The key considerations when completing death certificates are as follows:
- Whether or not you may complete death certificate
- Whether or not you are required to examine the body
- Whether the death is to be classified as procedural related or unnatural or natural death.
The Birth and Deaths Registration Act 51 of 1992 (the Act) is the authority that governs the completion of the DHA-1663 A form. Ultimately, it is this legislation which will be considered should you find yourself facing any criticism for the completion or refusal to complete a death notice. The wording of the Act provides a helpful guideline.
Natural and unnatural deaths
The Act makes a distinction between natural and unnatural deaths in sections 14 and 17 respectively. The requirements for the completion of the prescribed certificate regarding the death is dealt with in section 15.
Section 15 (1) stipulates the following:
“Where a medical practitioner is satisfied that the death of any person who was attended before his or her death by the medical practitioner was due to natural causes, he or she shall issue a prescribed certificate stating the cause of death.”
The use of the word attended is generally held to refer to an HCP who attended to the patient prior to their death and had personal knowledge of the deceased pre-morbid state of health.
On the contrary subsection (2) requires an examination of the body if the practitioner did not examine the patient prior to his demise:
“A medical practitioner who did not attend any person before his or her death but after the death of the person examined the corpse and is satisfied that the death was due to natural causes, may issue a prescribed certificate to that effect.”
Healthcare practitioners (HCPs) must be vigilant when completing the DHA-1663 A form as the wording can be contradictory and ambiguous when referring to the practitioner examining the body. In Section B, the document reads:
“I, the undersigned, hereby certify that I examined the body of the deceased named in section A and declare that the deceased, to the best of my knowledge and belief died due to natural or unnatural causes as indicated in paragraph 22.”
You may strike through the words “examined the body of the deceased named in section A” and initial next to the strike through if you have not examined the body, and add that the body was not examined because the practitioner is the “attending practitioner” I will discuss the nuances with regards to the sight of the body later.
Procedure related deaths
If the patient underwent any medical treatment or procedure shortly prior to their demise which could possibly have contributed to their death, it would likely be considered an unnatural death. In this case, a notice of death certificate cannot be completed as if it were a natural death and should be referred to the South African Police services for further investigation. The above is stipulated in section 15(3) of the Act:
“If a medical practitioner is of the opinion that the death was due to other than natural causes, he or she shall not issue a certificate mentioned in subsection (1) or (2) and shall inform a police officer as to his or her opinion in that regard.”
If the patient recently underwent a procedure, it is safer to refer the patient for a postmortem for certainty, rather than speculate on the cause of death.
Examining or attending to the patient
The Act specifically differentiates between the HCP “attending” to the patient prior to death and the HCP “examining” the corpse after death. The common element in both sections of the Act is that there should be some physical oversight of the deceased patient either shortly before the patient’s death, or the physical examination of the corpse.
These provisions therefore pose a difficulty in respect of the completion of the death certificate if a patient was assessed on a purely virtual platform, for example. If you find yourself facing a situation where the patient was seen virtually, please contact Medical Protection for further advice.
A question which often arises, is in relation to the duration of time between the last consultation with the patient and the patient’s death. It is generally accepted that the death certificate can be issued by an HCP who has attended the deceased during their last illness. This is likely to be interpreted to be the attendance before the patient’s death.
The crux of dealing with the issue of examining the body or attending to the patient, is mainly whether your involvement with the patient amounted to seeing patient for a condition shortly prior to death, or whether you examined the deceased shortly after death.
Cases of uncertainty
If you were to find yourself in a position where you were asked to complete a death notice for a patient unknown to you, or a patient that you have not physically assessed or examined, where you are told that the patient died of natural causes, it is advised that further investigations be made into the patient’s history. The Act requires a practitioner to “satisfy” themselves that the patient’s death was of natural causes. Generally, when you are approached to complete the death certificate, it is highly likely that there will be additional information such as a declaration of death by emergency services, or hospital records, which can be used in support of your documentation. If the patient demised in hospital, you could refer the requesting party back to the doctor who last treated the patient at the hospital. The investigation of these factors demonstrate diligence and care on your part should the cause of the patient’s death be challenged at any point.
For example, if you were to be contacted by a family member stating that the patient died at home, and upon further questioning it appears as if no medical assistance was requested at the time, it raises suspicion about the cause of death.
Section G of the form provides options under the heading “Method used to ascertain the cause of death” three of these stated options include the opinion of the attending medical practitioner, and an interview with a family member and “Other” (that is required to be specified).
If you do not have enough information you may decline to complete the certificate, since you cannot be satisfied what the cause of death was, or because you are of the view that the death was caused by unnatural causes. There are other options available to the undertakers to obtain the notice of death certificate and burial order.
Section 14(1)(b) provides that where notice of a person’s death cannot be given by means of a certificate because a HCP did not attend the deceased before his or her death, or was not available to examine the corpse, any person who was present at the death, or who became aware thereof, must give notice of the death in the prescribed manner to the Director General.
In summary, you should consider your most recent interaction with the patient when asked to complete the death notice. It is imperative that you consider whether there is a possibility that the death may be unnatural, or procedure related.
Please note this a broad overview, if you are unsure about whether to complete the death certificate, please contact Medical Protection to request advice that is specific to your case.
