A Duty to Certify Death:

A Duty to Certify Death:
Compliance with the Coroner’s Act and Death
Certificate Completion
Dr. Stephen Wetmore
Victoria Family Medical Centre
Coroner
London Ontario

Objectives
Review Coroner’s Act
Coroner’s Investigations
Completion of Death Certificates

Case 1
JY, 85, CVA, right hemiplegia, aphasia
Hypertension; atrial fibrillation
Aspiration and aspiration pneumonia
Herpes Zoster
Sacral ulceration; infection
Dehydration; unable to maintain nutrition
Died while wife was feeding him

Case 1
Your are the resident doctor on call.
Is this a coroner’s case?
How would you complete the death
certificate?

Reporting to a Coroner
Patient dies in hospital
MD to pronounce
Is it a coroner’s case?
Yes or not sure No
Call coroner
Coroner calls back
Decides to investigate?
Advise about body
Advise about death certificate
Ask next of kin for
autopsy consent

Reporting to a Coroner
Patient dies at home
Expected death - MD or RN (EC)
If no arrangements or unexpected coroner will be called
Coroner to
investigate
Coroner decides not to
investigate
Family doctor to
complete death
certificate

CORONER SYSTEM - overview
Ministry of Public Safety and
Security - Ontario
Chief Coroner - Ontario
Investigation
Coroner
Regional Coroner
Inquest Coroner

Office of the Chief Coroner
Mission Statement:
We speak for the dead to
protect the living

Coroner - Legislative Authority
Coroner’s Act
– Duty to Report – Section 10
Coroner’s Amendment Act 2009
– Establishes Ontario Forensic Pathology Service
– Establishes Death Investigation Oversight
Council and Complaints Committee
– Establishes nature of coroner’s investigation
» Answer the five questions
» Decide on inquest
» Focus on prevention of future deaths, similar circumstances

Coroner’s Investigation
How do you know if you should report a
death to a coroner?

THE CORONER’S ACT-1
DUTY TO REPORT TO CORONER
– violence
– misadventure
– negligence
– misconduct, or
– malpractice
– by unfair means

THE CORONER’S ACT-2
During pregnancy or following pregnancy
suddenly and unexpectedly
disease not treated by legal practitioner
any cause other than disease
under such circumstances as may require
investigation

THE CORONER’S ACT-3
while resident or inpatient of:
– charitable institution
– children’s residence
– home for the aged
– home for retarded persons
– psychiatric facility
– nursing home
– any hospital if transferred from above sites

THE CORONER’S ACT-4
Where a person dies while:
– psychiatric patient
– correctional institution
– ward of the crown
– custody under Young Offenders Act
– custody of police or in prison

ROLE OF CORONER
Investigate deaths reported under the Act
– death scene
– Examine the body
– autopsy
– seek other reports, e.g.. Fire marshal
Report completion
Inquest decision
Coroner’s recommendations

Role of Coroner:
Regarding the Body
Warrant to take possession
Identification of deceased
Arrangement for autopsy
Ensure no alteration of the body after death
pending autopsy
Authorizes release of body to funeral home
Authorizes cremation

Role of Coroner:
Death due to Trauma
Make sure the events of the trauma are
investigated - police investigation
Autopsy is done in nearly all cases
Blood may be seized for toxicology
Records may be seized for later use

POWERS OF CORONER
Enter and inspect locations
inspect records or writings
seize anything pertinent to investigation
authorize other medical practitioners or
police officers to exercise powers

CORONER’S REPORT
Who the deceased was
When the deceased died
Where the deceased died
How the deceased came to death (cause)
By what means the deceased came to death
(natural, accident, suicide, homicide, undetermined)

Coroner’s Investigations -
Outcomes
Coroner’s report communicated to family
Coroner’s inquest
Coroner’s recommendations
– May recommend or ask for hospital review and
report
Regional supervising coroner’s review

Examine body and
position
evidence of trauma?
pills, count
alcohol, drugs
suicide notes
hanging apparatus
SIDS – bedding
DEATH SCENE
INVESTIGATION
Medical devices, monitors

Signs of Death
Lack of respirations, circulation
Rigor mortis
Lividity
Decomposition

Lividity
TIMING OF DEATH
– Usually blue in colour
– May be pink
– Visible 30 min – 3 hr
– Fully developed 8-12
hr
– Fixed , 12-15 hr.

Body temperature
– 1 o /hr x 12hrs
TIMING OF DEATH
– 0.5 o /hr x 12 hrs
Stomach contents
– Variable and not helpful
Rigor mortis
– depends on various factors
– Starts immediately, gradual
– Noticeable 3-4 hr.
– Fully developed 8-12 hr

DEATH INVESTIGATION -
Police reports
Fire Marshall
Dept. of Labour
Aviation
Centre Forensic
Science
Family doctor
Medical records
OTHER

Completion of Death Certificates

Family Physician Responsibilities
“The responsibilities of the family physician
do not end with the death of the patient.
Through careful and accurate completion of
death certificates, the family physician can
help to ensure that the far-reaching
consequences of the patient’s death are as
they should be.”
Nowells D. Am Fam Physician 70
(9);

Vital Statistics Act
“Any legally qualified medical practitioner who
has been in attendance during the last illness of the
deceased person or who has sufficient knowledge
of the last illness shall forthwith after the death
complete and sign a medical certificate of death in
the prescribed form, stating the cause of death
according to the classification of diseases adopted
by reference in the regulations, and shall deliver
the medical certificate to the funeral director or
other person in charge of the body.”

Death Certificates -- importance
Source of information for mortality
statistics
Potentially used by policymakers for public
health goals, funding priorities, research
May help settle estates of the deceased and
allowing payments to beneficiaries

Death certificates -- evidence
1993 survey of the house officers and
family physicians
90% of respondents felt accurate death
certificate information was important
> 50% felt that they needed more education
in this skill.
Maudsley et al J Public Health Med
1993;15(2):192-201

Death certificates -- evidence
1993, Jordan and Bass
31.9% of death certificates at a tertiary
teaching hospital contained errors
The department of medicine had the highest
rate of errors – 40% of certificates were
classed as unacceptable
Jordan and Bass. Clin Invest Med
1993;16(4):249-55

Death certificates -- errors
As as many as 30% of death certificates can have
major errors
Major errors generally fall into two categories
– Listing mechanism of death without underlying cause
– Improper sequencing of death certificate information
Myers at all showed an educational intervention
significantly improved the major error rate in
death certificates, but not the minor error rate.
Myers and Farquhar. CMAJ
1998;158:1317-23

Death Certificates
Recommendations of the World Health
Organization
Part I; 3 lines, a,b,c, underlying cause of
death, as well as immediate and antecedent
causes
Part II; other significant conditions
contributing to the death

Death Certificates
Underlying cause of death is the disease that
triggered the chain of events leading to the
patient’s death. – must be the lowest line of
part I (from your knowledge of patient and
circumstances – on balance of probabilities)
An underlying cause of death can stand
alone as the only completed line in part I
Revised Death Certificates can be
completed when further information is
available

Death Certificates -- examples
75-year-old male smoker, five year history of
emphysema, is admitted to hospital with
pneumonia caused by Haemophilus influenza.
Other history includes 10 years of coronary artery
disease.
One week after admission, he is found dead in
bed.
You are called to complete the death certificate

Respiratory Arrest Failure
Coronary Artery Disease

Death Certificate -- examples
Part I
A) respiratory arrest
Part II
Coronary artery
disease
Mechanism is listed
without an underlying
cause of death
No time intervals are
listed

Emphysema
Pneumonia
Coronary Artery Disease

Death Certificate -- examples
Part I
A) Emphysema
B) Pneumonia
Part II
Coronary Artery
Disease
Improper sequencing
Absence of time
intervals

Emphysema 5 yr
CAD 10 yr

Death Certificate -- examples
Part I
A) Emphysema 5 yr
B) CAD 10 yr
Part II
Competing causes of
death
Abbreviations used

Pneumonia – Hemophilus Influenza 1 wk
Emphysema 5 yr
Coronary Artery Disease
10 yr

Death Certificate -- examples
Part I
A) Haemophilus
Influenza Pneumonia
B) Emphysema
Part II
Coronary Artery Disease
1 week
5 years
10 years

Examples - 1
Mrs. Jones, age 75, suffered from
rheumatoid arthritis for 25 years
Two weeks ago, she fell and fractured her
right hip. She was admitted had an
arthroplasty.
One week ago, she developed pneumonia
and despite treatment died today.
You are called to pronounce death and
complete death certificate

Pneumonia 1 wk
Fall - Right hip fracture
2 wks
Rheumatoid Arthritis 25 yr

Examples - 2
Mrs. K., aged 86, died in the nursing home
after 10 days of intermittent vomiting and
diarrhea.
There was a gastrointestinal outbreak at the
home. No etiologic agent was identified.
She was admitted to the home five years
earlier with advanced dementia.

Dehydration 10 d
Viral Gastroenteritis
Advanced Dementia
10 d
5 yr

Examples -- 3
Mr. Y., aged 56, died at home, surrounded
by family members after a long battle with
cirrhosis of the liver caused by alcohol
abuse
For the last two weeks. He has been
virtually unconscious, deeply jaundiced,
and had a pronounced periodic jerking
tremor

Hepatic Encephalopathy 2 wk
Cirrhosis of Liver mths
Alcohol Abuse
years

Examples -- 4
75-year-old man who had two heart attacks over
the past eight years and is on antihypertensive
medication and Lipitor for 10 years is admitted
after a fender bender accident in which he slid
forward and impacted his chest into the steering
wheel.
X-rays are negative for fracture. A CT scan shows
no injury.
Later that night he goes into V. Tach, then V Fib
and cannot be resuscitated.

Cardiac Arrhythymia Min.
Chest Contusion Hrs
Motor vehicle Accident
Hrs
Coronary Artery Disease 8 yr
Hypertension yrs

Age 72, female
Alcoholic
Examples - 5
Drinking heavily at friends
Went to bathroom
Found collapsed in BR 1 hr later
PM – 75 % stenosis LAD

Complications of Coronary Artery
Disease
yrs
Chronic Alcoholism Yrs.

Examples -6
84 years, female, lives alone
History of hypertension, osteoarthritis
Falls down 8 stairs, calls neighbour with
alert button
Hospitalized with fractured pelvis
Dies in hospital 8 days later
PM shows fat embolism, toxic level
Verapamil

Fat Embolism 8 days
Fractured Pelvis 8 days
Fall down stairs
8 days
Possible Verapamil toxicity ?
Hypertension Yrs

Examples -7
95 year old female, lives alone
Your patient for years; mild hypertension,
some osteoarthritis, mild cognitive decline
Carotid bruits; no CVA
You have prescribed HCT but she doesn’t
take it.
Found dead in bed

Arteriosclerosis Yrs

Hypertension Yrs

Cerebrovascular Insufficiency Yrs

49 year old male
Examples - 8
Looked after at home by his wife
Carcinoma of lung with brain and liver mets
for 1 year
You are making house calls, managing pain
and symptoms
One morning you are called; he has died at
home

Metastatic Carcinoma Lung – Small
Cell
1 yr

Case 1 - Reminder
JY, 85, CVA, right hemiplegia, aphasia
Hypertension; atrial fibrillation
Aspiration and aspiration pneumonia
Herpes Zoster
Sacral ulceration; infection
Dehydration; unable to maintain nutrition
Died while wife was feeding him

Aspiration Pneumonia Days
Cerebrovascular Accident years
Decubitus Ulcer Wks

Key Points
Don’t call the coroner for expected or natural deaths at
home.
Do call the coroner when the manner of death is not
natural.
Do be as accurate as possible based on your knowledge of
the patient when completing death certificates
Death certificates may be amended after they are
completed.
Old age is not a cause of death ( Ontario).
Mechanism of death is not the same as a cause of death.
Death due to a complication after a fall is an accident.