As a junior doctor in your first few years of practice, you will spend a lot of time at work. This means that you will often be called upon to sign MCCD forms and cremation forms by the Bereavement Office in your Trust. You'll find this is particularly the case if you've been working nights during which patients have died, and the Bereavement Office are keen to get the relevant certificates signed before you finish your shift.
Working in specialties involving the care of elderly patients or those with chronic conditions, such as cancer, cardiovascular or pulmonary disease, is more likely to expose a junior doctor to having to verify and certify death. Even if you aren't normally working for these specialties, you're likely to be covering them when you are on call.
Signing any form of certificate or report brings with it a lot of responsibility, and MCCD and cremation forms are legal documents. The MCCD is often referred to as the death certificate, however, the death certificate is actually a form used by the registrar of births, deaths and marriages. Where you are asked to complete a death certificate by your employer, this will really mean the MCCD.
Check your facts
The MCCD is a statutory document and there are penalties for its false completion – whether deliberate or not. The GMC says that you must be honest and trustworthy when signing forms and make sure that what you write is not false or misleading.
It's important to check that what you are writing is factually correct and that you do not leave out relevant information. Not completing a MCCD accurately, therefore, could result in a GMC investigation if it were brought to their attention.
Verifying vs certifying
Verifying a patient's death and certifying it are two different things. As a junior doctor you can verify a patient's death if you are appropriately trained and competent to do so. Again, acting outside the limits of your competence could lead you into trouble with the GMC.
A death is verified following examination of the body to determine that circulatory, respiratory and cerebral function has ceased. You should document your findings in the patient's notes, including the time at which the death was verified, your name (signed and printed) and your bleep/contact number. The patient's notes will be sent to the Bereavement Office, who will then contact you to sign the MCCD.
If you weren't the doctor who verified death, or did not care for the patient during their last 14 days, you are not eligible to sign the MCCD. You may already be familiar with the patient's medical history, but if not, you will need to review the notes carefully to ensure that you are able to establish the cause of death and any other relevant conditions. If you are unsure, you should speak to the consultant who was in charge of the patient's care.
During your final attachments in hospital as a medical student, you may find it helpful to accompany junior doctors who are asked to complete MCCD and cremation forms so that you can familiarise yourself with the forms. As soon as you start your new job, it is advisable to make yourself familiar to the Bereavement Office staff, who can guide you through the form if you are unsure of anything.
You must be honest and trustworthy when signing forms and make sure that what you write is not false or misleading.
Cause of death
There are a number of sections to fill in on the MCCD, and it's a good idea to become familiar with these. Most are straightforward, but the one that often causes most difficulty is the 'cause of death' section, which comprises four hierarchical sections.
If these are completed incorrectly, the form may be rejected by the registrar and this may lead to delays in the family being able to register the death and make arrangements for the funeral. It is very important, therefore, that you have a good understanding of what is, and is not, appropriate for this section.
In section 1a you should record the disease or condition which directly led to the patient's death. This is the immediate terminal event. An example of this would be a pulmonary embolus or subarachnoid haemorrhage.
In section 1b, you should record any other disease or condition, if any, which led to 1a. This could include, for example, deep vein thrombosis or ruptured berry aneurysm.
Section 1c should note any other disease or condition, if any, which led to 1b. Where there has been a PE and DVT, this could for example include obesity. The conditions mentioned in 1b and 1c should have directly caused all of the conditions listed in 1a.
Section 2 of the 'cause of death' section is for any other conditions contributing to the death, but not related to the disease that caused it. This could include a chronic condition, such as diabetes or ischaemic heart disease.
It is not usually appropriate to record 'old age' or 'natural causes' as a cause of death. Similarly, statements such as 'organ failure' or 'cardiac arrest' are too non-specific. Terms such as 'cerebrovascular accident' should also be avoided – as an 'accidental' death would need to be reported to the coroner/procurator fiscal. It is better to state 'cerebral infarction' or 'cerebral haemorrhage'.
Review the notes carefully to ensure that you are able to establish the cause of death and any other relevant conditions.
Abbreviations should also be avoided, as they may mean different things to different people, and the family would not be familiar with these. As with all clinical documentation, it is important to write legibly. If your handwriting is not very neat, especially after a night on call, it would be better to write in capitals.
Once you have completed the main page of the MCCD, don't forget to complete the counterfoil carefully so that it is consistent with the main certificate. This counterfoil is kept by the Bereavement Office as a record that the MCCD has been issued.
Signing cremation forms
Where a patient has died in England, Scotland or Wales and is to be cremated, separate forms need to be completed (separate forms are no longer required in Scotland) and again, these need to be accurate and legible.
As a junior doctor, you will only be eligible to complete form Cremation 4 and you must have inspected the body after death. If you weren't the person who verified the death, therefore, this may mean a trip to the mortuary.
In order to sign this form, you should have treated the deceased during their last illness and have seen them within 14 days of their death. A more senior doctor, who has been fully registered for at least five years with a licence to practise, must check Cremation 4 before completing form Cremation 5. This senior doctor must be fully independent of the doctor signing Cremation 4 and not involved in the care of the patient.
Where the cause of death is unknown, and under other circumstances, you will not be in a position to complete the MCCD and the death will need to be reported to the Coroner.
Dr Kathryn Leask
BSc (Hons) MBChB (Hons) LLB MA MRCPCH FFFLM DMedEth
Kathryn has been a medico-legal adviser with the MDU since 2007 and is a team leader, trainer and mentor in the medical advisory department. Before joining the MDU, she worked in paediatrics gaining her MRCPCH in 2002 and did her specialty training in clinical genetics. She has an MA in Health Care Ethics and Law, a Bachelor of Law and a Professional Doctorate in Medical Ethics. She is also a fellow of the Faculty of Forensic and Legal Medicine and has previously been an examiner and Deputy Chief Examiner for the faculty exam. Kathryn is currently a member of the faculty's Training and Education Subcommittee.
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