A recent case involving a doctor who
became embroiled in a coroner’s inquest into an elderly woman’s death after
they were asked to sign her death certificate, highlights why you need to be
clear on whether you can sign a death certificate or not.
The task of
signing death certificates frequently falls to general practitioners and
relatively junior hospital doctors who are faced with the family of the
deceased or the police putting pressure on the medical practitioner to sign
the death certificate.
In this case, the patient’s
doctor was asked to sign a death certificate for Mrs L, who suffered
dementia, after being told by the aged care facility where she resided, that
she had been found lying in the grounds next to a fountain, deceased from a
suspected heart attack.
After visiting the aged care facility where Mrs L
was lying peacefully in her room, the doctor dutifully signed the death
certificate. At the time, the doctor did not feel it was necessary to ask any
questions and did not report the death to the coroner.
the doctor was furious to discover that some of the staff at the aged care
facility had covered up the more sinister circumstances of Mrs L’s death and
in fact, she fell into a fountain in the nursing home grounds and most likely
The police launched an investigation and the doctor was
involved in an inquest into Mrs L’s death in which their professional approach
to writing death certificates was scrutinised.
uncovered CCTV footage which showed that Mrs L had actually tripped over the
garden light and fallen head first into the fountain, possibly striking her
Evidence suggested that staff discovered her fifty minutes later
and removed her from the fountain.
During the inquest into Mrs L’s death,
the nurse in charge on the day she died said the facility manager had
threatened to sack her if she did not falsify progress notes to state that
she had been found in the courtyard lying on the ground after suffering a
suspected heart attack.
The nurse told the inquest that a carer had
dried off Mrs L and reclothed her in preparation for the family.
Coroner found the cause of death to be immersion with underlying cause
undetermined in circumstances of a fall into a courtyard water
When to report a death to the coroner
emphasises the importance for doctors who are asked to provide a death
certificate to ensure they conduct a thorough examination of the body and to
ask any relevant questions.
The doctor conceded that as the death had
involved a fall, it should have been reported it to the coroner and agreed
that when in doubt about whether a death was reportable, it was better to
err on the side of caution and report it.
A doctor responsible for a
patient’s care immediately prior to death or who saw the deceased after death
must sign such a certificate unless the death is reportable to the
“If the death is reportable or you cannot confidently certify
the cause of death you should not sign the death certificate,” John Kamaras,
Special Counsel – Coronial, Avant, said.
‘Reportable deaths’ must be
notified to the coroner or police, and no death certificate should be
When in doubt, you can also either contact Avant for
advice on 1800 128 268 or contact the coroner’s office directly for
Read Avant’s fact sheet on providing cause of death certificates.
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