Dr Graham Howarth, Medical Protection Society (MPS) Medical South Africa Lead.

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Late last year Medical Brief reported on the case of a GP who was found guilty of completing “death certificates” on two deceased patients, whose bodies he had allegedly not examined prior to completing the documentation. 

It is further alleged that the “death 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 COVID-19 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 that this article is written based on the contents of the Medial Brief article on December 14. Secondly, 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 deceased to allow for the deceased’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 of Home Affairs issues an abridged death certificate which plays an important role in relatives accessing insurance benefits, 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 overemphasised. 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 deaths considered not to be natural in nature.

Our experience at Medical Protection is that procedure related deaths are probably underreported. 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 deceased and you are satisfied that the deceased died from natural causes there is no statutory obligation to examine the body prior to completing a Notice of Death form. If you had not previously treated the deceased, but examined the body of the deceased and are satisfied that the death was from natural causes one 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 one does not have a statutory obligation to examine the body, is satisfied that the death was from natural causes and completes the Notice of Death form without examining the deceased’s body one must be ready to justify the documentation if challenged.

Here we will run through some important sections of the Notice of Death form that require specific attention.

It is easy for the unwary, when completing the form, to give the impression they have 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 deceased’s 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 of the deceased 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 are minded to tick this section you should not be completing the form and rather inform a police officer that you are not satisfied that the death was due to natural causes.

Finally, in Section G at point 79 on the form, one is asked to comment on the method used to ascertain the cause of death. If you did examine the body of the deceased 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 one did not examine the body of the deceased one is advised to consider ticking 79.3 stating that the cause of death was based on the clinician’s opinion. Under 79.7, under other, one could add: “body not examined”.

Without all the above-mentioned suggestions it is possible that the doctor concerned inadvertently gives the impression that the body of the deceased 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 of the deceased and may complete a Notice of Death form if satisfied that the death is due to natural causes. Clearly the option least likely to lead to criticism is to examine the body of the deceased, prior to completing a Notice of Death form. This will lessen the risk of criticism regarding identification of the deceased and satisfy that the death was from natural causes. 

Conclusion

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 alive to the possibility of how an informant may mislead you, how well you know the informant and whether they are trustworthy. Have a low threshold for challenging the informant. 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 deceased’s body?

Even if you do not have a statutory obligation to examine the deceased’s 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 the death was due to 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.

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This article was originally published in Medical Brief and is republished with permission.