Guidance

Guidance for doctors completing medical certificates of cause of death in England and Wales (accessible version)

Updated 25 March 2022

Guidance for doctors completing medical certificates of cause of death in England and Wales

This guidance is intended to complement the notes for doctors in the front of every book of medical certificate of cause of death (MCCD). Those instructions remain current, and doctors should familiarise themselves with the MCCD notes, and consult them if they are in any doubt about whether, or how, to certify a death.

This guidance replaces the guidance provided during the Coronavirus pandemic and doctors should familiarise themselves with these updated procedures relating to the issue of an MCCD.

1. The purposes of death certification

Prompt and accurate certification of death is essential as it serves a number of functions. A medical certificate of cause of death (MCCD) enables the deceased’s family to register the death. This provides a permanent legal record of the fact of death and enables the family to arrange disposal of the body, and to settle the deceased’s estate.

The doctor who attended the deceased during their last illness has a legal responsibility to complete a MCCD and arrange for the delivery of it to the relevant registrar as soon as possible to enable the registration to take place. It is encouraged that this is done electronically by scanning and emailing the MCCD to the relevant register office. The operational arrangements for this should be agreed with the register office concerned. Deaths are required by law to be registered within 5 days of their occurrence unless there is to be a coroner’s postmortem or an inquest.

The certifying doctor must also advise the informant that the MCCD has been issued.

After registering the death, the informant (normally the next of kin) gets a certified copy of the register entry (‘death certificate’), which includes an exact copy of the cause of death information that you give. This provides them with an explanation of how and why their patient died. It also gives them a permanent record of information about the medical history, which may be important for their own health and that of future generations. For all of these reasons it is extremely important that you provide clear, accurate and complete information in a timely manner about the diseases or conditions that caused your patient’s death.

Information from death certificates is used to measure the relative contributions of different diseases to mortality. Statistical information on deaths by underlying cause is important for monitoring the health of the population, designing, and evaluating public health interventions, recognising priorities for medical research and health services, planning health services, and assessing the effectiveness of those services. Death certificate data are extensively used in research into the health effects of exposure to a wide range of risk factors through the environment, work, medical and surgical care, and other sources.

2. Who should certify the death?

When a patient dies it is the statutory duty of the doctor who has attended in the last illness to issue the MCCD. Although there is no clear legal definition of ‘attended’, it is generally accepted to mean a doctor who has cared for the patient during the illness that led to death and so is familiar with the patient’s medical history, investigations and treatment. The certifying doctor should also have access to relevant medical records and the results of investigations. There is no provision under current legislation to delegate this statutory duty to any non-medical staff.

In hospital, there may be several doctors in a team caring for the patient. It is ultimately the responsibility of the consultant in charge of the patient’s care to ensure that the death is properly certified. Any subsequent enquiries, such as for the results of postmortem or ante-mortem investigations, will be addressed to the consultant.

In general practice, more than one GP may have been involved in the patient’s care and so be able to certify the death. If no doctor who cared for the patient can be found, the death must be referred to the coroner to investigate and certify the cause.

If the attending doctor has not seen the patient within the 28 days preceding death, and has not seen the body after death either, the registrar is obliged to refer the death to the coroner before it can be registered; the last ‘seen’ requirement within 28 days can include consultation using video technology (not telephone/audio) however the ‘seen’ after death requirement can only be met through personal attendance. In these circumstances, the coroner may instruct the registrar to accept the attending doctor’s MCCD for registration, despite the prolonged interval.

In contrast, a doctor who has not been directly involved in the patient’s care at any time during the illness from which they died cannot certify under current legislation but should provide the coroner with any information that may help to determine the cause of death. The coroner may then provide this information to the registrar of deaths. It will be used for mortality statistics, but the death will be legally ‘uncertified’ if the coroner does not investigate through an autopsy, an inquest, or both.

3. Referring deaths to the coroner

Doctors are reminded that:

  • COVID-19 is an acceptable direct or underlying cause of death for the purposes of completing the MCCD
  • COVID-19 is not a reason on its own to refer a death to a coroner under the Coroners and Justice Act 2009
  • the fact that COVID-19 is a notifiable disease under the Health Protection (Notification) Regulations 2010 does not mean referral to a coroner is required by virtue of its notifiable status

Doctors (under the Notification of Deaths Regulations 2019) and registrars of births and deaths (under the Registration of Births and Deaths Regulations 1987) have a legal obligation to report certain categories of deaths to the coroner before they can be registered. These include deaths where there is reason to suspect the death was unnatural, unknown, violent or where the death occurs in custody or otherwise in state detention. This can include where the death is due to the person undergoing a treatment or procedure of a medical or similar nature: for example, a death during an operation or before full recovery from an anaesthetic. In addition, there will always be cases which may on one view be ‘natural’ which have some other element (for examples concerns about neglect or standards of care) which brings them within the orbit of the coroner. These should be reported to the coroner.

Deaths for which the cause is not known must also be reported to the coroner, likewise if no doctor has attended the deceased or the certifying doctor has not seen the deceased within 28 days prior to their death (this can include video consultation but not telephone/audio) or the deceased was not seen in person after death by the certifying doctor, the death must be referred to the coroner.

Strictly speaking, the law requires where a doctor can issue an MCCD they should do so, even when a death has been referred to the coroner. But in practice, if the coroner has decided to order a postmortem and/or to hold an inquest, he may tell the doctor not to complete the MCCD. However, the coroner can only legally certify the cause of death if he has investigated it through autopsy, inquest, or both. This means that, if the coroner decides not to investigate, the registrar will need to obtain an MCCD from a doctor who attended the deceased before the death can be registered. This may cause inconvenience to the doctor and the family if you have not already provided one.

When a death is referred, it is up to the coroner to decide whether or not it should be investigated further. It is very important that the coroner is given all of the facts relevant to this decision. The doctor should discuss the case with the coroner before issuing an MCCD if at all uncertain whether he or she should certify the death. This allows the coroner to make enquiries and decide whether or not any further investigation is needed, before the informant tries to register the death.

The coroner may decide that the death can be registered from the doctor’s MCCD. For example, a large proportion of deaths with fractured neck of femur mentioned on the certificate are registered from the original MCCD following referral to the coroner. Omitting to mention on the MCCD conditions or events that contributed to the death in order to avoid referral to the coroner is unacceptable and a breach of the doctor’s legal obligations. If these come to light when the informant registers the death, the registrar will be obliged to refer it to the coroner. If the fact emerges after the death is registered, an inquest may still be held.

4. How to complete the cause of death section

Doctors are required to certify causes of death “to the best of their knowledge and belief”. Without diagnostic proof, if appropriate and to avoid delay, doctors can circle ‘2’ in the MCCD (“information from postmortem may be available later”) or tick Box B on the reverse of the MCCD for antemortem investigations. For example, if before death the patient had symptoms typical of COVID-19 infection, but the test result has not been received, it would be satisfactory to give ‘COVID-19’ as the cause of death, tick Box B and then share the test result when it becomes available. In the circumstances of there being no swab, it is satisfactory to apply clinical judgement.

As previously mentioned, doctors are expected to state the cause of death to the best of their knowledge and belief; they are not expected to be infallible. Even without any changes to the law, there is increased scrutiny of death certification and patterns of mortality by local and national agencies as a result of the Shipman Inquiry. Suspicions may be raised if death certificates appear to give inadequate or vague causes of death. For example, if a patient dies under the care of an orthopaedic surgeon, it might be expected that some orthopaedic condition contributed to the death and so this condition would be mentioned in part I or part II of the certificate.

Similarly, it would be surprising if a patient was being treated in an acute hospital, but no significant disease or injury at all was mentioned on their death certificate. The level of certainty as to the cause of death varies. What to do, depending on the degree of certainty or uncertainty about the exact cause of death, is discussed below.

4.1. Sequence leading to death, underlying cause and contributory cases

The MCCD is set out in two parts, in accordance with World Health Organisation (WHO) recommendations in the International Statistical Classification of Diseases and Related Health Problems (ICD). You are asked to start with the immediate, direct cause of death on line Ia, then to go back through the sequence of events or conditions that led to death on subsequent lines, until you reach the one that started the fatal sequence. If the certificate has been completed properly, the condition on the lowest completed line of part I will have caused all of the conditions on the lines above it. This initiating condition, on the lowest line of part I will usually be selected as the underlying cause of death, following the ICD coding rules.

WHO defines the underlying cause of death as “a) the disease or injury which initiated the train of morbid events leading directly to death, or b) the circumstances of the accident or violence which produced the fatal injury”. From a public health point of view, preventing this first disease or injury will result in the greatest health gain. Most routine mortality statistics are based on the underlying cause. Underlying cause statistics are widely used to determine priorities for health service and public health programmes and for resource allocation. Remember that the underlying cause may be a longstanding, chronic disease or disorder that predisposed the patient to later fatal complications.

You should also enter any other diseases, injuries, conditions, or events that contributed to the death, but were not part of the direct sequence, in part two of the MCCD. The conditions mentioned in part II must be known or suspected to have contributed to the death, not merely be other conditions which were present at the time.

Examples of cause of death section from MCCDs

Cause of death: the disease or condition thought to be the underlying cause should appear in the lowest completed line of part I

Part I

(a) Disease or condition leading directly to death – intraperitoneal haemorrhage.

(b) Other disease or condition, if any, leading to I(a) – ruptured metastatic deposit in liver.

(c) Other disease or condition, if any, leading to I(b) – primary adenocarinmoma of ascending colon.

Part II

Other significant conditions contributing to death but not related to the disease or condition causing it – non-insulin dependent diabetes mellitus

Note: The colon cancer on line 1(c) led directly to the liver metastases on line 1(b), which ruptured, causing the fatal haemorrhage on 1(a). Adenocarcinoma of the colon is the underlying cause of death.

Cause of death: the disease or condition thought to be the underlying cause should appear in the lowest completed line of part I

Part I

(a) Disease or condition leading directly to death – cerebral infarction.

(b) Other disease or condition, if any, leading to I(a) – thrombosis of basilar artery.

(c) Other disease or condition, if any, leading to I(b) – cerebrovascular atherosclerosis.

Part II

Other significant conditions contributing to death but not related to the disease or condition causing it –

Note: In subsequent examples, to save space, the layout of the MCCD has not been reproduced. All examples are taken from actual MCCDs of deaths in England and Wales.

In some cases, a single disease may be wholly responsible for the death. In this case, it should be entered on line Ia, for example:

  • Ia. Meningococcal septicaemia

Meningococcal septicaemia is the underlying cause of this death.

More than three conditions in the sequence

The MCCD in use in England and Wales currently has 3 lines in part I for the sequence leading directly to death. If you want to include more than 3 steps in the sequence, you can do so by writing more than one condition on a line, indicating clearly that one is due to the next, for example:

  • Ia. Post-transplant lymphoma
  • Ib. Immunosuppression following renal transplant 15 years ago
  • Ic. Glomerulonephrosis due to insulin dependent diabetes mellitus
  • II. Recurrent urinary tract infections

Insulin dependent diabetes with renal complications is the underlying cause.

More than one disease may have led to death

If you know that your patient had more than one disease or condition that was compatible with the way in which he or she died, but you cannot say which was the most likely cause of death, you should include them all on the certificate. They should be written on the same line, and you can indicate that you think they contributed equally by writing “joint causes of death” in brackets, for example:

  • Ia. Cardiorespiratory failure
  • Ib. Ischaemic heart disease and chronic obstructive airways disease
  • Ic.
  • II. Osteoarthritis

or

  • Ia. Hepatic failure
  • Ib. Liver cirrhosis
  • Ic. Chronic hepatitis C infection and alcoholism (joint causes of death)
  • II.

Where more than one condition is given on the lowest used line of part 1, the Office for National Statistics (ONS) will use the internationally agreed mortality coding rules in ICD-10 to select the underlying cause for routine mortality statistics.

Since 1993, ONS also code all the other conditions mentioned on the certificate. These multiple cause of death data are used by ONS in a variety of routine and ad hoc analyses and can be made available for research in some circumstances. Multiple cause data provides useful additional information on the mortality burden associated with diseases that are not often selected as the main cause of death. For example, conditions that are very often complications of another disease or its treatment, such as deep vein thrombosis/pulmonary embolism or health care associated infections should rarely be the underlying cause of death. Their contribution to mortality is better estimated from multiple cause data.

In contrast to the above, if you do not know that your patient actually had any specific disease compatible with the mode and circumstances of death, you must refer the death to the coroner. For example, if your patient died after the sudden onset of chest pain that lasted several hours and you have no way of knowing whether he or she may have had a myocardial infarct, a pulmonary embolus, a thoracic aortic dissection, or another pathology, it is up to the coroner to decide what investigations to pursue.

4.2 Results of investigations awaited

If in broad terms you know the disease that caused your patient’s death, but you are awaiting the results of laboratory investigation for further detail, you need not delay completing the MCCD. For example, a death can be certified as bacterial meningitis once the diagnosis is firmly established, even though the organism may not yet have been identified.

Similarly, a death from cancer can be certified as such while still awaiting detailed histopathology. This allows the family to register the death and arrange the funeral. However, you should indicate clearly on the MCCD that information from investigations might be available later. You can do this by circling ‘2’ on the front of the MCCD for autopsy information, or by ticking box ‘B’ on the back of the certificate for results of investigations initiated antemortem. It is important for public health surveillance to have this information on a national basis; for example, to know how many meningitis and septicaemia deaths are due to meningococcus, or to other bacterial infections. The registrar will write to the certifying doctor if a GP, or to the patient’s consultant for hospital deaths, with a form requesting further details to be returned to ONS.

4.3 Avoid ‘old age’ alone

Old age, ‘senility’ or ‘frailty of old age’ should only be given as the sole cause of death in very limited circumstances. These are when:

  • have personally cared for the deceased over a long period (years, or many months)
  • you have observed a gradual decline in your patient’s general health and functioning
  • you are not aware of any identifiable disease or injury that contributed to the death
  • you are certain that there is no reason that the death should be reported to the coroner

You may mention old age or frailty as a contributory cause, especially if it explains the severe effect of a condition that is not usually fatal. If the immediate cause of death was COVID-19 or its consequences, and the patient had no specific pre-existing health conditions, but appears to have been especially vulnerable to COVID-19 or its effects because of old age or frailty, it is appropriate to state old age as contributing to the death.

You should bear in mind that coroners, crematorium referees, registrars and organisations that regulate standards in health and social care, may ask you to support your statement with information from the patient’s medical records and any investigations that might have a bearing on the cause of death. You should also be aware that the patient’s family may not regard old age as an adequate explanation for their relative’s death and may request further investigation.

It is unlikely that patients would be admitted to an acute hospital if they had no apparent disease or injury. It follows that deaths in acute hospitals are unlikely to fulfil the conditions above. You can specify old age as the underlying cause of death, but you should also mention in part I or part II, as appropriate, any medical or surgical conditions that may have contributed to the death, for example:

  • Ia. Pathological fractures of femoral neck and thoracic vertebrae
  • Ib. Severe osteoporosis
  • Ic. Old age
  • II. Fibrosing alveolitis

or

  • Ia. Old age
  • Ib.
  • Ic.
  • II. Non-insulin dependent diabetes mellitus, essential hypertension and diverticular disease

or

  • Ia. Hypostatic pneumonia
  • Ib. Dementia
  • Ic. Old age
  • II.

While there is no statutory age limit or restriction on referring to ‘old age’, a death certified as due to old age or senility alone will usually be referred to the coroner, unless the deceased was 80 or older, all the conditions listed above are fulfilled and there is no other reason that the death should be referred. Similar terms, such as ‘frailty of old age’, will be treated in the same way.

4.4. Never use ‘natural causes’ alone

The term ‘natural causes’ alone, with no specification of any disease on a doctor’s MCCD, is not sufficient to allow the death to be registered without referral to the coroner. If you do not have any idea what disease caused your patient’s death, it is up to the coroner to decide what investigations may be needed.

4.5. Avoid organ failure alone

Do not certify deaths as due to the failure of any organ without specifying the disease or condition that led to the organ failure. Failure of most organs can be due to unnatural causes, such as poisoning, injury or industrial disease. This means that the death will have to be referred to the coroner if no natural disease responsible for organ failure is specified. For example:

  • Ia. Renal failure
  • Ib. Necrotising-proliferative nephropathy
  • Ic. Systemic lupus erythematosus
  • II. Raynaud’s phenomenon and vasculitis

or

  • Ia. Liver failure
  • Ib. Hepatocellular carcinoma
  • Ic. Chronic Hepatitis B infection
  • II. Congestive cardiac failure
  • Essential hypertension

Conditions such as renal failure may come to medical attention for the first time in frail, elderly patients in whom vigorous investigation and treatment may be contraindicated, even though the cause is not known. When such a patient dies, you are advised to discuss the case with the coroner before certifying.

If the coroner is satisfied that no further investigation is warranted, the registrar can be instructed to register the death based on the information available on the MCCD. The registrar cannot accept an MCCD that gives only organ failure as the cause of death without explicit instruction from the coroner the only exception is heart failure, which is acceptable on its own, although the underlying cause should be stated where known.

4.6. Avoid physical and mental conditions which are not fatal in themselves

Long-term physical disabilities, mental health problems and learning difficulties (also known as learning disabilities or intellectual disabilities) are rarely sufficient medical explanation of the death in themselves. If such a condition is considered to be relevant, the more immediate mechanism(s) or train of events leading to death must be made clear.

Example 1: A person with learning difficulties may develop aspiration pneumonia. Aspiration pneumonia should be given as the immediate cause of death; the person’s learning difficulties could be included in Part 2 of the certificate if thought to be a contributory factor, but not in Part 1, as having learning difficulties does not form a direct sequence of events to having pneumonia.

Example 2: A congenital syndrome which causes learning difficulties may also cause an organ defect which can lead to premature death. The organ failure should then be included in the certificate.

A description such as ‘learning difficulties’ should not be the only cause of death. You may give a degenerative condition such as Alzheimer’s disease as the only cause of death if the mechanism by which it caused death is unclear, but it is fully supported by the clinical history as the underlying cause.

4.7. Avoid terminal events, modes of dying and other vague terms

Terms that do not identify a disease or pathological process clearly are not acceptable as the only cause of death. This includes terminal events, or modes of dying such as cardiac or respiratory arrest, syncope or shock.

Very vague statements such as cardiovascular event or incident, debility or frailty are equally unacceptable. ‘Cardiovascular event’ could be intended to mean a stroke or myocardial infarction. It could, however, also include cardiac arrest or fainting, or a surgical or radiological procedure. If no clear disease can be identified as the cause of death, referral to the coroner will be necessary.

4.8. Never use abbreviations or symbols

Do not use abbreviations on MCCDs. Their meaning may seem obvious to you in the context of your patient and their medical history, but it may not be clear to others. For example, does a death from “MI” refer to myocardial infarction or mitral incompetence? Is “RTI” a respiratory or reproductive tract infection, or a road traffic incident? The registrar should not accept an MCCD that includes any abbreviations. (The only exceptions, which the registrar can accept, are HIV and AIDS for human immunodeficiency virus infection and acquired immune deficiency syndrome.) You, or the patient’s consultant, may be required to complete a new certificate with the conditions written out in full, before the death can be registered. This is inconvenient for you and for the family of the deceased. The same applies to medical symbols.

5. Specific causes of death

5.1. Stroke and cerebrovascular disorders

Give as much detail about the nature and site of the lesion as is available to you. For example, specify whether the cause was haemorrhage, thrombosis or embolism, and the specific artery involved, if known. Remember to include any antecedent conditions or treatments, such as atrial fibrillation, artificial heart valves, or anticoagulants that may have led to cerebral emboli or haemorrhage. Avoid the term ‘cerebrovascular accident’ and consider using terms such as ‘stroke’ or ‘cerebral infarction’ if no more specific description can be given. For example:

  • Ia. Subarachnoid haemorrhage
  • Ib. Ruptured aneurysm of anterior communicating artery
  • Ic.
  • II.

or

  • Ia. Intraventricular haemorrhage
  • Ib. Warfarin anticoagulation
  • Ic. atrial fibrillation
  • II.

5.2. Neoplasms

Malignant neoplasms (cancers) remain a major cause of death. Accurate statistics are important for planning care and assessing the effects of changes in policy or practice. Where applicable, you should indicate whether a neoplasm was benign, malignant, or of uncertain behaviour. Please remember to specify the histological type and anatomical site of the cancer, for example:

  • Ia. Carcinomatosis
  • Ib. Small cell carcinoma of left main bronchus
  • Ic. Heavy smoker for 40 years
  • II. Hypertension, cerebral arteriosclerosis, ischaemic heart disease

You should make sure that there is no ambiguity about the primary site if both primary and secondary cancer sites are mentioned. Do not use the terms ‘metastatic’ or ‘metastases’ unless you specify whether you mean metastasis to, or metastasis from, the named site.

  • Ia. Intraperitoneal haemorrhage
  • Ib. Metastases in liver
  • Ic. From primary adenocarcinoma of ascending colon
  • II. Non-insulin dependent diabetes mellitus

or

  • Ia. Pathological fractures of left shoulder, spine and shaft of right femur
  • Ib. Widespread skeletal secondaries
  • Ic. Primary adenocarcinoma of breast
  • II. Hypercalcaemia

or

  • Ia. Lung metastases
  • Ib. From testicular teratoma
  • Ic.
  • II.

If you mention two sites that are independent primary malignant neoplasms, make that clear, for example:

  • Ia. Massive haemoptysis
  • Ib. Primary small cell carcinoma of left main bronchus
  • Ic.
  • II. Primary adenocarcinoma of prostate

If a patient has widespread metastases, but the primary site could not be determined, you should state this clearly.

  • Ia. Multiple organ failure
  • Ib. Poorly differentiated metastases throughout abdominal cavity
  • Ic. Unknown primary site
  • II.

If you do not yet know the cancer type and are expecting the result of histopathology, indicate that this information may be available later by initialing box ‘B’ on the back of the MCCD. You, or the consultant responsible for the patient’s care, may be sent a letter requesting this information at a later date.

In the case of leukaemia, specify whether it is acute, sub-acute or chronic, and the cell type involved, for example:

  • Ia. Neutropenic sepsis
  • Ib. Acute myeloid leukaemia
  • Ic.
  • II.

or

  • Ia. Haemorrhagic gastritis
  • Ib. Chronic lymphocytic leukaemia
  • 1c.
  • II. Myocardial ischaemia, valvular heart disease

5.3. Diabetes mellitus

Always remember to specify whether your patient’s diabetes was insulin dependent/Type I, or non-insulin dependent/Type II. If diabetes is the underlying cause of death, specify the complication or consequence that led to death, such as ketoacidosis. For example:

  • Ia. End-stage renal failure
  • Ib. Diabetic nephropathy
  • Ic. Insulin dependent diabetes mellitus
  • II.

or

  • Ia. Septicaemia - fully sensitive staphylococcus aureus
  • Ib. Gangrene of both feet due to peripheral vascular disease
  • Ic. Non-insulin-dependent diabetes mellitus
  • II. Ischaemic heart disease

5.4. Deaths involving infections and communicable diseases

  • That COVID-19 is a notifiable disease under the Health Protection (Notification) Regulations 2010 does not mean referral to a coroner is required by virtue of its notifiable status.

  • If you are aware that a virology test for COVID-19 has been carried out, state the result if known, for example ‘COVID-19 (positive test)’. However, certification should not be delayed in order to await test results.

Mortality data are important in the surveillance of infectious diseases, as well as monitoring the effectiveness of immunisation and other prevention programmes. If the patient’s death involved a notifiable disease, you have a statutory duty to notify the proper officer for the area, unless the case has already been notified. This is normally a consultant in communicable disease control (CCDC) in your local Health Protection Team (HPT). If you are not sure whether a case is notifiable, you can get advice from your local HPT who will also advise on appropriate microbiological investigations. Find further information about notification and surveillance of infectious diseases on GOV.UK.

In deaths from infectious disease, you should state the manifestation or body site, for example pneumonia, pyelonephritis, hepatitis, meningitis, septicaemia or wound infection. You should also specify, giving as much detail as is available:

  • the infecting organism, such as pneumococcus, influenza A virus, meningococcus
  • antibiotic resistance, if relevant, for example methicillin-resistant Staphylococcus aureus (MRSA), or multiple drug resistant Mycobacterium tuberculosis
  • the source and/or route of infection, if known, such as food poisoning, needle sharing, contaminated blood products, post-operative, community or hospital acquired, or health care associated infection

For example:

  • Ia. Bilateral pneumothoraces
  • Ib. Multiple bronchopulmonary fistulae
  • Ic. Extensive, cavitating pulmonary tuberculosis (smear and culture positive)
  • II. Iron deficiency anaemia; ventilator associated pseudomonas pneumonia

You need not delay completing the certificate until laboratory results are available, provided you are satisfied that the death need not be referred to the coroner. You should indicate, by ticking box ‘B’ on the back of the MCCD, that further information may be available later. A letter may then be sent to you, or to the patient’s consultant, requesting this information.

Failure to specify the infecting organism can lead to unnecessary investigation. For example, deaths are sometimes certified as being due to spinal or paraspinal abscess, without stating the organism(s) involved. These are then coded as tuberculosis following the ICD index and rules, which can lead to unnecessary efforts by the local CCDC to investigate the case.

Remember to specify any underlying disease that may have suppressed the patient’s immunity or made them more susceptible to the infection that led to the death.

5.4.1. Healthcare associated infections

It is a matter for your clinical judgment whether a condition the patient had at death, or in the preceding period, contributed to their death, and so whether it should be included on the MCCD. However, families may be surprised if you do not include something that they believe contributed to their relative’s death.

ONS receives frequent queries from a wide range of sources about mortality related to healthcare associated infections, and complaints about the quality of information given about them on death certificates. Where infection does follow treatment, including surgery, radiotherapy, antineoplastic, immunosuppressive, antibiotic or other drug treatment for another disease, remember to specify the treatment and the disease for which it was given.

If a healthcare associated infection was part of the sequence leading to death, it should be in part I of the MCCD, and you should include all the conditions in the sequence of events back to the original disease being treated. For example:

  • Ia. Clostridium difficile pseudomembranous colitis
  • Ib. Multiple antibiotic therapy
  • Ic. Community acquired pneumonia with severe sepsis
  • II. Immobility, polymyalgia rheumatica, osteoporosis

or

  • Ia. Bronchopneumonia (hospital acquired meticillin resistant Staph aureus)
  • Ib. Multiple myeloma
  • Ic.
  • II. Chronic obstructive airways disease

If your patient had a healthcare associated infection which was not part of the direct sequence, but which you think contributed at all to their death, it should be mentioned in part II, for example:

  • Ia. Carcinomatosis and renal failure
  • Ib. Adenocarcinoma of the prostate
  • Ic.
  • II. Chronic obstructive airways disease and catheter associated Escherichia coli urinary tract infection

5.4.2. Pneumonia

Pneumonia may present in previously fit adults, but often it occurs as a complication of another disease affecting the lungs, mobility, immunity, or swallowing. Pneumonia may also follow other infections and may be associated with treatment for disease, injury or poisoning, especially when ventilatory assistance is required. Remember to specify, where possible, whether it was lobar or bronchopneumonia and whether primarily hypostatic or related to aspiration and the organism involved.

You should include the whole sequence of conditions and events leading up to it. If known, specify whether the pneumonia was hospital or community acquired. If it was associated with mechanical ventilation, or invasive treatment, this should be clearly stated. For example:

  • Ia. Pneumococcal pneumonia
  • Ib. Influenza A
  • Ic.
  • II. Ischaemic heart disease

If you report bronchopneumonia, remember to include in the sequence in part I any predisposing conditions, especially those that may have led to paralysis, immobility, depressed immunity or wasting, as well as chronic respiratory conditions such as chronic bronchitis. For example:

  • Ia. Bronchopneumonia
  • Ib. Immobility and wasting
  • Ic. Alzheimer’s disease
  • II.

5.5. Injuries and external causes

All deaths involving any form of injury or poisoning must be referred to the coroner. If the death is not one that must be certified by the coroner and s/he instructs you, as the patient’s clinician, to certify, remember to include details as to how the injury occurred and where it happened, such as at home, in the street, or at work. For example:

  • Ia. Pulmonary embolism
  • Ib. Fractured neck of femur
  • Ic. Tripped on loose floor rug at home
  • II. Left sided weakness and difficulty with balance since haemorrhagic stroke 5 years ago; hemiarthroplasty 2 days after fracture

Remember to state clearly if a fracture was pathological, that is due to an underlying disease process such as a metastasis from a malignant neoplasm or osteoporosis.

5.6 Substance misuse

Deaths from diseases related to chronic alcohol or tobacco use need not be referred to the coroner, provided the disease is clearly stated on the MCCD. For example:

  • Ia. Carcinomatosis
  • Ib. Bronchogenic carcinoma upper lobe left lung
  • Ic. Smoked 30 cigarettes a day
  • II. Chronic bronchitis and ischaemic heart disease.

or

  • Ia. Hepatic encephalopathy
  • Ib. Alcoholic liver cirrhosis
  • Ic.
  • II. Difficult to control insulin dependent diabetes

Deaths due to acute or chronic poisoning, by any substance, and deaths involving drug dependence or misuse of substances other than alcohol and tobacco must be referred.