Deaths within critical care are rarely unexpected. The majority of patients who die will have had active treatment withdrawal decisions made either following brainstem death tests or on grounds of futility. There is a critical care end of life care document which should be completed for every patient in receipt of palliation. 

It is the responsibility of the critical care resident to verify patient death as soon as possible after death. Please refer to the diagnosis of death guidelines. The examination must be recorded on the cause of death proforma and filed in patient’s pink notes. If the patient is fully ventilated but asystolic the ventilator should be turned off prior to verification of death. The nursing staff may ask the doctor to do this. This can be an exceptionally distressing time for the patient’s family so compassion and understanding are required. 

All patients in whom life-sustaining treatment withdrawal decisions have been made should be discussed with the tissue and organ donation specialist nurse. Currently this is a national requirement. 

Death certification, the Medical Examiner and referral to the coroner

The Medical Examiner Service was introduced in June 2018. 

The aims of the service are to: 

1. Improve the accuracy of the death certification process 

2. Provide more consistent and appropriate referrals to the Coroner 

3. Ensure direct contact with bereaved relatives to identify /address concerns at an early stage 

4. Complete the second part of the cremation form 

5. Perform first level mortality review 

The process for death certification, referral to coroner and urgent release are explained on the following flow charts:

  

The indications for referral to the HM coroner can be viewed clicking here

There are close working relations with Bereavement Service, the Coroner’s office and the Mortuary team. 

The team of medical examiners include: 

• Col Douglas Bryant, Oral and Maxillo-Facial Surgery 
• Dr David Broughtom, Stroke Medicine 
• Dr David R Chadwick, Infectious Diseases 
• Dr Richard Graham, Cardiology 
• Dr Diane Monkhouse, Critical Care 
• Dr Nick Quinn, Acute Medicine and Diabetes 
• Dr Mohamed Shawgi, Radiology 
• Dr Tom Ward, Respiratory and palliative Care 
• Dr Judith Wright, Anaesthesia and Critical Care 

The Medical Examiners’ office is based on the ground floor of the Murray building next to the Bereavement office. Opening hours will be 08:00 until 16:00 Monday to Friday. 

Appointments with the ME should be arranged via the bereavement service. There is an expectation that junior medical staff have discussed a proposed cause of death with their consultant prior to meeting the ME. The Medical Certificate of Cause of Death (MCCD) should be completed in the Medical Examiners’ office after discussion and scrutiny of the health care records. Death certificates will no longer be completed on the ward. 

Please document exactly what has been written on the certificate in the pink notes. 

The ME role will support and advise as necessary. 

Many of our deaths need to be discussed with the Coroner’s Officer. Please check with the Critical Care Consultant and the ME and document any conversation with the Coroner’s office in the notes. Occasionally, the case needs to be discussed with the Coroner’s Office before death occurs e.g. in trauma patients who could be potential organ donors. 

Cremation forms 

With regard to the cremation form, the attending doctor will be asked to complete part 1 of the form in the ME office. Part 2 will be completed by the ME who will also contact the patient’s next of kin to explain the contents of MCCD. Following scrutiny of the health care records, a first level mortality review will be performed by the ME. Any cases requiring more detailed review will be passed onto parent specialty and mortality surveillance teams. Health care records will be returned to the ward on completion of the process. Please do not leave the pink notes in the ME office. 

NB: The doctor who completes the cremation form must have looked after the patient when were alive and have seen the body of the patient after death. 

If you are completing the cremation form and were not the doctor who certified the death of the patient then you must go to the hospital mortuary to view the body. You should sign the mortuary book to confirm your attendance. Cremation forms are subject to strict scrutiny please complete them legibly, if you are unsure what to put in any section then please ask a senior doctor. Please put a contact telephone number on which you can be contacted (even if you are off duty) in case there are any problems or queries with the form. Please document in the pink notes if you have completed a cremation form. 

It is essential that after-death duties are completed in a timely manner to avoid delays for grieving families.