Coronavirus Act – excess death provisions: information and guidance for medical practitioners
Publications approval reference: 001559 / C0126
31 March 2020
The Coronavirus Act of Parliament gained Royal Assent on 25 March 2020, and the commencement order for the clauses relating to death certification and cremation forms was signed on 26 March 2020. Guidance and information on these clauses are set out below, along with previous COVID-19 advice issued on 10 March,* included here for completeness.
1. Medical certificate of cause of death
Guidance on the medical certificate of cause of death (MCCD) is here.
a. Any medical practitioner with GMC registration can sign the MCCD, even if they did not attend the deceased during their last illness, if the following conditions are met:
- (i) the medical practitioner who attended is unable to sign the MCCD or it is impractical for them to do so and,
- (ii) the medical practitioner who proposes to sign the MCCD is able to state the cause of death to the best of their knowledge and belief, and
- (iii) a medical practitioner has attended the deceased (including visual/video consultation) within 28 days before death, or viewed the body in person after death (including for verification).
If another medical practitioner attended the deceased during their last illness or after death, the medical practitioner signing the MCCD should record the name and GMC number of the medical practitioner who attended the deceased during their last illness or after death at the ‘last seen alive’ section of the MCCD.
In addition to (i) to (iii) above, if no medical practitioner attended the deceased in the 28 days before death* or after death, a medical practitioner can sign the MCCD if the following conditions are met:
- (iv) the medical practitioner who proposes to sign the MCCD is able to state the cause of death to the best of their knowledge and belief, and
- (v) the medical practitioner has obtained agreement from the coroner they can complete the MCCD.
* See 2(d) regarding registrars’ duties where the deceased was not seen alive in the 28 days before death
Medical practitioners working in the same practice/hospital should find this straightforward as they can access patient records. Reasons it is impractical for the attending medical practitioner to complete the MCCD might include: severe pressure on NHS services and the need to ensure medical practitioners with appropriate skills are available to treat patients; and/or medical practitioners becoming infected with COVID-19 and needing to self-isolate. During periods of excess deaths due to COVID-19, healthcare providers are encouraged to redeploy medical practitioners whose role does not usually include direct patient care, such as some medical examiners, to provide indirect support by working as dedicated certifiers, completing MCCDs to enable other medical practitioners to focus on providing patient care.
b. Medical practitioners are required to certify causes of death “to the best of their knowledge and belief”. Without diagnostic proof, if appropriate and to avoid delay, medical practitioners can circle ‘2’ in the MCCD (“information from post-mortem may be available later”) or tick Box B on the reverse of the MCCD for ante-mortem 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.
c. The period during which an attending medical practitioner completing an MCCD must have seen the deceased before death (the ‘last seen alive’ requirement) is extended from 14 days to 28 days before death. ‘Seen’ in this context includes consultation using video technology. However, it does not include consultation by telephone/audio only.
d. The MCCD can be scanned or photographed and sent from a secure email account to registrars as an attachment. We recommend electronic transfer of MCCDs is used as standard practice. We expect registrars to determine the appropriate email address – for example, a secure email account.
e. COVID-19 is an acceptable direct or underlying cause of death for the purposes of completing the MCCD.
a. As noted in 1(d), MCCDs can be scanned or photographed and sent by email to registrars as an attachment. We recommend electronic transfer of MCCDs is used as standard practice to reduce unnecessary contact between individuals and to accelerate processes.
b. Where electronic transfer is not possible, and the next of kin/informant is following self-isolation procedures, please arrange for an alternative informant who has not been in self-isolation to collect the MCCD and deliver to the registrar for registration purposes.
c. An informant can be someone who was present at the death, a hospital official, someone who is ‘in charge of a body’, or a funeral director.
d. If the deceased was not seen in the 28 days before death or after death by a medical practitioner, the MCCD can be completed if the conditions in 1a(iv)-(v) are met, but the death will need to be notified to the coroner. Medical practitioners are encouraged to work with registrars to establish processes to enable registration to be concluded rapidly where the cause of death is clear.
National guidance regarding notification of deaths to coroners is available here.
a. COVID-19 is not a reason on its own to refer a death to a coroner under the Coroners and Justice Act 2009.*
b. 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.*
c. Where an attending medical practitioner cannot complete an MCCD (or the attending medical practitioner is unable to complete it in a timely manner), the death should only be notified to the coroner if there is no other medical practitioner who can complete the MCCD as outlined at Section 1 above.
* Advice sent to regional NHS emergency preparedness, resilience and response (EPRR) co-ordinators including heads of EPRR and regional COVID-19 incident co-ordination centres to cascade to COVID-19 leads in all NHS organisations on 10 March and repeated here for completeness.
a. Subject to secure local procedures being available and followed, the body can be released out of hours when the MCCD has been completed but without formal registration. Registration can take place later – though it should be noted that bodies cannot be disposed of until the registrar issues the green form.
Guidance regarding medical certificates for cremation is here.
a. The requirement to complete form Cremation 5 is suspended during any period when the amended regulations apply. Cremations can be authorised on the basis of one medical certificate (form Cremation 4), without the requirement to also complete a confirmatory medical certificate (form Cremation 5).
b. The form Cremation 4 is an interactive PDF and can be completed and saved before sending, or paper copies can be scanned/photographed and submitted electronically. Electronic signature includes being sent from the secure email account of the person completing the form Cremation 4.
c. Any medical practitioner can complete form Cremation 4, even if they did not attend the deceased during their last illness, if the following conditions are fulfilled:
- (i) the medical practitioner who attended is unable to sign the form Cremation 4 or it is impractical for them to do so and,
- (ii) the MCCD has been completed because
- (iii) a medical practitioner has attended the deceased (including visual/video consultation) within 28 days before death or viewed the body in person after death (including for verification).
d. Examination of the body is not required for completion of form Cremation 4 if the deceased was seen either:
- (i) after death by a medical practitioner (including verification), or
- (ii) by a medical practitioner in the 28 days before death (including visual/video consultation).
e. When a medical practitioner who did not attend the deceased completes form Cremation 4, the following guidance applies:
- (i) Question 5: ‘Certifying doctor’ is an acceptable medical role in relation to the deceased but the name, GMC number and role of a medical practitioner who attended the deceased should be entered at Question 9, along with the date the medical practitioner attended the deceased.
- (ii) Question 6: ‘Not applicable’ is acceptable.
- (iii) Question 7: ‘Not applicable’ is acceptable.
- (iv) Question 8: ‘Not applicable’ is acceptable. If the form Cremation 4 is being completed on the basis of another medical practitioner having seen the deceased after death, verification of the fact of death is acceptable. The date, time and nature of examination should be recorded at Question 9.