Imagine you, a healthcare practitioner, are sitting at the funeral of an elderly family friend, who died earlier in the week, and you are somewhat uncomfortable at what you have heard regarding the death. The deceased had undergone a hip operation a couple of weeks ago and due to a combination of her age and the pain, had been immobilised. A week after discharge from hospital a DVT was diagnosed and two days later the patient was found dead in her bed. Apparently, her GP considered the cause of death to have been a pulmonary embolism. Given the proximity of the funeral to the patient’s death, the death must have been classified as due to natural causes. You know that, given the history, a pulmonary embolism was not an unreasonable call by the GP, but you have a nagging concern that, given the recent procedure, the death was probably procedure-related, should have been classified as of unnatural causes, and been further investigated. Are you right and what are your obligations as a healthcare practitioner?

When a patient dies the Births and Deaths Registration Act places an obligation upon the practitioner to classify the cause of death as either natural or unnatural. The decision may be made either by a practitioner who attended the patient prior to the patient’s death or a practitioner that examined the deceased after the patient’s death. This examination of the deceased cannot be a cursory examination; the whole body needs to be examined as a practitioner must satisfy themselves that the death was due to natural causes. According to the Act, to classify the cause of death as being natural the practitioner must be satisfied that the death was due to natural causes.

Deaths due to unnatural causes misclassified as of natural causes evade the scrutiny of investigation while deaths due to natural causes misclassified as unnatural causes congest the already resource restrained Forensic Pathology Service. Clearly it is important that practitioners know what causes of death are considered to be unnatural. The regulations of the National Health Act consider deaths due to the following causes to be due to unnatural causes:

• Any death due to a physical or chemical influence, direct or indirect, and/or related to complications.

• Any death, including those deaths that would normally be considered to be due to natural causes, which in the opinion of the medical practitioner, has been as the result of an act or omission which may be criminal in nature.

• Any procedure related (including anaesthesia-related) death as contemplated in section 48 of the Health Professions Amendment Act 29 of 20075.

• Where death is sudden and unexpected, or unexplained, or where the cause of death is not apparent.

While it is important for perioperative practitioners to understand the nuances of procedure related deaths, the knowledge and application of the law related to procedure related deaths is poor in South Africa. In 2007 the Health Professions Act was amended to broaden the concept of anaesthesia-related deaths to procedure-related deaths – a term that clearly extends beyond the former. A death is considered to be procedure related if:

The act does not qualify the procedures nor when a procedure is deemed to have started or ended.  It has been suggested that a surgical procedure starts when the anaesthetist starts the placement of the anaesthetic paraphernalia and ends when the patient is transferred from the recovery room.  Does this mean one only includes deaths that occur in theatre or the recovery room?  Given the inclusion of the subclause – or of which any aspect of such a procedure has been a contributory cause – the answer to the aforementioned question is a resounding no. 

It would be prudent to strongly reflect upon any death related to a surgical procedure where the patient dies prior to hospital discharge, as a procedure-related death. Obviously, any death related to an acknowledged complication of the procedure, either prior to or subsequent to discharge, also fulfils the criteria of a procedure-related death. So a post-discharge pulmonary embolism, despite prophylactic anticoagulation, clearly qualifies to be included as a procedure-related death.  

It is important to remember that a maternal death associated with a caesarean section constitutes not only an unnatural death but also a notifiable medical condition.

The reason for including procedure-related deaths in deaths whose cause is considered to be unnatural is so that they can be fully investigated and open to independent review of the care given. Prudence dictates that any death related to a procedure be considered to be a procedure-related death, particularly if the death occurs while the patient is still an in-patient. One does not want an allegation that a death was misclassified in an attempt to circumvent scrutiny. If there is uncertainty one would be well advised to contact the local Forensic Pathology Service and contemporaneously document the conversation – particularly if they advise against classifying the death as a procedure related death.

Unless there is a belief that the case has or will be reported to the police, the Inquest Act places an obligation to report a death considered to be unnatural to a police officer as soon possible.  The responsibilities of those at the health facility include:

• Reporting the procedure related death to SAPS.

• Ensuring that the body is not removed by an undertaker.

• The body should be handed over as it was when the deceased died so medical paraphernalia (drips/lines/catheters/drains etc) should not be removed.

• Provide the deceased person’s full medical records including special investigation results.

• A Death Notification Form (DHA -1663) should not be completed.

• The responsible clinician/s needs to complete the somewhat anachronistic GW7/24 form – Report of a Person Whose Death is Associated with the Administration of an Anaesthetic or Diagnostic or Therapeutic Procedure.  The form makes provision for both the individual who performed the procedure as well as the anaesthesiologist (if anaesthesia was administered).

Once all the relevant information is available a magistrate will decide whether to hold a formal or informal inquest. The former involves a prosecutor and witnesses and is rare in South Africa while, in the latter, the magistrate reviews the death based on the documents available.

Given the importance of the topic and the statutory nature of the obligations it should come as no surprise that failure to comply with one’s obligations is punishable.  Were it determined that a practitioner made a false statement, particularly knowingly, punishment could include a criminal record, the possibility of a fine and even imprisonment. Likewise registered professionals, if in violation of their obligations, may be vulnerable to investigation, prosecution and if found guilty disciplinary steps by their regulator.  

So to return to you at the funeral – it could very likely be argued that, despite the patient having been discharged, the procedure could have been a contributory cause to the patient’s death. That being the case the death should not have been deemed to be a death from natural causes as contemplated by the Inquest Act. So now you are aware of a death that was probably not from natural causes and the Inquest Act places obligations on one to report such deaths to a Police Officer – somewhat of a dilemma.