Death certification

Recognition of death¹

It is vital when certifying death, to ensure that death has indeed occurred. In the modern world of advanced intensive care techniques and potential for organ donation, this can be a challenge, In the UK at present, there is no legal definition of death and there is no international consensus, although it is generally taken to mean the irreversible loss of capacity for consciousness combined with the irreversible loss of capacity to breathe. Guidance from the Academy of Medical Royal Colleges on the diagnosis and confirmation of death was updated in 2025. 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), whereas confirming death in the community is usually more straightforward.

Guidance on the diagnosis and confirmation of death from the Academy of Medical Royal Colleges

Proceed without unnecessary delay.

Death may be confirmed by 3 types of criteria - somatic, circulatory or neurological.

Somatic criteria

These are obvious signs of death and include:

• Decapitation or separation of the two halves of the body at the waist.

• Massive destruction of the skull and brain tissue, with no signs of life.

• Full-thickness burns over >95% of the body with no signs of life.

• Rigor mortis or decomposition.

• Maceration in a newborn.

Circulatory criteria

These should only be used when a decision has been made not to commence CPR, or it has been unsuccessful. The patient should be observed for five minutes (although auscultation does not need to be done for the whole of this time), during which time the following are noted:

• Continuous unconsciousness.

• Continuous absence of breathing (no visible chest movements and no audible breath sounds using a stethoscope).

• Continuous absence of a central pulse on palpation and absence of heart sounds using a stethoscope.

Neurological criteria

This is only relevant in secondary care and involves clinical tests such as the apnoea test, testing of brainstem reflexes and in some cases other investigations.

Verification of death

Who can verify death?¹

UK laws

• Do not require a doctor to confirm death has occurred or that "life is extinct".

• Do not require a doctor to view the body of a deceased person in order to certify death.

• Do require the doctor to issue a certificate detailing the cause of death (unless the death is referred to a coroner or Scottish procurator fiscal).

So a doctor's legal duty is to notify the cause of death, but not necessarily to verify that it has happened. Death can be verified by healthcare professionals and some other individuals, such as police officers. There is no legal obligation on a doctor to see or examine the deceased before signing a death certificate. This is the case across the UK.

Remote verification of death

During the COVID-19 pandemic the BMA issued a protocol for the remote verification of death.² This enables non-medically trained persons to verify death under the guidance of a doctor, usually using a mobile phone with a camera. In the post-pandemic era, remove verification should be considered an unusual thing to do and is not standard practice. ³

Should a GP visit?

There is no contractual obligation on a GP to visit a patient to confirm death,³ but this is often requested and in many cases done, as part of the GP's holistic care to the living family, who are usually often registered with the same practice. 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. It is however important that time-pressed GPs prioritise the care of the living, particularly in care homes where staff should be able to verify death. In this situation, a GP visit may merely delay the body being removed by a funeral director and is less likely to add value. It is common for the GP to be unable to attend until their clinic is finished which may be many hours after the death of the patient.

Death certification

The GP can complete the medical certificate of cause of death (MCCD) if they can establish the cause of death to the best of their knowledge or belief and the death is not required to be notified to the coroner. ⁴

Medical certificate of cause of death (MCCD)

The MCCD (more commonly known as the death certificate) fulfils a number of purposes:

• It allows the relatives of the deceased to register the death.

• It provides a permanent legal record of death

• It allows the relatives to arrange for the funeral, etc and to settle the estate of the deceased.

• It is used to provide national statistics about causes of death and trends in disease which go on to guide research, health services planning, etc.

In England and Wales, any medical practitioner who has attended the deceased within their lifetime can complete an MCCD.⁴ There is no legal definition of 'attended', but it is generally accepted to mean that they have cared for the patient and are familiar with their medical history and have access to their medical records. In Scotland it must be a doctor who has attended the patient during their last illness, but where this is not possible another doctor in the team with knowledge of the deceased or access to the relevant records may complete the MCCD.⁵ In Northern Ireland, the doctor who signs the MCCD must have seen the patient in the last 28 days; if there is no such doctor available, the death must be reported to the coroner.⁶

When to report a death to the coroner⁷

In some circumstances, a doctor is unable to provide a death certificate and the death must be reported to the coroner (or procurator fiscal in Scotland) rather than issuing a death certificate. Such circumstances include the following, but the list is not exhaustive and if in doubt the GP should discuss with the coroner or coroner's officer:

• No doctor satisfies the attendance requirements for being able to certify death (subject to the caveats listed above.

• The cause of the death is unknown.

• Deaths in prison or in any other form of state detention.

• Death attributable to employment held by the person during their lifetime.

• Death due to a medical treatment or procedure.

• A suspicion that the death is due to one of the following:

  • Sudden, unexpected, suspicious, violent (homicide, suicide, accidental) or unnatural deaths.

  • Deaths resulting from injury or poisoning, exposure to/contact with a toxic substance or use of a medicinal product, controlled drug or psychoactive substance.

  • Deaths related to surgery or anaesthetic.

  • Identity of deceased unknown.

  • Death from an industrial disease.

  • Death from neglect (including self-neglect).

Completing the death certificate⁴

There is detailed information at the front of the death certificate book explaining how to fill in each section. A few specific points are worth mentioning:

• Old age. Old age (or 'frailty of old age') may be mentioned as a contributory cause, particularly if it explains the severe effect of a condition which is not usually fatal. It should not be used as the sole cause on a death certificate unless the following requirements are met:

  • The deceased is 80 years of age or more.

  • You have personally cared for the deceased over a long period (several months as a minimum).

  • 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 have considered checking with relatives that they are satisfied with this explanation for the cause of death.

• Organ failure. Avoid organ failure alone as the cause of death. Specify the condition which led to organ failure below. If no natural cause of organ failure is listed, the disease will have to be referred to the coroner to exclude causes such as poisoning, injury or industrial disease.

• Mode of dying or terminal events. These cannot be used as the cause of death (eg, cardiac arrest or shock).

• Abbreviations and symbols. Do not use abbreviations or symbols on a death certificate.

• Diabetes. Specify type 1 or type 2 and give the complication which led to death.

• COVID-19. COVID-19 is an acceptable cause of death if a test has been carried out.

• Natural causes should never be used alone on an MCCD.

Cremation certificate and forms

There is no longer a requirement for a cremation form in England and Wales, ⁴but information that used to be on the form (such as the presence of a pacemaker or other implantable device) now needs to be included in the MCCD. Cremation forms are still a requirement in Scotland and Northern Ireland. ⁸

Involvement of the medical examiner (ME)⁹

Since 9th September 2024, there is a statutory requirement for an ME to scrutinise all deaths in England and Wales.⁴ The system should work as follows:

• Attending practitioner (AP) views the health record to see if they can establish a cause of death. If they cannot, they may refer directly to the coroner.

• The AP completes the MCCD and sends it to the ME, who will have access to the patient's notes. The mechanism for ensuring this access may vary by area - in some cases the ME will have direct electronic access and in others the AP may need to send a specified extract from the notes to the ME with the MCCD.

• The ME then sends the MCCD to the registrar, once the cause of death has been agreed. In some cases this agreement is straightforward and in others it may need discussion between the ME and the AP.

• If the ME feels that the death should be referred to the coroner, they can do so.

MEs should carry out a proportionate review of medical records and interact with both the AP and the bereaved relatives. They do not investigate concerns in depth - if they feel that such an investigation is necessary, there are pathways for them to escalate their concern. MEs are supported by medical examiner officers (MEOs) who enable the effective operation of the system. An ME must be a registered medical practitioner but an MEO does not have to be.

Summary: what to do when called to a death in primary care

• Be sensitive and supportive towards bereaved and/or shocked relatives.

• Verify that death has taken place as in the section above.

• Document the time death was verified.

• In an expected death, complete the death certificate and interaction with the ME as soon as possible, or arrange for another doctor to do so if you cannot (for example, you have not seen the patient in the legal time periods for the country of the UK in which you practice).

• In an unexpected or suspicious death, document anything on or around the body which may point towards a cause of death. Explain to the relatives it may not be possible to issue a certificate until a cause of death has been established, and to do this you will need to refer the death to the coroner or procurator fiscal. Explain that the coroner will then ascertain if further investigation is required, or if a certificate can be issued. Phone the coroner or police and explain to the relatives that the coroner or police officer will advise about moving the body.

• If cremation forms are required (Scotland and Northern Ireland only) , the funeral service will contact you and ask you to complete Form 4.

• Where relevant, follow up with ongoing offers of support to the family.

Faith deaths

The Jewish and Muslim faiths have a requirement for burial to be done as soon as possible, ideally within 24 hours. This can cause issues when a patient dies in the community at the weekend or on a bank holiday. ME offices are usually open at weekends and bank holidays (though sometimes with restricted hours) and registrars have systems to process such MCCDs rapidly. There is however no formal system for GP availability during the weekend and no contractual responsibility for a GP to make themselves available. If there is no other registered medical practitioner who can sign the MCCD (for example a hospital or hospice doctor who has seen the patient during their lifetime and is available to sign the MCCD even if the patient died in the community), then there will necessarily be delay until the next working day. Informal systems may exist, particularly in the private sector or when the GP is a member of the same faith community.