Dr Antonia Field-SmithConsultant in Palliative Medicine

West Middlesex University Hospital

Post mortem

Overview

• Diagnosis and verification of death• Medical certificate of cause of death (MCCD)• Coroner system• Mortality review process

Diagnosis and verification of death

Diagnosis of death

"the definition of death should be regarded as the irreversible loss of the capacity for consciousness, combined with irreversible loss of the capacity to breathe”

A Code of Practice for the Diagnosis and Confirmation of DeathAcademy of Medical Royal Colleges (AoMRC) 2008

Recognition of Life Extinct (ROLE)

ØDecapitationØMassive cranial and cerebral disruptionØHemicorporectomy (or similar massive injury)ØIncineration (>95% full thickness burns)ØDecomposition/putrefactionØRigor mortis and hypostasis

UK Ambulance Service Clinical Practice Guidelines 2013

Confirmation of death after cardiorespiratory arrest (UK)

• Simultaneous and irreversible onset of circulatory arrest, unconsciousness, and apnoea • Observe and examine for a full five minutes to establish:

• pulselessness – at carotid/femoral artery • apnoea – no respiratory effort • no heart sounds – on auscultation

• Then examine specifically for:• fixed dilated pupils • absent corneal reflex • lack of a response to supra-orbital pressure

Guidance from the Academy of Medical Royal Colleges (AoMRC) 2008

Brainstem death

• Patient is deeply comatose, unresponsive and apnoeic, with his/her lungs being artificially ventilated• Essential components:

1. Aetiology of irreversible brain damage 2. Exclusion of potentially reversible causes of coma and apnoea3. Absent brainstem reflexes

• Diagnosis by 2 doctors ( at least 1 consultant) who have been registered for >5 years and are competent in the procedure• Evidence of whole brain death required in USA and Europe

English Law

• does not require a doctor to verify death• does not require a doctor to view the body of a deceased person• does not require a doctor to report the fact that death has occurred• does require the doctor who attended the deceased during the last

illness to issue a certificate detailing the cause of death

• No statutory duty for a doctor to report any death to a coroner

Registered nurse verification of expected adult death (RNVoEAD)

• Explicit local policy in place• RN must be trained and deemed

competent to verify the death• Verification is timely

• within 1 hr hospital setting • within 4 hrs community setting

• Relatives are aware of care plan

• Valid DNACPR order• Death must:• Be expected and no

suspicious circumstances• Occur in a private residence,

hospice, residential home, nursing home, prison or hospital

“Last Offices”

Repatriation

• Only the coroner can give permission for the deceased to be moved from England and Wales

• Deceased needs to be embalmed and certified as free from infection

• Most funeral directors will co-ordinate the process

• Ashes usually taken as hand luggage but can be checked in

Medical certificate of cause of death (MCCD)

Anita Berlin (2009) Death certification: topical tips for GPs, London Journal of Primary Care, 2:2,

130-137, DOI: 10.1080/17571472.2009.11493267

Coroner system

• 43% of all deaths in 2017 reported to coroner • 37% of reported deaths had post mortem exam• No inquest in the majority (83%) of cases• Duty of confidentiality persists after death but exception if providing

information to coroner• 85% coroners are from non medical professional background

Deaths reportable to the coroner

Not seen by a doctor during last illness

Attending doctor not available to certify

Under anaesthesia or ‘on table’

At work or due to industrial disease

Sudden and unexplained

Unnatural including any poisoning

Violence or neglect

Other suspicious circumstances

Prison, police custody or state detention

Duty to investigate

• No Further Action ‘NFA’ – 60%• Issue Form 100A so death can be registered• Attending doctor issues MCCD

• Open an investigation• Request post mortem • Issue Burial Order or Cremation Form 6 whilst awaiting outcome • If NFA (natural causes) – issue Form 100B to register death

• Open an inquest (10-15%) +/- post mortem

Duty to hold inquest

• Must be held by law if a death is due to unnatural causes• A public judicial inquiry presided over by the Coroner• Jury required in certain circumstances e.g. RTA• Neutral, fact-finding exercise• Asks who was the deceased, where, when and how did they die? • Conclusion includes legal determination, findings and narrative

Problems with death certification

• Dependent on the integrity and judgement of a single doctor

• Pressure for doctors to complete quickly • Under reporting of appropriate deaths to coroner• Poor quality of certification• Lack of information exchange with relatives• Need for registrars to understand medical

terminology• No system of audit or review

Medical examiner system

• Coroners and Justice Act 2009 reforms - need for increased scrutiny and safeguards• Rolling out in hospitals in England and Wales from April 2019

• All deaths scrutinised by Medical Examiner employed by NHS TrustØImproved quality and accuracy of MCCDsØMore appropriate referrals to coroner ØOpportunity for relatives to raise concerns (The Shipman Question)ØOpportunity to report clinical governance concerns

Mortality review process

Learning from Deaths

• Each Trust should at a minimum ensure: ØMeaningful engagement and support of bereaved families and carers ØIntroduction of structured case record reviews when reviewing patient deathsØMechanisms to review all deaths of people:

• With a Learning Disability • With a Serious Mental Health Illness • Those aged under 18 years • Perinatal and maternal deaths

ØPublish quarterly data and develop a learning from deaths policy

National Mortality Case Record Review programme

• Review of case records of adult patients who have died in acute hospitals

• Standardized and evidence based methodology• Includes explicit judgement statements and phase

of care scores about the perceived safety and quality of care

• Qualitative analysis of mortality data linked to quality improvement activity

https://www.england.nhs.uk/wp-content/uploads/2018/08/information-for-families-following-a-bereavement.pdf

“Death rounds”

References• A Code of Practice for the Diagnosis and Confirmation of Death (AOMRC):

http://www.aomrc.org.uk/wp-content/uploads/2016/04/Code_Practice_Confirmation_Diagnosis_Death_1008-4.pdf

• Hospice UK publications: https://www.hospiceuk.org/what-we-offer/publications• Guidance for completing MCCD and cremation forms:

• https://www.gro.gov.uk/Images/medcert_July_2010.pdf• https://www.gov.uk/government/publications/medical-practitioners-guidance-on-

completing-cremation-forms• Medical examiner reforms: https://www.gov.uk/government/publications/changes-to-

the-death-certification-process/an-overview-of-the-death-certification-reforms• Guide to Coroner Services:

https://www.coronersociety.org.uk/_img/pics/pdf_1503323588.pdf• National Guidance on Learning from Deaths: https://www.england.nhs.uk/wp-

content/uploads/2017/03/nqb-national-guidance-learning-from-deaths.pdf• Using the structured judgement review method: A guide for reviewers

https://www.rcplondon.ac.uk/sites/default/files/media/Documents/NMCRR%20guide%20England_0.pdf