The importance of correctly identifying a body as well as cause of death – and the subsequent accurate completion of notice of death forms – cannot be over-estimated, says Dr Graham Howarth, Medical Protection Society (MPS) South Africa.
Late last year MedicalBrief reported on the case of a GP who was found guilty of completing “death certificates” on two deceased patients, whose bodies he had not examined before completing the documentation.
It is further alleged that the certificates were then subsequently used in large fraudulent insurance claims. The elderly retired GP was convicted of fraud and sentenced to eight years’ imprisonment, wholly suspended for five years.
The deaths occurred during the pandemic and both were certified as being due to natural causes. In this case, the criminal conviction was clearly related to fraud, but the bureaucratic management of notification of death is not without its risks and difficulties.
From the outset it is important to state this article is written based on the contents of the MedicalBrief article on 14 December. Second, it is assumed that while this article refers to the GP having filled in “death certificates”, it is more likely that he filled in Notice of Death forms (DHA-1663).
Completion of these Notice of Death forms has certain important administrative functions. They are:
• To confirm the identity of the body to allow for the person’s name to be removed from the National Population Register;
• To confirm the circumstances or manner of the death as being from natural causes;
• To give the cause of death that can then be recorded for statistical purposes.
If the clinician is not satisfied that the death was from natural causes, a Notice of Death form should not be completed and a police officer should instead be informed.
Acceptance of the Notice of Death by the Department of Home Affairs allows for the issuing of a Burial Order (DHA-14), which means a body can be disposed of.
Likewise, the department issues an abridged death certificate, which plays an important role in relatives accessing insurance benefits, and issues related to pension claim settlements and settlement of the deceased’s estate.
The relevance of correctly identifying the deceased is obvious. The importance of the distinction between natural and unnatural causes of death also cannot be over-emphasised. Excessive administrative oversight of natural deaths is unnecessary and wasteful while the inadequate investigation and oversight of a death from unnatural causes is clearly unacceptable.
If the police are informed that a death is not considered to be due to natural causes the death will then be forensically reviewed and considered by an inquest magistrate who may decide on an informal or formal inquest.
Paraphrasing from the relevant Acts and regulations, deaths from unnatural causes include deaths due to a physical or chemical influence, a death from natural causes where an act or omission of a criminal nature may have played a role, a sudden or unexpected death, or a death where the cause of death is not apparent.
The Health Professions Amendment Act adds procedure-related deaths to the list of those considered not to be natural in nature.
Our experience at Medical Protection is that procedure-related deaths are probably under-reported. On occasions where there may be a degree of uncertainty that can be resolved by speaking to a state forensic pathologist, the clinician should call the local Forensic Pathology Service and follow the advice, provided while also documenting it contemporaneously in the patient’s notes.
If you previously treated the person and you are satisfied that he or she died from natural causes, there is no statutory obligation to examine the body before completing a Notice of Death form.
If you had not previously treated the deceased, but examined the body and are satisfied that the death was from natural causes, you may also complete a Notice of Death form. To be satisfied, you do not have to be certain but must be able to justify on what grounds you were satisfied, should you be challenged.
If you do not have a statutory obligation to examine the body, are satisfied that the death was from natural causes and complete the Notice of Death form without examining the body, you must be ready to justify the documentation if challenged.
Filling out the Notice of Death form
Some important sections of the Notice of Death form will require specific attention.
It is easy for the unwary, when completing the form, to give the impression of having examined the body. The instructions under Section A of the Notice of Death read:
“To be filled out by the Authorised Medical Practitioner/Professional Nurse, who is responsible for examining the body to determine the cause of death.”
If you did not examine the body it may be prudent to score out the words underlined.
In Section B of the Notice of Death form there is a paragraph that reads:
“I, the undersigned, hereby certify that I examined the body 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.”
Again, if you did not examine the body, it would be prudent to score out the section of the paragraph underlined.
Additionally, section 22.2 reads:
“I, the undersigned, am not in a position to certify that the deceased died exclusively due to natural causes.”
If you tick this section, you should not be completing the form, and should rather tell a police officer you are not satisfied death was from natural causes.
Finally, you are asked to comment on the method used to ascertain the cause of death. If you did examine the body, then you may tick 79.2 (post-mortem examination), which refers to having examined the body (as opposed to 79.1 where an autopsy has been performed).
If you did not examine the body, you should consider ticking 79.3 stating that the cause of death was based on the clinician’s opinion. Under 79.7, under other, you could add: “Body not examined”.
Without all of the above-mentioned suggestions, it is possible that the doctor concerned inadvertently gives the impression that the body was examined – and allegations of deceit or dishonesty may be made.
A clinician who has previously treated a patient does not have a statutory obligation to examine the body, and may complete a Notice of Death form if satisfied that death is from natural causes.
Clearly the option least likely to lead to criticism is to examine the body before completing a Notice of Death form. This will lessen the risk of criticism regarding identification, and satisfy that death was from natural causes.
Before completing the form, it may be worthwhile reflecting on what your understanding is of the death having been from natural causes – in case you are challenged. Likewise, a clinician who has not previously treated a deceased may complete the form, if after examining the body he or she is satisfied it was a natural death.
Section D of the Notice of Death form reveals the details of the informant – the person responsible for verifying the identity of the body. Being able to fully trust the informant, particularly if the body is not examined, is of cardinal importance, especially if you are later challenged on the identification.
Sadly, fraud is rife and if the informant misleads a clinician that could be to the clinician’s disadvantage – and may even extend to criminal liability.
In summary, if you are asked to complete a Notice of Death form, always reflect carefully on your responsibilities and be cognisant of how you can be misled.
Be aware of how an informant may mislead you, how well you know the person, and whether they are trustworthy. Have a low threshold for challenging that person. If you have previously treated the patient, do you have enough information to satisfy yourself that the death was from natural causes without examining the body?
Even if you do not have a statutory obligation to examine the body, having a low threshold for going out and examining the body is always the safer option. Likewise, even if you examine the body would you be able to defend your position of being satisfied that death was from natural causes?
If in doubt, speak to a local state forensic pathologist and document and follow their advice. Above all, be diligent, be vigilant and be careful.
See more MPS columns from MedicalBrief archives:
What the law requires after procedure-related deaths
New CEO as more challenges unfold in 2024
Survey highlights mental well-being of SA doctors