Sudden Death

The term sudden death is usually taken as being synonymous with unexpected death. It also tends to exclude unnatural causes of death.

About 25% of deaths occur at home. Not all are unexpected as many people with terminal illness elect to die at home. Unexpected death may occur at home or in a public place.

When a person calls to say that someone has died there is probably a degree of panic and distress. Be calm and reassuring and try to get some information.

• Confirm the identity of the deceased and the address. Your records may show a terminal illness, evidence of heart disease or no obvious predictor of death.
• Confirm the grounds for believing that the person is dead. The caller is almost always correct but occasionally the "deceased" is just deeply asleep.
• Try to get some background as to what happened. The individual may be unrousable in bed or may have collapsed having complained of indigestion. "Collapsed" is a very loose term that the public apply to anything from sitting down because of feeling vaguely unwell to dead.
• Tell the caller that nothing must be moved or changed and that you will be round soon.
• Either ask the caller to call an ambulance or do so yourself but the caller should be aware of the impending arrival. Ambulance personnel will not take a dead body to hospital but they may initiate resuscitation if appropriate.

Although it may seem that the dead should wait while the doctor finishes attending to the living, there are a number of reasons for expediting the visit. The person may not be dead but in need of urgent attention. Those around will be distraught and even the realization of their worst fear is better than uncertainty. Ambulance personnel may be involved in futile resuscitation or simply having to wait for the doctor to arrive before they may move on. Expeditious attention is kind to those around and enhances the productive use of resources.

Anyone may pronounce death, but only a doctor may certify death. A GP is not contractually obliged to attend a corpse, presumably because his obligation ceased when life expired. However, what may be contractually required and what is kindness and common sense may be very different matters. It is also important to realize that a sudden and unexpected death may be a forensic situation. According to the BMA, the Broderick report of 1971 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. This may change in the light of the Shipman Inquiry.

On arrival at the house acknowledge those present and ask to see the body. You may be met by a policeman or ambulance personnel. They may be able to give you a little history.

A brief inspection shows that the body is lifeless. There is no spontaneous movement and no sign of respiratory effort. Feel for a pulse. The carotid may be a better place to feel that the radial pulse. Listen to the chest. Is it silent? Use 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. This involves touching the body. Note the temperature. Is the body still warm or very cold. Police surgeons may carry low reading thermometers to measure the temperature of the body and, noting the temperature of the environment, this will help indicate the time of death. Most doctors do not carry such an instrument.

Having confirmed death, have a more general look. The scene may have been radically changed if CPR has been attempted. For example, the body may have been moved off the bed and on to the floor. Remember that an unexpected death may be a crime, even in an old person. It may be rare but it is important not to overlook such as case if it occurs. Are there signs of a struggle or a pool of blood?

Look around the room. There may be medicine bottles indicating a disease and possibly GTN immediately at hand suggesting recent use. There may be empty packaging suggesting a drug overdose or even a suicide note. Be careful about moving more than is necessary, both as a mark of respect and because if it is not clear that death was from natural causes, this is a scene of crime.

Look at the body. Note the position and if it has been changed. Look at the face. Was this a peaceful death in sleep or is there pain or fear on the face? Is the face congested. Petechial haemorrhages suggest asphyxiation. That does not necessarily mean strangulation but inspect the neck. Note any unexplained bruises, abrasions or marks.

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.

Within the realms of discretion, inspect the body on both sides and as widely as seems appropriate so as not to miss anything. It would be an enormous embarrassment to write a death certificate for myocardial infarction and to have the undertaker complain that there is a knife protruding from the back.

In detective fiction, any doctor can ascertain the time of death with consummate ease and with breath-taking accuracy. In real life, ascertaining the time of death is very much more difficult¹ and where the expert treads with great caution, the 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 stoney 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 hours¹ to set in, probably being faster in a warm environment. The time for rigor mortis to resolve is probably just as variable.

The doctor should inform those present of the fact of death in a manner that is sympathetic but unambiguous. A sentence such as, "I am afraid that as you thought he is dead," is less likely to lead to misunderstanding than the use of euphemisms. Give a short while for the information to be taken in and then something like, "I am afraid that I need to ask you a few questions so that I can get an idea of exactly what happened."

Try to get some history of what happened. Had he been well until then or perhaps he had retired to bed complaining of something? Perhaps he had been up and about but complaining of "indigestion" before collapsing and dying. Examination may even show some white antacid around the mouth. Abdominal pain may have been a dissecting aortic aneurysm.

All sudden or unexpected deaths where a doctor has not attended within the previous 2 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 have no examination, the appropriate box on the death certificate should be ticked.

Relatives are often eager to avoid post mortem 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 not just bureaucratic nicety. It 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. It is very important that murder does not go undetected.

Some people may say that their religious beliefs are contrary to post mortem examination but the law of the land is paramount in such a case and their religion will accept this.

In the light of the report from the Shipman Inquiry,² it is likely that there will be statutory changes with regard to the reporting of unexpected deaths.

If you arrive at the scene and find CPR being performed on a body that is cold or has rigor mortis, this is futile and must be stopped. Even a flat ECG tracing of asystole carries very little hope of successful resuscitation. 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 not kind.

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. 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 must be fully investigated.³

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.⁴ It is important for the purposes of research that such open verdicts are included in analysis.⁵

A duty of care also extends to the bereaved. An anticipated death can be quite traumatic but an unexpected death is far more difficult. After the immediate realization, the most difficult time is often not leading up to the funeral which is a busy time of making arrangements and everyone is most supportive. It is after the funeral when the emptiness and the loneliness strikes. A funeral is a very important time. Sometimes people are kept away from funerals, especially children, as "it would be too much for them". In Scotland there was a tradition that women would not go to the graveside, as if there was a fear that they may cause embarrassment by behaving inappropriately, such as showing emotion. A funeral is a very important time to say goodbye.

Sometimes the use of sleeping tablets, for the first night or even a few nights after may be justified but it is important not to let habit develop. It is often worth suggesting to the bereaved that they should make an appointment to see their own doctor. The best time for this is often after the funeral as the long emptiness begins.

In 1999 the 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, GPs would be quite right to explain that the needs of the living must take priority over the requirements of the dead. On a parallel basis, case law exists to confirm that a NHS general practitioner does not have a contractual obligation to attend upon the body of a patient declared to be dead. Once again the fact that a contractual obligation does not exist should never be used by GPs to avoid the ethical and moral responsibility to make the experience of bereavement as gentle and easy as possible for relatives and friends."

This seems to give a sensible balance between contractual and moral responsibilities. As mentioned above, certification of death may well change in the light of the Shipman Inquiry.