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Dr James Lucas, Medico-legal Consultant at the Medical Protection Society (MPS), outlines the implications of Covid-19 for death certification
At MPS, we appreciate that doctors are grappling with a complex web of Covid-19-related guidance that is being issued by Government agencies, professional bodies and other organisations. At the same time, many doctors are under considerable pressure, possibly working in unfamiliar clinical environments and adapting their customary practices to suit the demands of this extraordinary public health situation. We are doing our best to assist our members in understanding the fast-changing landscape, allowing doctors to focus on patient care and reduce their medico-legal risk.
For reasons that are depressingly obvious, many countries are in the process of, or have already amended, their normal systems for dealing with deaths in the face of the pandemic. In Ireland, the requirement on the representatives of the deceased to attend a civil registration service in person to register the death has been suspended. The Government advises that a family member or next-of-kin of the deceased can send the death notification form (DNF), signed by the medical practitioner, along with a copy of photo ID by post to the local Civil Registration Office or by post or email to the General Register Office.
Some jurisdictions have relaxed the usual stringent requirements placed upon medical practitioners in terms of certifying the cause of a patient’s death, in anticipation of the need for a more flexible approach on the ground; for example, allowing certification by a doctor who did not treat the deceased but who can state the cause of death to the best of his or her knowledge and belief.
It is important to note that in Ireland, notification to the coroner and certification of the cause of death by the treating doctor, where applicable, will proceed in the usual manner. It is possible that this could change, depending on how the situation evolves over the coming weeks and we will keep you informed.
Before considering the issues that are particularly relevant to Covid-19, it is perhaps useful to recap on the general principles regarding death registration.
It is a legal requirement in Ireland that every death which takes place in the State must be recorded and registered. Records of deaths in Ireland are held in the General Register Office, which is the central civil repository for records relating to births, marriages and deaths.
Following a death, a registered medical practitioner who attended the deceased during the illness that caused the death must complete and sign part 1 of the DNF, stating to the best of his or her knowledge or belief the cause of death. This obligation flows from the Civil Registration Act 2004.
This form must be given to a qualified informant within the meaning of the legislation.
The qualified informant must then complete and sign part two of the DNF, which contains the particulars of the deceased and is required to complete the registration.
Once completed, the DNF must be given to a registrar within three months of the death.
The Civil Registration Act 2004 must be considered alongside the coronial legislation, which places an onus on persons, including medical practitioners, nurses or midwives and any paramedic or advanced paramedic, to report a death to the coroner under specified circumstances. There are many different categories of ‘reportable death’. In the context of Covid-19 cases, the most obvious reporting obligation arises on foot of the requirement to notify the coroner about a notifiable disease or condition, but also under some of the other categories outlined in the legislation.
Healthcare professionals will already be aware that Covid-19 is a notifiable disease pursuant to the Infectious Diseases (Amendment) Regulations 2020.
The coroner service and Coroners Society of Ireland have approved guidance in relation to the reporting of deaths. The guidance indicates that there are a number of anticipated scenarios in which such reported deaths will arise.
We are advising healthcare professionals to check the website of the coroner service to determine which scenario applies in any given case and to confirm that they are adopting the most up-to-date guidance. Whilst the approach to be adopted varies from scenario-to-scenario, it is important to note that there is a common requirement to report the death to the district coroner in all of the scenarios described in the guidance.
The guidance helpfully reminds healthcare professionals of the hazard group classification of Covid-19 and the importance of following the relevant statutory regulations and guidelines from the HSE and Health Protection Surveillance Centre when handling, transporting and viewing the body of the deceased person.
The Coroners Society has also published a policy document relating to modified requirements for death pronouncement during the pandemic. The document explains that the pronouncement of death (as opposed to the certification of the cause of death) is a clinical practice requirement and is not provided for in legislation. To date, the coroner has relied upon a medical doctor to satisfy themselves that a person reported to them is deceased. However, during the pandemic, the needs of the living may be such that the coroners will accept a competent, trained person pronouncing expected death if a doctor is unavailable. This could be a senior nurse in a long-term care facility, public health nurse, palliative care nurse appropriately trained, or a paramedic if available in the community, for example.
The policy document states that death pronouncement may need to be by whatever means are available as the situation evolves and the policy will be kept under active review. The Coroners Society has indicated that identifying competent, trained persons and matters in relation to what constitutes an examination for the purpose of pronouncing death are for the competent healthcare authority. Furthermore, nothing in the policy alters the requirement for formal death pronouncement by a doctor in an unexpected death.
It is important to continue using the clinical record as a repository of relevant information when documenting decisions that are made in connection with the death of a patient, including reports to the coroner, and communication with coroners’ officers, the family of the deceased, and other healthcare professionals.
Any MPS members who have queries about reporting deaths to the coroner or pronouncing deaths that are not addressed in the guidance are very welcome to call our advice line for further information.
References on request