ETHICS: Death and the Law

Question 1

How is death verified?

Answer 1

No response to verbal or painful stimulus
No palpable carotid pulse
No heart sounds (2 minutes)
No breath sounds (2 minutes)
Pupils fixed and dilated (non-responsive to light)

Document in medical notes (date and time)
Notify
- consultant (discuss cause of death for certificate)
- family (arrange for this to happen, may not be you doing it)

Question 2

What is the pathway for Medical Certificate of Cause of Death from the patient being alive?

Answer 2

Question 3

Who has a statutory duty to issue a medical certificate of the cause of death (MCDD)?

Answer 3

The doctor attending during the last illness of a person who has died… a statutory duty to issue a medical certificate of the cause of death (MCCD)
* Conversely, if you were not present for the deceased, you cannot write the death certificate

Question 4

What format is used for writing the cause of death?

Answer 4

1a, 1b, 1c, II format

1a = ultimate cause of death
1b = caused 1a
1c = caused 1b

II = other diseases related to cause of death but not related to 1a-c

You would not include other diseases if they did not contribute to cause of death

No Abbreviations allowed

Question 5

What is this patient’s cause of death?

Answer 5

Question 6

What is this patient’s cause of death?

Answer 6

Question 7

What are the following forms of?

a) Form 4
b) Form 5
c) Form 6
d) Form 7
e) Form 11

Answer 7

a) 4: Medical certificate
b) 5: Confirmatory certificate (being phased out)
c) 6: Medical referee certificate
d) 7: Following anatomy dissection
e) 11: After autopsy certificate

Question 8

Types of autopsy

Answer 8

Consented (hospital) - <10%

• MCCD issued
• determine disease outline, support teaching/training

Medicolegal
- MCCD cannot be issued
- used for Forensics (Coroner’s Rules, Forensic pathologist, Police involvement) or Coroner (Coroner’s Rules, General pathologist)

Question 9

Types of medicolegal autopsies

Answer 9

1. Forensic
   - coroner’s rules
   - forensic pathologist
   - police involvement
2. Coroner
   - coroner’s rules
   - general pathologist

Question 10

What does a coroner do?

Answer 10

Concerned with who died, when they died, where they died, and how they died

Will instruct doctors to carry out autopsy/examination and determine MCCD on the balance of probability

Question 11

When must you refer to the coroner?

Answer 11

1. Unknown cause of death
2. Not seen by a doctor during last illness or last 28 days
3. During or within 12 months of pregnancy
4. Death in custody
5. While detained under the Mental Health Act
6. Death due to:
   - suicide
   - accident/trauma
   - industrial disease
   - medical/surgical treatment
   - abortion
   - anaesthetic care
   - lack of medical care
   - murder
   - self-neglect
7. Any hx of violence
8. Any element of suspicion
9. Any allegation of medical negligence
10. Any other unusual/disturbing feature

NOTE: time of death in relation to the above DOES NOT EXPIRE

IF IN DOUBT = CONSIDER REFERRAL

Question 12

What can the coroner’s officer do once they receive a referral about a cause of death?

Answer 12

Accepts -> autopsy/death investigation
Suggests acceptable cause of death -> MCCD

It is your signature on the MCCD. It is your license at risk. You do not have to accept their suggestion

Question 13

Answer 13

Should be referred to coroner – trauma/violence…

Question 14

Answer 14

It makes no sense!!!!!
1c should lead to 1b should lead to 1a the ultimate cause of death

Question 15

What is consent?

Answer 15

‘Consent’ is a patient’s agreement for a health professional to provide care. Patients may indicate consent implicitly / orally / in writing

The patient must have the CAPACITY to give consent

Question 16

What competency must a doctor have to consent a patient?

Answer 16

a) They themselves can carry out the procedure
b) They have received specialist training in advising patients about this procedure, have been assessed, and are aware of their own knowledge limitations

Question 17

When is a person unable to make a decision?

Answer 17

If they cannot:

1. Understand the information relevant to the decision
2. Retain that information
3. Use or weight that information as part of the process of making the decision, or
4. Communicate their decision

Question 18

What is hte Mental Capacity Act?

Answer 18

• Protects people who cannot make decisions for themselves
• Presumes that someone has capacity
• People are allowed to make ‘poor decisions’
• You must determine INCAPACITY

A person is unable to make a decision if they cannot:
* understand the information relevant to the decision,
* retain that information,
* use or weigh that information as part of the process of making the decision, or
* communicate the decision.

Question 19

What does the Human Tissue Act (2004) do?

Answer 19

Deals with consent, performance of autopsies and storage of material retained, as well as collection and retention of material taken from the living

Came into effect September 2006, established by Human Tissue Authority

Question 20

Outline the key rulings about The Human Tissue Act

Answer 20

16 (2) b –a post mortem examination

16 (2) c – The removal from the body of a deceased person of relevant material of which the body consists or which it contains for a scheduled purpose other than transplantation

16 (2) e – The storage of the body of a deceased person or relevant material which has come from a human body for use for a scheduled purpose.

These activities can only take place under the authority of a license

Question 21

What are scheduled purposes of The human Tissue Act (2004)?

Answer 21

Purposes requiring consent: deceased persons
1. Clinical audit
2. Education or training related to human health
3. Performance assessment
4. Public health monitoring
5. Quality assurance

Question 22

Who can give consent for removal, use of storage of tissue after death?

Answer 22

• The person before death - if competent
• Nominated representative (nominated before death when the person was mentally competent)
• Consent from an adult in a qualifying relationship (according to Human Tissue Authority hierarchy of consent)

Question 23

What is the hierarchy of consent in the Human Tissue Authority act?

Answer 23

1. Partner/spouse
2. Parent/child
3. Sibling
4. Grandparent/grandchild
5. Nibling
6. Step parent
7. Half sibling
8. Friend of longstanding

Question 24

What consent is required in pathology?

Answer 24

Surgical specimens
* Diagnostic material
* Teaching, audit, +/- research

Post Mortem specimens
* Consented autopsy – specifies use as above
* Coroners autopsy – consent from coroner to take tissue for further investigation into death only. Not for use in teaching, audit, research
* Coroners autopsy – can gain consent from family

Question 25

What is the Organ Donation Act 2019?

Answer 25

Consent for organ/tissue donation will be deemed if: a) there was no expressed consent/refusal prior to death b) no nominated representative Deemed consent may be rejected if the family provide reasonable reason to believe that the potential donor would not have given consent ## Footnote Deemed consent does not apply for: Children under 18 years An adult who lacked capacity for a significant period before their death An adult not ordinarily resident in England for the 12 months prior to death

Question 26

What are justifications for breaking confidentiality?

Answer 26

1. Best interest of patient or safeguarding the wellbeing of others 2. Statutory Requirements - Road Traffic Act 1988 - Prevention of Terrorism Act 1989 - Public Health (Control of Disease) Act 1984 3. Public Interest - public good vs obligation of confidentiality to patient - protection of confidence is a public interest

Question 27

Exceptions to keeping confidentiality after death in reality

Answer 27

1. Assist coroner/officer involved with inquest 2. National Confidential Inquiries 3. MCCD (death certificates) 4. Public health surveillance 5. Parent seeking information, i.e. child's death 6. Insurance companies (lawfully) 7. Partner/close relative/friend if you have no reason to believe the patient would have objected

Question 28

Which of the statements are incorrect in relation to a doctor asked to complete a death certificate? a) Needs to speak to Medical Examiner in all cases b) Must raise any concerns known about the care given with the Medical Examiner c) Should discuss the cause of death with the family prior to completing the MCCD d) Is required to draw up the Medical Examiner's notification paperwork before writing up the MCCD e) When referral to the Coroner is clearly required needs to contact the Coroner without further delay f) Does so to the best of their knowledge and belief which is not equivalent to the criminal standard of 'beyond reasonable doubt'

Answer 28

c) Should discuss the cause of death with the family prior to completing the MCCD e) When referral to the Coroner is clearly required needs to contact the Coroner without further delay Complete paperwork asap and send to Medical Examiner who will discuss circumstances to you and this will enable you to complete MCCD or refer to Coroner for further discussion or more formal reasons

Question 29

Death follows from a recognised complication of a medical procedure for which appropriate and comprehensive written consent was obtained Does this need a coroner referral?

Answer 29

Yes | = death due to medical/surgical treatment

Question 30

The cause of death is bronchopneumonia in a patient with metastatic ovarian cancer who was undergoing palliative chemotherapy without evidence of neutropaenia Does this need a coroner referral?

Answer 30

No

Question 31

The death was due to massive pulmonary embolism in a patient with known deep vein thrombosis and very limited mobility following a motorcycle accident several months before (whilst working as a courier) Does this need a coroner referral?

Answer 31

Yes = death due to accident/trauma = death due to industrial disease

Question 32

The patient died of an acute myocardial infarction with a history of coronary artery stenting two years before. The patient had undergone an apparently successful hip replacement the previous month. Does this need a coroner referral?

Answer 32

No

Question 33

The patient was detained under section 3 MHA and died from a peritonitis following perforation of inoperable advanced colonic carcinoma. Does this need a coroner referral?

Answer 33

Yes | = death occurred while detained under the Mental Health Act

Question 34

Which of the statements are correct in relation to the Coroner? a) Is appointed by the local council and investigates deaths reported that appear violent or unnatural, or where the cause of death is unknown or where the deceased died whilst in “state detention”; b) His or her officers are not required to have a medical background; c) Will investigate some deaths with a post mortem examination and will hold a formal hearing when evidence is given in court (an Inquest) for all deaths d) May decide not to investigate a referred death further where the cause of death notified to him is “uncertain” if the doctor has proposed a cause of death; e) Needs to investigate any death where the family of the deceased have concerns about the medical care given.

Answer 34

a) Is appointed by the local council and investigates deaths reported that appear violent or unnatural, or where the cause of death is unknown or where the deceased died whilst in “state detention”; b) His or her officers are not required to have a medical background; d) May decide not to investigate a referred death further where the cause of death notified to him is “uncertain” if the doctor has proposed a cause of death;

Question 35

Patricia Liu is a 26 year old woman who has been estranged from her family for several years. She is brought into hospital, having been found unconscious in her flat, surrounded by used syringes and needles. Shortly after arriving in the emergency room, she has a cardiac arrest and dies. Her brother, Adam Liu, is traced and is her next of kin. How should the ED doctor proceed? a) The cause of death is uncertain so consent should be sought from Adam Liu for a hospital post mortem. b) If the police confirm that Patricia Liu’s death is a suspected crime, then the case should be referred to the Coroner for a Coroner’s post mortem c) The cause of death is uncertain so the team should request a hospital post mortem d) The cause of death is uncertain so the team should refer to the Coroner for a Coroner’s post mortem e) The cause of death is uncertain so the team should refer to the Coroner for a Coroner’s post mortem provided Adam Liu gives his consent

Answer 35

d) The cause of death is uncertain so the team should refer to the Coroner for a Coroner’s post mortem = History of violence/element of suspicion/unusual or disturbing feature then REFER TO CORONER

Question 36

A 76 year old woman who suffers a fractured neck of femur after falling down some steps and is admitted to hospital for internal fixation of the fracture. The operation goes smoothly. Three days post operatively she suddenly becomes short of breath. CTPA reveals a pulmonary embolus (PE). She has a swollen tender left calf consistent with a deep venous thrombosis. She dies shortly after the PE is identified. Does this woman's death need to be referred to the coroner? a) Yes b) No c) maybe

Answer 36

a) Yes = any allegation of medical negligence needs referral

Question 37

A 76 year old woman who suffers a fractured neck of femur after falling down some steps and is admitted to hospital for internal fixation of the fracture. The operation goes smoothly. Three days post operatively she suddenly becomes short of breath. CTPA reveals a pulmonary embolus. She has a swollen tender calf muscle consistent with a deep venous thrombosis. She dies shortly after the PE is diagnosed. What is the correct cause of death? a) 1a Pulmonary embolus, 1b Deep venous thrombosis b) 1a Pulmonary embolus c) 1a Deep venous thrombosis, 1b Pulmonary embolus d) 1a Fractured neck of femur (operated on, date), 1b Deep venous thrombosis e) 1a Pulmonary embolus, 1b Deep venous thrombosis, 1c Fractured neck of femur (operated on, date)

Answer 37

e) 1a Pulmonary embolus, 1b Deep venous thrombosis, 1c Fractured neck of femur (operated on, date)

Question 38

A 78 year old man with longstanding type 2 diabetes and a previous history of pulmonary embolus and recently diagnosed squamous cell carcinoma of the lung is admitted unconscious following a generalised seizure and reduced conscious level. A brain CT shows a massive cerebral metastasis with midline shift and cerebral herniation. A few hours later he suffers a cardio-respiratory arrest and dies. What is the correct cause of death? a) Part 1a should state pulmonary embolus and Part 1b squamous cell carcinoma of the lung. Part 2 should state Type 2 diabetes b) Part 1a should state cerebral metastasis and Part 2 squamous cell carcinoma of the lung c) Part 1a should state squamous cell carcinoma of the lung and Part 1b Type 2 Diabetes d) Part 1a should state cerebral metastasis, Part 1b should state squamous cell carcinoma of the lung and Part 1c should state pulmonary embolus

Answer 38

b) Part 1a should state cerebral metastasis and Part 2 squamous cell carcinoma of the lung

Question 39

When may 'old age' be used as a cause of death on MCCD?

Answer 39

Unusual in an acute hospital setting as patients are generally admitted with a disease/condition/injury Thus more likely in the general practice setting and need to – a) Have cared for Deceased over a long period b) Have noticed a gradual decline in the Deceased’s health and functioning c) Not aware of any identifiable disease/injury that contributed to death d) You are certain the death should not be reported to the Coroner

Question 40

A 76 year old nun dies suddenly in the convent. Dr T, consultant pathologist, conducts a Coroner’s post mortem on the deceased. A haemopericardium is noted associated with a ruptured left ventricle secondary to a myocardial infarction. Dr T is currently conducting research on post mortem kidney tissue and this post mortem provides an excellent opportunity to restock his supply of post mortem kidney tissue. What should Dr T do? a) Give the cause of death to the Coroner and take kidney tissue for research, you do not need consent as it is a Coroners post mortem b) Provided only a small amount of tissue is needed, further consent is not required c) Give the cause of death to the coroner and ask the family for consent to take kidney tissue for research d) Await toxicology before giving a cause of death e) Refer the case for a forensic post mortem

Answer 40

c) Give the cause of death to the coroner and ask the family for consent to take kidney tissue for research = Human Tissue Act (2004): You need consent for examination, removal, storage and ANY type of use – teaching, research, audit, clinical governance etc

Question 41

John Johnson is a 24 year old single man with known cystic fibrosis and severe learning disability (mental age of 4 years) who is admitted to hospital with a severe pneumonia. He dies on day 10 of his admission. His mother died over 10 years previously. His stepfather, who has been his main carer since his mother died, has requested a post mortem but John Johnson’s older brother is deeply opposed to this. How should you advise his medical team in relation to the post mortem request? a) John Johnson’s stepfather, as the main carer, is the official next of kin and therefore the post-mortem can be performed with his consent. b) The post mortem cannot be performed in this situation as there is family disagreement c) The post mortem cannot be performed in this situation as the brother is refusing d) If there is family a disagreement a post-mortem cannot be legally performed e) If there is family disagreement, the decision regarding a post mortem should go to the Court of Protection

Answer 41

c) The post mortem cannot be performed in this situation as the brother is refusing = Hierarchy of consent from Human Tissue Act (2004)

Question 42

What is the role of medical examiners?

Answer 42

* contacted by doctor who writes death certificate * conducts independent review of patient's circumstances * doctor and medical examiner discuss wording and decice on the cause of death * medial examiner discusses cause of death with the family * then doctor can write the MCDD (death certificate)

Question 43

Can you refer to the coroner directly?

Answer 43

No, need to go through medical examiner who discusses the case with you before the case goes to the coroner

Question 44

Indications for referring to the coroner

Answer 44

* died from a recognised complication of a procedure * \*obviously if not recognised complication then doesn't need to be referred\* * Allegation of medical negligence * medical intervention that appear to have played a role in causing/ accelerating death * Any case that has occurred on the background of trauma or violence * eg a fracture in an elderly lady - could have been pushed etc. * Any element of suspicion/ unusual factors * Death whilst being detained by the state - MHA, prison, young offenders institution, police cells

Question 45

Do coroner's need to have a medical background?

Answer 45

**No** but they can have medical qualifications

Question 46

Do coroners have to investigate if families raise concerns about healthcare?

Answer 46

Nah- only depending on the level of the concern

Question 47

Does post mortem require the consent of the family?

Answer 47

No

Question 48

What does the human tissue act advocate for?

Answer 48

You need consent for examination, removal, storage and ANY type of use – teaching, research, audit, clinical governance etc Hierarchy of consent: Partner/ spouse Parent/ Child Sibling Grandparent/ grandchild Niece/ Nephew Step-parent Half sibling Friend of longstanding

Question 49

Hospital vs coroner post mortem - which one needs consent?

Answer 49

Hosptal needs consent - either from person before they died or from their next of kin Coroner does not need consent