Death (Recognition and Certification)

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PatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

It is vital when certifying death, to ensure that death has indeed occurred. In the UK at present, there is no legal definition of death; although guidelines do exist for the diagnosis of death in more complex situations.[1] There has been recent guidance on the diagnosis and confirmation of death from the Academy of Medical Royal Colleges.[2] The guidance is mainly concerned with confirmation of death in hospital and in circumstances where the diagnosis of death may be more difficult (patients on ventilators for example).

New guidance on confirmation of death:[2] Proceed without unnecessary and distressing delay. Death may be obvious with clear signs pathognomonic of death (hypostasis, rigor mortis). If not obvious death should be identified by 'the simultaneous and irreversible onset of apnoea and unconsciousness in the absence of the circulation'. The new guidance in addition requires that:
  • Full and extensive attempts at reversal of any contributing cause to the cardiorespiratory arrest have been made (for example body temperature, endocrine, metabolic and biochemical abnormalities more relevant in hospital).
  • One of the following is fulfilled:
    • The individual meets the criteria for not attempting cardiopulmonary resuscitation
    • Attempts at cardiopulmonary resuscitation have failed
    • Treatment aimed at sustaining life has been withdrawn because it has been decided to be of no further benefit to the patient and not in his/her best interest to continue and/or is in respect of the patient’s wishes in an advanced directive
  • The individual should be observed by the person responsible for confirming death for a minimum of five minutes to establish that irreversible cardiorespiratory arrest has occurred. In primary care the absence of mechanical cardiac function is normally confirmed using a combination of the following:
    • Absence of a central pulse on palpation
    • Absence of heart sounds on auscultation
    In hospital this can be supplemented by one or more of the following:
    • Asystole on a continuous ECG display
    • Absence of pulsatile flow using direct intra-arterial pressure monitoring
    • Absence of contractile activity using echocardiography
  • Any spontaneous return of cardiac or respiratory activity during this period of observation should prompt a further five minutes observation from the next point of cardiorespiratory arrest
  • After five minutes of continued cardiorespiratory arrest the absence of the pupillary responses to light, of the corneal reflexes, and of any motor response to supra-orbital pressure should be confirmed
  • The time of death is recorded as the time at which these criteria are fulfilled.

The current recommendations state that:
"Death should be verified by a doctor, or other suitably qualified personnel."[3] Deaths are increasingly occurring in patient's own homes, as improved community nursing provision enables dying patients to remain out of hospital. The precise moment of death may be difficult to recognise, and for a period of time after respiration has ceased, and the heart has stopped, the patient may still potentially be resuscitated. In certain conditions a patient may appear dead if not thoroughly examined:

  • Following prolonged submersion in cold water
  • Following ingestion of alcohol or drugs
  • When hypoglycaemic, or in a coma

They may recover completely, if treated appropriately. It should be remembered that hypothermia protects against hypoxic neurological damage, and that children under the age of 5 are more resilient to hypoxic brain injury, and therefore resuscitation should be continued in these circumstances until normal body temperature is reached, even if the patient appears to be dead.

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A thorough physical examination should be carried out to ascertain whether or not death has taken place.[4] First inspection should reveal a deathly pallor (particularly of the face and lips), and relaxation of the facial muscles. This leads to drooping of the lower jaw and open staring eyes. Further examination should include:

  • Palpation of all major pulses.
  • Auscultation of the heart and lungs for at least one minute, and repeated at intervals over at least five minutes.
  • Inspection of the eyes for fixed dilated pupils, absence of corneal reflexes, cloudiness of the cornea and loss of eye tension.
  • Examination of the fundi for segmentation of retinal blood columns "boxcars" ( only present in 30%).
  • Examination of the trunk may show evidence of post mortem staining as a result of hypostasis.
  • Examination of muscle tone for rigor mortis ( begins approximately 3 hours after death).
  • Decreased temperature - will depend on ambient temperature, but may not occur for up to 8 hours.
For practical purposes in General Practice, death may be deemed to exist in an unresponsive patient, with a body temperature over 35°C, who has not been taking drugs or alcohol if:
  • There are no spontaneous movements.
  • There is no respiratory effort (examine for one minute).
  • There are no heart sounds or palpable pulses (examine for one minute).
  • There is an absence of reflexes eg corneal.
  • The pupils are fixed and dilated.

Management of a death will depend on:

  • The circumstances of the death
  • Where it has occurred
  • Whether or not it was anticipated
  • Whether or not there is any suspicion of foul play.

Relatives and/or friends of the deceased may be very distressed and GPs attending a death should offer support where appropriate. Bereaved families may also require guidance on the procedures following a death, particularly if the death was unexpected.
Verification of death may be performed by any appropriately qualified person.

Death certificate

A death certificate may be issued by a doctor who has provided care during the last illness and who has seen the deceased within 14 days of death ( 28 days in Northern Ireland) or after death. They should be confident about the cause of death.

The death certificate is given to the next of kin who is required to deliver it to the Registrar of Births, Deaths and Marriages within five days. In the absence of a next of kin, the Births and Deaths Registration Act 1953[5] specifies who else can do this:

  • Any relative of the deceased person present at the death or in attendance during his last illness.
  • Any other relative of the deceased residing or being in the sub–district where the death occurred.
  • Any person present at the death.
  • The occupier of the house if he knew of the happening of the death.
  • Any inmate of the house who knew of the happening of the death;
  • The person causing the disposal of the body.

If the Registrar decides that the death does not need reporting to the Coroner he will issue:

  • A Certificate for Burial or Cremation
  • A Certificate of Registration of Death (for Social Security purposes)
  • (On request), copies of the Death Register (at least two copies advisable because banks and insurance companies expect to see them).

If the body is to be buried in England, there are no further formalities. If the burial is to be outside of England, an Out of England Order is needed from the coroner. If the burial is to be at sea, and Out of England Order and a licence from the Ministry of Agriculture, Food and Fisheries is needed, and the District Inspector of Fisheries should be notified.

Cremation certificate and forms

New regulations and new cremation forms were introduced in January 2009.[6][7] Old cremation forms can now no longer be used.

There are very few policy changes which require different procedures. The only significant one is that applicants now have the right to inspect the medical forms (Forms Cremation 4 and Cremation 5) before the medical referee authorises the cremation. It is expected that numbers of applicants wishing to exercise this right will be low. Where a post-mortem examination is requested by the medical referee the applicant should, on request, be able to have a copy of the post mortem examination report.

This certificate is usually given to the undertaker who takes it to the Medical Referee at the Crematorium who checks the forms and gives the final approval necessary for cremation to occur.
Occasionally, circumstances occur in which the death must be reported to the coroner or procurator (Scotland) rather than issuing a death certificate. Legally, this is the responsibility of the Registrar, but it is good practice (and saves time and distress for relatives) for doctors to report directly to the coroner or procurator:

If no doctor satisfies the attendance requirements for being able to certify death eg the only doctor who has provided care during the last illness is away on holiday, then the death must be reported to the coroner/procurator.
Other examples which require reporting include:
  • Identity of deceased unknown
  • If the cause of the death is unknown
  • Sudden, unexpected, suspicious, violent (homicide, suicide, accidental) or unnatural deaths
  • Deaths due to alcohol or drugs
  • Doubtful stillbirth
  • Deaths related to surgery or anaesthetic
  • Deaths within 24 hours of admission to hospital
  • Deaths in prison

In some cases a death certificate may be issued, but ticking a box on the reverse of the death certificate will alert the coroner or other agencies that further action may be required. Deaths which may require this include:

  • Death from an industrial disease, poisoning or accident
  • Death of a patient in receipt of an industrial or war pension
  • Death by suicide, poisoning or drugs
  • Death as a result of an illegal abortion
  • Death from neglect, want or exposure

Further reading & references

  1. A code of practice for the diagnosis of brain stem death. London; HMSO, March 1998
  2. A code of practice for the diagnosis and confirmation of death, Academy of Medical Royal Colleges (October 2008)
  3. RCGP; Death Certification and Investigation in England, Wales and Northern Ireland. Summary Paper, June 2003.
  4. Charlton R; Diagnosing Death. BMJ October 1996.
  5. OPSI; The Births and Deaths Registration Act 1953.
  6. OPSI; The Cremation (England and Wales) Regulations 2008.
  7. Ministry of Justice; Cremation Regulations 2008: Guidance for Cremation Authorities and Cremation Managers.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

Original Author:
Dr Richard Draper
Current Version:
Document ID:
2029 (v23)
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