Concluded Case

Death Certification during COVID outbreak

Normally the physician certifies death, but if not witnessed such as a death at home with suspicion of COVID 19. Who signs ? Autopsy mandatory? What are the regulations in place to consider in pandemic cases ? Does the law enforcement authorities and medicolegal practitioners ensure that all sudden and unexpected deaths are thoroughly investigated even during pandemic outbreaks ?

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The practitioner who attended the deceased during their last illness should complete the medical certificate of cause of death (MCCD). The updated guidance for doctors on completing medical certificates of cause of death in England and Wales states: "There is no clear legal definition of attended", but it is generally accepted to mean a doctor who has cared for the patient during the illness that led to death and so is familiar with the patient's medical history, investigations and treatment. For the purposes of the emergency period, the attendance may be in person, via video/visual consultation, but not audio (e.g. via telephone). The certifying doctor should also have access to relevant medical records and the results of investigations. The guidance goes on to state that where the certifying doctor has not seen the deceased before death, they should delete the words 'last seen by me'. If the patient was seen by another medical practitioner within the last 28 days, but not the certifying doctor, that doctor's name should be included on the MCCD. The Ministry of Justice has updated its detailed guidance for doctors on how to complete cremation forms to take into account changes introduced by the Coronavirus Act. The Act also allows an MCCD to be completed if a patient was not seen by any medical practitioner during their last illness. If that happens, a doctor would need to state to the best of their knowledge and belief the cause of death. Guidance from NHS England and NHS Improvement states that a doctor intending to complete the MCCD should obtain agreement from the coroner that they can do so. It remains the case that if there is no doctor at all who can give a cause of death then the death will still need to be referred to the coroner in the usual way. COVID-19 is now an acceptable 'direct' or 'underlying' cause of death for the purposes of the MCCD and although COVID-19 is a notifiable disease, this does not mean that deaths from COVID must be reported to the coroner. Indian Council of Medical Research (ICMR) on Wednesday said that invasive technique should not be adopted for forensic autopsy in coronavirus death cases as mortuary staff are exposed to potentially dangerous health risks due to organ fluids and secretions even after taking the highest precautions. ICMR in its 'Standard Guidelines for Medico-legal autopsy in COVID-19 deaths in India', said, "It will prevent the spread of infection to doctors, mortuary staff, police persons and all the people in the chain of dead body disposal." The move comes after reports of mortuary and medical staff also being tested positive at places. The forensic autopsy of these cases may be waived off," it said. In some homicidal, accidental or suicidal death cases, the deceased may be coronavirus confirmed or suspected. If the patient dies in hospital, the clinical records and all other relevant documents may be sent along with the body for forensic autopsy. "The investigating police officer must proactively take steps to waive off unnecessary autopsies during such a pandemic situation," the guidelines said.

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The practitioner who attended the deceased during their last illness should complete the medical certificate of cause of death (MCCD). The updated guidance for doctors on completing medical certificates of cause of death in England and Wales states: "There is no clear legal definition of attended", but it is generally accepted to mean a doctor who has cared for the patient during the illness that led to death and so is familiar with the patient's medical history, investigations and treatment. For the purposes of the emergency period, the attendance may be in person, via video/visual consultation, but not audio (e.g. via telephone). The certifying doctor should also have access to relevant medical records and the results of investigations. The guidance goes on to state that where the certifying doctor has not seen the deceased before death, they should delete the words 'last seen by me'. If the patient was seen by another medical practitioner within the last 28 days, but not the certifying doctor, that doctor's name should be included on the MCCD. The Ministry of Justice has updated its detailed guidance for doctors on how to complete cremation forms to take into account changes introduced by the Coronavirus Act. The Act also allows an MCCD to be completed if a patient was not seen by any medical practitioner during their last illness. If that happens, a doctor would need to state to the best of their knowledge and belief the cause of death. Guidance from NHS England and NHS Improvement states that a doctor intending to complete the MCCD should obtain agreement from the coroner that they can do so. It remains the case that if there is no doctor at all who can give a cause of death then the death will still need to be referred to the coroner in the usual way. COVID-19 is now an acceptable 'direct' or 'underlying' cause of death for the purposes of the MCCD and although COVID-19 is a notifiable disease, this does not mean that deaths from COVID must be reported to the coroner. Indian Council of Medical Research (ICMR) on Wednesday said that invasive technique should not be adopted for forensic autopsy in coronavirus death cases as mortuary staff are exposed to potentially dangerous health risks due to organ fluids and secretions even after taking the highest precautions. ICMR in its 'Standard Guidelines for Medico-legal autopsy in COVID-19 deaths in India', said, "It will prevent the spread of infection to doctors, mortuary staff, police persons and all the people in the chain of dead body disposal." The move comes after reports of mortuary and medical staff also being tested positive at places. The forensic autopsy of these cases may be waived off," it said. In some homicidal, accidental or suicidal death cases, the deceased may be coronavirus confirmed or suspected. If the patient dies in hospital, the clinical records and all other relevant documents may be sent along with the body for forensic autopsy. "The investigating police officer must proactively take steps to waive off unnecessary autopsies during such a pandemic situation," the guidelines said.

Thank you sir for your valuable answer. ICMR guidelines are not conclusive, as it says No autopsy at work one place and also mentions of Partial/Limited autopsy at the other. Investigating officers and Medicolegal experts are in dilemma whether to go for NO Autopsy or LIMITED autopsy.
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Yes this pandemic time should be investigated

Typical situation Yes it is mandatory on part of physician crrtifying death to r/o death is non covid As swab can be taken from dead body and get confirmation or send for autopsy It is necessary to follow protocols of disposal of cadaver.

Thank you sir. If deadbody swab result is positive ICMR says No autopsy but Investigating officers insisting for autopsy particularly non-hospital deaths
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Doing Autopsy on suspected COVID 19 is risky Body fluid may contain viruses and may transmit disease Adequate precautions are necessary to prevent transmission

A swab must be taken from dead body and get confirmation. and the disposal must be according to the protocols

I don’t know sir