the difference between body temperature and the surroundings. Rigor mortis can take between 2 and 12 hours to set in, probably being faster in a warm environment. The time for rigor mortis to resolve is probably just as variable.
- This is affected by ambient temperature (warmer temperature means faster onset), level of glycogen stores (struggling before death means faster onset).
- 0-3 hours: warm and flaccid.
- 3-8 hours: warm and stiff - small joints (fingers, toes, jaw) first, then large joints, stiffen.
- 8-36 hours: cold and stiff - small joints start to loosen after 18 hours.
- 36+ hours: cold and flaccid.
Informing those present
The doctor should inform those present of the fact of death in a manner that is sympathetic but unambiguous. Avoid euphemisms for death which can lead to misunderstanding. Use the good guidance available when 'breaking bad news'.
Allow time for relatives to compose themselves. Try to get some further history of what happened. Had the deceased been unwell or complained of symptoms? For example, symptoms of indigestion may be significant. Examination may even show some white antacid around the mouth. Severe abdominal pain, with or without back pain, may have been caused by a dissecting aortic aneurysm. If a patient was known to have a potentially lethal condition such as coronary heart disease, this is probably the cause of sudden death, but not invariably.
All sudden or unexpected deaths where a doctor has not attended within the previous two weeks must be reported to the coroner or procurator fiscal in Scotland. This is usually done via the police. It is necessary to consult with the coroner or procurator fiscal about whether a postmortem examination is needed. If he consents to having no examination, the appropriate box on the death certificate should be ticked.
Relatives are often eager to avoid postmortem examinations and it may seem kind to comply but statutory requirements must be fulfilled.
- The younger the person or the more unexpected the death, the more important it is to have a definitive cause of death.
- Stating an accurate cause of death is important to obtain meaningful epidemiological data to identify health needs and perhaps to uncover hidden risks.
- If there is any doubt or suspicion about the cause of death, then call the police immediately.
- Futile attempts at resuscitation should be curtailed (for example, on a body that is cold or has rigor mortis). However, drowning or near drowning, especially in a child with hypothermia may well merit very persistent attempts at resuscitation.
- Attempted resuscitation on a patient with a known terminal disease is inappropriate and unkind.
- The younger a person who dies suddenly, the more important it is that the death should be fully investigated. Exertion can cause sudden death with aortic stenosis or cardiomyopathy even in adolescents. Sudden death in young people may also be associated with drug abuse. Sudden infant death syndrome (SIDS) must be fully investigated.
- A coroner's verdict of suicide is distressing to the family and it does appear that an open verdict is often given rather than a verdict of suicide. It is important for the purposes of research that such open verdicts be included in analysis.
A duty of care also extends to the bereaved. Sudden or unexpected deaths are likely to produce more immediate distress, not only to family and relatives but also to others including carers, witnesses, friends and neighbours. It is important to bear this in mind when dealing with a sudden death, however minor any involvement is.
British Medical Association guidance
In 1999, the General Practitioners Committee (GPC) issued the following guidance: "The Broderick report recommended that a doctor should be required to inspect the body of a deceased person before issuing the certificate but this recommendation has never been implemented. Thus, there is no requirement in English law for a general practitioner or any other registered medical practitioner to see or examine the body of a person who is said to be dead. General practitioners as a body would not, and as individuals should not, seek to use this quirk of English law to avoid attending upon an apparently deceased patient for whom the GP is responsible. However, the fact that there is no legal obligation upon a GP to attend a corpse should be remembered and, if necessary, quoted when organisations such as the emergency services ask general practitioners, either in or out of hours, to attend a corpse as a matter of urgency."
If a patient is declared to be dead by a relative, a member of staff in a nursing home, ambulance personnel or the police then a GP visit is not usually appropriate or necessary. However the absence of any contractual obligation does not prevent ethical and moral considerations prevailing and encouraging the doctor to make the experience of bereavement as gentle and easy as possible for relatives and friends.
The BMA guidance encourages a balance between contractual and moral responsibilities.
Further reading & references
- Bereavement, Royal College of Psychiatrists
- A code of practice for the diagnosis and confirmation of death, Academy of Medical Royal Colleges (October 2008)
- Postmortem changes and time of death, Department of Forensic Medicine, University of Dundee; Lecture notes
- Registering a death, Directgov; Home Office guidance for doctors completing Medical Certificates of Cause of Death in England and Wales 2008
- The Shipman Inquiry; Independent public inquiry into the issues arising from the case of Harold Frederick Shipman; Chairman Dame Janet Smith
- Levene S, Bacon CJ; Sudden unexpected death and covert homicide in infancy.; Arch Dis Child. 2004 May;89(5):443-7.
- Sampson HH, Rutty GN; Under-reporting of suicide in South Yorkshire (West): a retrospective study of suicide and open verdicts returned by HM Coroner, 1992-1997.; J Clin Forensic Med. 1999 Jun;6(2):72-6.
- Linsley KR, Schapira K, Kelly TP; Open verdict v. suicide - importance to research.; Br J Psychiatry. 2001 May;178:465-8.
|Original Author: Dr Richard Draper||Current Version: Dr Hayley Willacy||Peer Reviewer: Dr Paul Scott|
|Last Checked: 19/08/2011||Document ID: 1653 Version: 23||© EMIS|
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