Death (Recognition and Certification)

It is vital when certifying death, to ensure that death has indeed occurred.
In the UK at present, there is no legal definition of death; although guidelines do exist for the diagnosis of death in more complex situations.¹
The current recommendations state that:
"Death should be verified by a doctor, or other suitably qualified personnel."²
Deaths are increasingly occurring in patient's own homes, as improved community nursing provision enables dying patients to remain out of hospital. The precise moment of death may be difficult to recognise, and for a period of time after respiration has ceased, and the heart has stopped, the patient may still potentially be resuscitated.
In certain conditions a patient may appear dead if not thoroughly examined:

• Following prolonged submersion in cold water
• Following ingestion of alcohol or drugs
• When hypoglycaemic, or in a coma

They may recover completely, if treated appropriately.
It should be remembered that hypothermia protects against hypoxic neurological damage, and that children under the age of 5 are more resilient to hypoxic brain injury, and therefore resuscitation should be continued in these circumstances until normal body temperature is reached, even if the patient appears to be dead.

A thorough physical examination should be carried out to ascertain whether or not death has taken place.³ First inspection should reveal a deathly pallor (particularly of the face and lips), and relaxation of the facial muscles. This leads to drooping of the lower jaw and open staring eyes. Further examination should include:

• Palpation of all major pulses.
• Auscultation of the heart and lungs for at least one minute, and repeated at intervals over at least five minutes.
• Inspection of the eyes for fixed dilated pupils, absence of corneal reflexes, cloudiness of the cornea and loss of eye tension.
• Examination of the fundi for segmentation of retinal blood columns "boxcars" ( only present in 30%).
• Examination of the trunk may show evidence of post mortem staining as a result of hypostasis.
• Examination of muscle tone for rigor mortis ( begins approximately 3 hours after death).
• Decreased temperature - will depend on ambient temperature, but may not occur for up to 8 hours.

Management of a death will depend on:

• The circumstances of the death
• Where it has occurred
• Whether or not it was anticipated
• Whether or not there is any suspicion of foul play.

Relatives and/or friends of the deceased may be very distressed and GPs attending a death should offer support where appropriate.
Bereaved families may also require guidance on the procedures following a death, particularly if the death was unexpected.
Verification of death may be performed by any appropriately qualified person.

Death certificate

A death certificate may be issued by a doctor who has provided care during the last illness and who has seen the deceased within 14 days of death ( 28 days in Northern Ireland) or after death. They should be confident about the cause of death.
The death certificate is given to the next of kin, who should take it to the local Registrar of Births, Deaths, and Marriages.
If the Registrar decides that the death does not need reporting to the Coroner he will issue:

• A Certificate for Burial or Cremation
• A Certificate of Registration of Death (for Social Security purposes)
• (On request), copies of the Death Register (at least two copies advisable because banks and insurance companies expect to see them).

If the body is to be buried in England, there are no further formalities.
If the burial is to be outside of England, an Out of England Order is needed from the coroner.
If the burial is to be at sea, and Out of England Order and a licence from the Ministry of Agriculture, Food and Fisheries is needed, and the District Inspector of Fisheries should be notified.

Cremation certificate

If there is to be a cremation, the doctor who has provided the medical certificate of death completes Part B of the cremation form.
A second doctor, not in partnership with the first, (who has been qualified for more than 5 years), may sign Part C of the Cremation Form. The second doctor completing Form C is expected to contact the person(s) caring for the deceased and ask if they have any concerns about the medical management of the deceased.
Part C of the Cremation Form may only be signed by the second doctor after he/she has seen the body and discussed the death with the first doctor, and preferably with any person present at the time of death.
This certificate is usually given to the undertaker who takes it to the Medical Referee at the Crematorium who checks the forms and gives the final approval necessary for cremation to occur.
Occasionally, circumstances occur in which the death must be reported to the coroner or procurator (Scotland) rather than issuing a death certificate. Legally, this is the responsibility of the Registrar, but it is good practice (and saves time and distress for relatives) for doctors to report directly to the coroner or procurator:

• Death from an industrial disease, poisoning or accident
• Death of a patient in receipt of an industrial or war pension
• Death by suicide, poisoning or drugs
• Death as a result of an illegal abortion
• Death from neglect, want or exposure