1. This communication is to provide guidance to doctors, colleagues in Police Scotland and Crown Office and Procurator Fiscal Service to help the processes for providing the Medical Certificate of Cause of Death (MCCD), or Form 11 of National Records of Scotland (NRS), during an Influenza Pandemic.
2. It updates and supersedes the CMO and Head of Fire and Civil Contingencies guidance provided in September 2007 .
3. In the National UK Risk Assessment, Pandemic Influenza is categorised as one of the top risks in terms of its likelihood and impact. History and science suggests that we are likely to face other Pandemic Influenza outbreaks in this century, but we are unable to predict when that might happen. The severity, spread in the population and duration of the Pandemic is also unpredictable. In the event of an Influenza Pandemic, there will be an increased number of deaths that will require to be certified.
4. In addition, due to public health reasons, there may be increased pressure for the rapid burial/cremation/other processes of those who have died. The method may also be specified if required for the protection of the public.
5. A national Pandemic Flu Exercise (Silver Swan) in Summer 2015, in Scotland, highlighted the need for an updated letter to support the reduction in time to provide the MCCD during an Influenza Pandemic.
7. The new guidance in Annex A ‘fast-tracks’ the completion of the MCCD to indicate where the cause of death is ‘pandemic flu’ or ‘presumed pandemic flu’, gives examples of situations, and outlines the circumstances that can be legitimately considered for certification. It is hoped that this combination will reduce delays in the registration of deaths in the event of Pandemic Influenza and enable doctors to provide an MCCD.
9. Thank you very much for your help in this matter.
Catherine Calderwood, Chief Medical Officer
Guidance to Medical Practitioners for Death Certification During an Influenza Pandemic
This guidance is intended to assist medical practitioners with their clinical responsibility for the appropriate certification of deaths in the event of an Influenza Pandemic, should such an event occur. Whilst the guidance is not all inclusive, it is intended to give medical practitioners assistance and support with their clinical responsibility for the appropriate certification of death and provision of the MCCD.
The aim is to provide some information that will assist in the certification process and to give medical practitioners the confidence to act appropriately when operating in an altered and pressurised environment. This approach to deaths during an Influenza Pandemic has been produced with the approval of the Academy of Royal Colleges, British Medical Association (BMA), Medical and Dental Defence Union of Scotland (MDDUS), Scottish Government Directorates, Association of Forensic Physicians, NRS, the Crown Office and Procurator Fiscal Service, (COPFS) and Police Scotland, with the view to assisting medical practitioners in the process of certification of death during an Influenza Pandemic.
In the event of an Influenza Pandemic there will be an increased number of deaths that will require to be certified. This increase may be so significant that that it will put pressure on medical practitioners and other services as a whole. It is likely that some medical practitioners and colleagues from other services such as Police Scotland, Crown Office and Procurator Fiscal Service, forensic pathologists, funeral directors, burial and cremation authorities, and others, will themselves be incapacitated by influenza for periods of time and this will put an even greater strain on capacity within current systems.
In addition, due to public health reasons there may be increased pressure for the rapid disposal of those who have died and there may even be requirements about the type of disposal procedures that need to be followed.
When a pandemic is declared in Scotland, the Death Certification Review system will be suspended via legislation at which point this guidance will come into force. The Death Certification Review system and normal guidance for death certification will recommence when the Pandemic is declared to be over. This means that the MCCDs will not be randomised by NRS for scrutiny and any MCCDs in the process of scrutiny will be completed, allowing the funeral to take place, despite the stage of the scrutiny. Any Interested Person’s requests for scrutiny will be kept on hold and re-visited once the pandemic is declared to be over.
It should be borne in mind by medical practitioners that their clinical responsibility for appropriate certification of death requires that they be satisfied on the balance of probabilities as to the likely cause of death. This complies with the concept of certification to the best of one’s knowledge and belief as required by the Registrar General for Scotland.
There are a number of situations where medical practitioners may need to consider whether a cause of death of “pandemic flu” can be certified. It is anticipated that the majority of deaths during an Influenza Pandemic will be readily identified as such. There may however be certain categories where identification of the cause of death is not so straightforward.
- There may well be deaths where there has been recent medical intervention but the medical practitioner still has some doubt as to the cause of death. In these circumstances the medical practitioner should consider the symptoms to see whether, on the balance of probabilities “Pandemic Influenza” is the likely cause of death. These symptoms should include fever, cough, and malaise, associated with either headache, coryzal symptoms, myalgia and sore throat in adults and fever, cough and rhinorrhoea in children. In infants, fever with non-specific symptoms of diarrhoea and vomiting are common, whereas pharyngitis and headaches are more common in older children. The symptoms will depend on the pandemic strain of the virus circulating at the time.
- There may be cases where there has been little or no recent medical intervention and the medical practitioner is short of information as to the deceased’s recent state of health. In these circumstances the medical practitioner should consider the symptoms outlined above from relatives or friends if available, as well as looking at the wider facts and circumstances. These wider facts and circumstances can include the fact that there is an Influenza Pandemic, that the Influenza Pandemic has struck in the locality, whether there was any evidence of medication suitable for treating the symptoms of an Influenza Pandemic found in or near the deceased’s possession e.g. ostletamivir (Tamiflu).
- There may also be cases where the medical practitioner finds some evidence of symptoms and/or surrounding circumstances that are compatible with, but perhaps not exclusive to, Pandemic Influenza as being the cause of death. The symptoms in the elderly including those in a care home, could be non-specific respiratory symptoms without fever, and lethargy. In such a case, and where there are no other indications as to the cause of death, and where there are no suspicious circumstances, it would be considered to be clinically responsible to certify the death as “presumed Pandemic Flu”. This will be accepted as a cause of death by the registrar.
If the practitioner is not able to satisfy himself/herself on the balance of probabilities of the likely cause of death, then the appropriate action would be to discuss the issue with the Procurator Fiscal. The Procurator Fiscal may:
- advise that a certificate can be issued with “presumed Pandemic Flu”,
- in some instances take over the investigation of the case with the help of Police Scotland, which may or may not involve a post mortem examination (autopsy).
The first responders at the death in the community are expected to follow the Management of Death in the Community (in hours and out of hours) implemented on the 29 February 2016. This process may need to be adapted for local needs, during Pandemic Influenza.
Police, liaising with the Procurator Fiscal, will continue to be involved in all suspicious deaths.
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