The Death Documentation template helps you follow the new death certification process from 9th September 2024. The template allows you to refer to the Medical Examiner by producing a form electronically and send via email, as well as recording all information relevant to Verification, Details of Death, Medical Examiner Referral, Certification, Coroner Referral and After Death Analysis.
Key Points from 9th September 2024:
- All non-coronial deaths (deaths that are not reportable to a coroner) must be referred to a local Medical Examiner's Office with a proposed cause of death by the attending practitioner.
- The requirement to have seen the patient in the 28 days before death, during their last illness, or to see the body after death has been withdrawn. A medical practitioner will be eligible to be an attending practitioner if they have attended the deceased in their lifetime (‘Attendance’ is defined as a documented consultation either in person or via video).
- The attending practitioner can report a death directly to the coroner as usual where they believe they are under a statutory duty to do so. In this scenario, there is no regulatory requirement for the attending practitioner to inform the medical examiner.
- If you are unsure of whether a coronial referral is required, the Medical Examiner service will guide you.
- GPs will usually initially communicate with their local Medical Examiner office in writing either via an online portal or GP IT system task where this is available.
- When the cause of death is agreed with the Medical Examiner’s Office the GP can then send the completed MCCD back to the ME office electronically where it is reviewed and given the final sign-off/countersignature by an ME.
- Final step: The medical examiner (or ME office) sends the MCCD to the registrar to notify them of the cause of death after their final sign-off, and this notification will also start the 5-day statutory time frame to register the death (not 5 days from the time of death).
- There will no longer be a requirement to complete cremation forms.
The template can be found within Auto-consultation > ardens CONDITIONS FRAILTY and EOL > Death Documentation, or Auto-consultation > ardens GENERAL > Death Documentation.
There is also a link from the Reception & Administration template.
It can also be added to F12 favourites for quick access.
The template is split into several tabs across the top, to make it easier to navigate to the area you wish to complete:
Home
This first section gives a summary of key information for the patient.
Verification
The Verification tab allows you to record specific codes to clearly document the verification of the death of the patient. This is divided into 3 sections - Pre-Authorisation, Verification and Verified by.
The Pre-Authorisation section is where you can code if the patient is close to death and also record that a Verification of expected death agreement is documented. There is a link to launch this Agreement in Word to the right of this code, which you can save to the patient record, print out and sign. You can also record a DNACPR Status here if the patient doesn't already have one, and to the right of this is a link through to the Future Care Planning template where you can record more information on this if required.
The Verification section has the required criteria to verify death and add to the patients record. Also includes BMA guidance.
Details of Death
A member of the reception or administration teams can use the Details tab to record the details for the patient's death. This page is a quick way of capturing all necessary information and a useful prompt for the questions to ask where appropriate.
The Information link next to Device & Implant Status will direct you through to the Devices & Implants tab where you can view if the patient has any of the listed devices in the box below. To go back to the Details tab, click the Details tab at the top of the template.
There is a New Task button available for ease and a link to the Home Visits screen if needed.
The Follow-Up link will show if the patient has any outstanding Appointments or Visits booked, Tasks, Recalls etc. These can be cancelled or removed by right-clicking and selecting the appropriate option.
Just below are Word documents which can be printed for relatives of the deceased listing useful contact telephone numbers to register the death, arrange a funeral and bereavement support services.
Medical Examiner Referral
For more information on the new Medical Examiner Referral process, please click on the following Medical Examiner Referral Support Article.
Coroner Referral
This screen allows you to select the appropriate reason for a Coroner Referral.
Contact Details should list the coroner's contact telephone number (if using Ardens Pro) under the 'Community' tab.
Click on Coroner Referral to create the referral document.
The Coroner referral as death possibly due to option is a free text field. However, clicking on the notepad icon to the right of the free text box will allow you to quickly add a bunch of presets into the free text area.
Outcome
Select the appropriate action taken and add any notes to the text boxes.
Certification
The Certification tab is divided into 3 sections - Criteria, MCCD, Devices & Implants and Final step.
The Criteria section allows you to answer the relevant questions and the guidance will update below on who can complete the MCCD and if the Coroner Referral is needed.
The MCCD section provides Death Certificate coding and sections to add the cause of death if not added previously.
The Devices & Implants section has a handy link to a page showing you if this patient has any existing codes showing if they have a device or implant. Simply click on 'Information' to take you there. Once viewed, click on the 'Certification' tab at the top of the template to bring you back to this page.
Final Step allows you to record the MCCD has be sent to the medical examiner for final sign off.
Notification of Death
This page allows you to record which teams or organisations you have notified of the patients death by ticking the relevant box. There is also a button to send to staff a New Notification or a New Notification of Death task depending on local policies.
There is also the option to produce a Notification of Death Letter which will merge into word for you to send to the relevant organisations you have selected. Any existing letters you might have produced will sit in the box below this, which you can right-click on and view, or even send via NHS Mail.
After Death Analysis
This page allows you to record the details around recording After Death Analysis of the patient.
In the Details section, you can record specific details to do with the death of the patient using the drop-down boxes.
The Counselling section will allow you to record who has been contacted with information on counselling, and even allow you to produce a Bereavement Letter which will open in Word with some useful contact details you can give to the family or friends of the patient. The SUDEP Bereavement Letter will open up a similar letter but for epilepsy-related deaths.
The Analysis section will allow you to create an 'ADA' form, either with merge fields or blank, which you can then fill out within Word. There is a link to the LeDeR Notification Form on an external website and at the bottom of the template there is a blank box to write any other free text notes you may feel is appropriate.
Devices & Implants
This page can be linked to by pressing the 'Information' button on the 'Details' page of the template. The template will list the sorts of battery-powered or other implants that could cause a problem at cremation, and in the box at the bottom, if there are any such devices that have been coded in the notes of the patient, they will appear here.
If the box is empty, it is likely that none of these devices have been recorded, but this is not a complete list so it is worth double-checking the patients full medical record.
Resources
A list of useful links. These can be sent via SMS or Email by highlighting the link, Copying with Ctrl+C, clicking on 'Send Message' and then pasting with 'Ctrl+V' into the relevant box.