based on

Summary

• Confirm the deceased’s identity, date/time and place of death, circumstances, relevant history, recent procedures, and any cremation-risk devices.
• Document how the cause-of-death opinion was formed:
  • Personal treatment.
  • Medical records.
  • Nursing, ambulance, police, family or specialist information.
• Before issuing the certificate, consider whether the death must be reported to the coroner, particularly where there is:
  • Trauma, fall or fracture.
  • Accident, suicide, homicide or suspicious circumstances.
  • Medication misadventure.
  • Possible healthcare-related complication.
  • Unexpected or unexplained death.
• Falls and trauma require special consideration:
  • A remote traumatic injury can remain the underlying cause if it started the causal chain.
  • A recent fall or fracture may instead be placed in Part II if it contributed to decline but did not directly cause the final disease.
  • In Queensland, a fall contributing to death commonly requires coronial notification.
• Part I should show a logical causal chain:
  • 1(a): Immediate condition directly causing death.
  • 1(b), 1(c), etc: Conditions that caused the line above.
  • The lowest completed line is the underlying cause.
  • Include an approximate duration for every condition.
• Part II is for other significant conditions that contributed to death but were not part of the direct causal chain. Do not list every past diagnosis.
• Avoid:
  • “Cardiac arrest” or “cardiorespiratory arrest” alone.
  • “Organ failure” without the cause.
  • “Natural causes.”
  • “Old age.”
  • “Frailty” without an associated disease process.
  • Acronyms and vague diagnoses.
• Dementia can be recorded as a cause of death. Record the subtype and duration where known.
• Delirium is not a standalone cause of death. Record the condition causing the delirium.
• In Queensland, select the probable cause of death on the balance of probabilities. Absolute certainty is not required.
• For an unexpected but apparently natural death, consider the most likely disease based on:
  • Known pathology and risk factors.
  • Recent symptoms.
  • Circumstances at the scene.
  • Police, ambulance and family information.
• For voluntary assisted dying:
  • Record the terminal disease.
  • Do not record VAD itself as the cause.
  • Report any suspected procedural error or misadventure.
• Check for cremation risks, including pacemakers, deep brain stimulators, spinal stimulators and recent radioactive treatments.
• Document:
  • Circumstances and clinical reasoning.
  • Coroner discussions.
  • Family and clinician discussions.
  • Proposed Part I and Part II entries.
  • Reasons for completing or declining the certificate.
• Before signing, confirm the sequence is logical, durations are included, terminology is specific, and coronial reporting has been appropriately considered.

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1. Confirm the deceased person’s details

• Confirm full legal name.
• Confirm correct spelling.
• Record any known aliases where relevant.
• Confirm date of birth.
• Confirm sex or gender details required on the form.
• Confirm usual residential address.
• Confirm place of death.
• Confirm date of death.
• Confirm exact time of death where known.
• Where the exact time is unknown:
  • Record the best available estimate.
  • Alternatively record an appropriate limited time range.
• Confirm whether the body has been formally identified.
• Confirm who provided the identifying information.
• Confirm whether police or ambulance officers attended.

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2. Document the basis for the medical opinion

• Record how the opinion regarding cause of death was formed.
• Relevant sources may include:
  • Personal treatment of the patient during life.
  • Recent clinical consultations.
  • Residential aged-care records.
  • Hospital discharge summaries.
  • Specialist correspondence.
  • Pathology results.
  • Imaging results.
  • Medication records.
  • Nursing observations.
  • Information from family members.
  • Information from ambulance officers.
  • Information from police.
  • Discussion with other treating doctors.
• In Queensland, a doctor may form an opinion from sufficiently detailed medical records even where the doctor did not personally treat the patient, provided the circumstances and probable cause of death are adequately established.
• My Health Record should not be accessed after death for the purpose of determining the cause of death.

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3. Establish the circumstances of death

• Determine:
  • Where the person was found.
  • Who found the person.
  • When the person was last seen alive.
  • Whether the person had symptoms before death.
  • Whether death was expected.
  • Whether there was a documented terminal illness.
  • Whether the person had recently deteriorated.
  • Whether there had been a recent fall.
  • Whether there was evidence of injury.
  • Whether there was possible medication overdose or misadventure.
  • Whether there were any suspicious circumstances.
  • Whether police have concerns.
  • Whether family members have concerns regarding treatment or care.
  • Whether a recent medical procedure may have contributed.
• Review the clinical course immediately before death:
  • Fever.
  • Dyspnoea.
  • Chest pain.
  • Neurological symptoms.
  • Reduced oral intake.
  • Increasing frailty.
  • Aspiration.
  • Infection.
  • Falls.
  • Bleeding.
  • Delirium.
  • Progressive malignancy.
  • End-stage organ disease.

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4. Decide whether the death is reportable to the coroner

• Do not complete the certificate until coronial reporting requirements have been considered.
• A death may require coronial notification where there is:
  • Trauma.
  • Accident.
  • A fall contributing to death.
  • Suspected suicide.
  • Suspected homicide.
  • Suspicious circumstances.
  • Possible overdose.
  • Medication misadventure.
  • Possible failure of healthcare.
  • Unexpected death with no reasonable probable natural cause.
  • Death in a facility subject to mandatory reporting.
  • A death apparently related to a procedure or treatment.
  • A death where the identity is uncertain.
• Death in a Queensland nursing home is not automatically reportable.
• However, deaths in some supported accommodation services and declared mental health facilities may be reportable.
• Where uncertain:
  • Contact the coroner’s office.
  • Discuss with attending police.
  • Discuss with ambulance officers.
  • Document the advice received.
  • Do not issue the certificate until the matter is clarified.

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Falls, trauma and fractures

5. Direct traumatic cause

• Trauma may remain part of the direct causal chain even where death occurs many years later.
• The passage of time does not remove the possible requirement for coronial reporting.
• A traumatic event can remain the originating underlying cause where it led to:
  • Permanent neurological injury.
  • Immobility.
  • Pressure injuries.
  • Recurrent infection.
  • Sepsis.
  • Death.
• Example causal chain:
  • 1(a): Sepsis — hours.
  • 1(b): Pressure injuries to both hips — months.
  • 1(c): Immobility and poor skin integrity — years.
  • 1(d): Closed head injury and brain damage — years.
  • 1(e): Motor vehicle accident — 18 years.
• In this example, the motor vehicle accident remains the originating event.
• The death is reportable because the causal chain ultimately ends in traumatic injury.

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6. Indirect contribution from a fall

• A fall or fracture may contribute significantly to death without being in the direct causal sequence.
• Consider whether:
  • The person’s death would probably have occurred in the same timeframe without the fall.
  • The fall caused immobility.
  • The fracture caused physiological stress.
  • Surgery contributed to deterioration.
  • The injury precipitated delirium, infection or cardiac decompensation.
  • The fall accelerated decline.
• Apply the practical “but for” test:
  • But for the fall or traumatic injury, would the person probably have died in the same timeframe?
• Where the answer is probably no, the fall or injury has materially contributed.
• In Queensland, such a death will commonly require coronial notification even where the immediate cause is a natural disease.
• Example:
  • 1(a): Myocardial infarction — minutes.
  • 1(b): Coronary artery disease — years.
  • 1(c): Hypertension — years.
  • Part II: Mechanical fall with right neck-of-femur fracture, surgically treated — 7 days.
• The myocardial infarction is the direct cause.
• The fracture is a significant contributing condition.
• The fracture is placed in Part II because it did not directly cause the coronary artery disease or myocardial infarction.

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Cause-of-death sequence

7. Part I: direct causal chain

• Part I records the sequence of diseases, injuries or complications that directly led to death.
• The sequence is written from the immediate cause backward to the originating underlying cause.

Line 1(a): immediate cause

• Record the final disease, injury or complication directly causing death.
• It should answer:
  • “What disease or condition directly caused the person to die?”
• Examples:
  • Bacterial pneumonia.
  • Sepsis.
  • Myocardial infarction.
  • Intracerebral haemorrhage.
  • Aspiration pneumonia.
  • Metastatic hepatocellular carcinoma.
  • Pulmonary embolism.

Lines 1(b), 1(c), 1(d) and 1(e): antecedent causes

• Record the conditions that caused or gave rise to the condition above.
• Each line should causally explain the preceding line.
• Work backward until the originating disease or event is recorded.
• The lowest completed line is generally the underlying cause of death.
• Example:
  • 1(a): Klebsiella pneumonia — days.
  • 1(b): Immobility — weeks.
  • 1(c): Lewy body dementia — 6 years.
• Read the chain from the bottom upward:
  • Lewy body dementia caused immobility.
  • Immobility predisposed to pneumonia.
  • Pneumonia directly caused death.
• A clear chronological and causal sequence is required. Merely listing all known diagnoses is not appropriate.

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8. Characteristics of a valid causal chain

• Each condition should be capable of causing the condition above it.
• Each line should represent a separate causal step.
• Avoid combining unrelated diagnoses on one line.
• Do not place background risk factors in Part I unless they genuinely form part of the direct causal sequence.
• Review the completed chain by asking:
  • Did condition C cause condition B?
  • Did condition B cause condition A?
  • Did condition A directly result in death?
• If the answer is not clinically logical, revise the sequence.

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9. Part II: other significant contributing conditions

• Part II is for conditions that contributed to death but were not directly responsible for the sequence in Part I.
• Part II conditions may:
  • Reduce physiological reserve.
  • Increase susceptibility to the immediate cause.
  • Accelerate the final illness.
  • Increase cardiovascular risk.
  • Cause immunosuppression.
  • Increase the severity of an infection.
  • Contribute to systemic stress.
• Examples:
  • Chronic obstructive pulmonary disease.
  • Cigarette smoking.
  • Diabetes mellitus.
  • Hypertension.
  • Obesity.
  • Chronic kidney disease.
  • Atrial fibrillation.
  • Recent hip fracture.
  • Immunosuppression.
  • Alcohol-related liver disease.
• Do not include every diagnosis in the patient’s history.
• Include only conditions that materially contributed to death.
• Record the approximate duration of each condition.

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Terminology

10. Do not record a mode of dying as the sole cause

• Avoid terminal physiological events that occur in virtually every death.
• These do not adequately explain why the person died.
• Inappropriate standalone entries include:
  • Cardiorespiratory arrest.
  • Cardiac arrest.
  • Respiratory arrest.
  • Multiorgan failure.
  • Organ failure.
  • Cardiovascular collapse.
• These may only be used where followed by an adequate underlying cause, although a more specific disease diagnosis is preferable.

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11. Heart failure

• “Heart failure” alone is generally insufficient.
• Identify the disease causing the heart failure where known.
• Examples:
  • Ischaemic heart disease.
  • Hypertensive heart disease.
  • Dilated cardiomyopathy.
  • Valvular heart disease.
  • Viral myocarditis.
  • Congenital heart disease.
• The certificate should explain the pathology, not merely the final physiological failure.

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12. Avoid vague terminology

• Avoid:
  • Natural causes.
  • Old age.
  • Frailty alone.
  • Senescence.
  • Debility alone.
  • Failure to thrive without explanation.
  • Unwell.
  • Infection without specifying the site or organism where known.
  • Cancer without identifying the primary site where known.
  • Stroke where a more specific diagnosis is known.
• For malignancy, specify:
  • Histological diagnosis where known.
  • Primary site.
  • Whether metastatic.
  • Relevant metastatic site where it explains death.
• Example:
  • “Metastatic moderately differentiated hepatocellular carcinoma.”
  • Preferable to simply writing “cancer.”

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13. Acronyms

• Do not use acronyms or abbreviations.
• Write diagnoses in full.
• Avoid:
  • MI.
  • IHD.
  • CVA.
  • COPD.
  • HCC.
  • AF.
  • CKD.
• Use:
  • Myocardial infarction.
  • Ischaemic heart disease.
  • Cerebrovascular accident or the specific stroke subtype.
  • Chronic obstructive pulmonary disease.
  • Hepatocellular carcinoma.
  • Atrial fibrillation.
  • Chronic kidney disease.

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Time intervals

14. Approximate interval between onset and death

• Record an approximate duration for each condition.
• Appropriate intervals include:
  • Immediate.
  • Minutes.
  • Hours.
  • Days.
  • Weeks.
  • Months.
  • Years.
• Durations should generally become longer down the causal chain.
• The immediate condition is usually shortest in duration.
• The originating chronic disease is usually longest.
• Example:
  • Myocardial infarction — minutes.
  • Coronary artery disease — years.
  • Hypertension — years.
• Where the exact duration is unknown:
  • Make a reasonable estimate.
  • Review available records.
  • Use wording such as “at least since [date]” where appropriate.
• Accurate duration is particularly important for cognitive disorders because the recorded duration may have implications for legal documents completed during life.

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Probable cause and unexpected natural death

15. Standard of certainty in Queensland

• The certificate records the probable cause of death.
• The legal standard is the balance of probabilities.
• The selected cause should be more likely than not.
• Absolute certainty is not required.
• A post-mortem diagnosis is not required where a reasonable probable natural cause can be established.
• Even after autopsy, some deaths remain unexplained.
• Consider:
  • Known disease burden.
  • Recent symptoms.
  • Risk factors.
  • Circumstances of death.
  • Absence of trauma or suspicious circumstances.
  • Ambulance findings.
  • Police observations.
  • Family concerns.
• The Queensland standard is the probable cause on the balance of probabilities.

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16. Unheralded death in an older person

• An older person may die suddenly without preceding symptoms.
• “Old age” should not be used as the sole cause.
• Consider probable sudden physiological events such as:
  • Myocardial infarction.
  • Fatal arrhythmia.
  • Sudden cardiac death.
  • Cerebrovascular accident.
  • Intracerebral haemorrhage.
  • Pulmonary embolism.
• Example:
  • A 97-year-old nursing-home resident is found deceased in bed.
  • He was apparently well the preceding day.
  • No injury or suspicious circumstances are identified.
  • A probable sudden central event is considered.
  • 1(a): Cerebrovascular accident — immediate.
• This is an opinion based on the most probable cause from the available information rather than certainty.

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17. Sudden death with cardiovascular risk factors

• Where the person is found deceased unexpectedly but:
  • There are no suspicious circumstances.
  • There is no evidence of trauma.
  • There is no evidence of overdose.
  • Significant cardiovascular risk factors are known.
• A probable cardiac cause may be reasonable.
• Example:
  • 1(a): Sudden cardiac death — immediate.
  • 1(b): Coronary artery disease — years.
  • 1(c): Hypertension and diabetes mellitus — years.
  • Part II: Cigarette smoking, recently ceased — years.
• Before certifying:
  • Confirm the premises were secure.
  • Confirm no evidence of a fall or injury.
  • Confirm no evidence of excess medication.
  • Speak with family where appropriate.
  • Confirm police have no concerns.
  • Document the reasoning.

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18. Known pathology without proof of a specific acute event

• Avoid overstating certainty.
• Where coronary atherosclerosis is known but myocardial infarction cannot be established:
  • It may be more appropriate to record coronary artery disease or coronary atherosclerosis.
• Where a stroke subtype is unknown:
  • Record cerebrovascular accident if clinically justified.
  • Do not specify cerebral infarction or intracerebral haemorrhage without supporting evidence.
• Where infection is clinically likely:
  • Specify the probable site if known.
  • Avoid naming an organism unless confirmed.

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Cognitive disorders and frailty

19. Dementia as a cause of death

• Dementia is an acceptable cause of death.
• Record the specific type where known:
  • Alzheimer disease.
  • Vascular dementia.
  • Lewy body dementia.
  • Frontotemporal dementia.
  • Mixed dementia.
• Dementia may cause death through:
  • Progressive immobility.
  • Dysphagia.
  • Aspiration.
  • Malnutrition.
  • Dehydration.
  • Inanition.
  • Pressure injury.
  • Recurrent infection.
  • Reduced physiological reserve.
• Example:
  • 1(a): Aspiration pneumonia — days.
  • 1(b): Oropharyngeal dysphagia — months.
  • 1(c): Advanced Alzheimer disease — years.
• Record the duration carefully.
• A long duration may have implications for capacity and legal documents executed during that period.

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20. Inanition and reduced oral intake

• In advanced dementia, a terminal decline may involve:
  • Refusal of food and fluids.
  • Loss of ability to eat.
  • Dysphagia.
  • Progressive weight loss.
  • Dehydration.
  • Inanition.
• Where the patient lacks capacity:
  • Confirm that the statutory health decision-maker agreed to comfort-focused care where relevant.
  • Document that forced feeding or hydration was not clinically appropriate.
  • Record the underlying disease process rather than simply “refused food.”
• Possible causal sequence:
  • 1(a): Inanition — weeks.
  • 1(b): Advanced dementia — years.
• Use this only where the clinical course clearly supports it.

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21. Delirium

• Delirium is not an acceptable standalone cause of death.
• Delirium is a syndrome caused by another condition.
• Identify and document the underlying condition.
• Examples:
  • Sepsis.
  • Pneumonia.
  • Urinary tract infection.
  • Dehydration.
  • Medication toxicity.
  • Renal failure.
  • Hypercalcaemia.
  • Intracranial pathology.
• Do not write:
  • “Delirium — days.”
• Prefer:
  • 1(a): Urosepsis — days.
  • 1(b): Urinary tract infection — days.
  • Part II: Advanced dementia — years.
• The underlying cause of delirium should be recorded instead.

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22. Old age and frailty

• Old age is not an appropriate standalone cause of death.
• Chronological age alone does not identify the disease or physiological event that caused death.
• Frailty should not be used without an associated disease process or terminal complication.
• Consider:
  • Probable cardiac event.
  • Probable cerebrovascular event.
  • Pneumonia.
  • Aspiration.
  • Dementia.
  • Malignancy.
  • Chronic organ disease.
  • Inanition.
  • Other clinically supported pathology.
• “Old age” should not be substituted for a proper assessment of probable cause.

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Voluntary assisted dying

23. VAD deaths

• Do not record “voluntary assisted dying” as the cause of death.
• Record the terminal disease that made the person eligible for VAD.
• A correctly conducted VAD death is generally not reportable to the coroner.
• A suspected procedural error, misadventure or incorrect administration is reportable.
• Example:
  • 1(a): Glioblastoma multiforme — 3 years.
  • Part II: Hypertension and diabetes mellitus — at least 7 years.
• The terminal illness is recorded as the cause of death.
• The VAD process itself is not listed.

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Recent procedures and cremation risk

24. Recent surgery or medical intervention

• Record recent surgery where requested on the form.
• The relevant period is commonly the preceding six weeks.
• Recent surgery does not automatically make the death reportable.
• However, coronial advice is required where:
  • The procedure may have contributed.
  • There was a complication.
  • There is concern regarding treatment.
  • The death was unexpected following the procedure.
  • There may have been a healthcare-related omission or error.

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25. Cremation risk

• Check for devices or treatments that may pose a cremation hazard.
• Devices requiring consideration include:
  • Traditional cardiac pacemaker.
  • Intracardiac pacemaker.
  • Deep brain stimulator.
  • Spinal cord stimulator.
• Traditional pacemakers generally require removal before cremation.
• Intracardiac pacemakers require consultation with local crematorium policy.
• Deep brain stimulators and spinal stimulators generally require removal.
• Recent radioactive treatment may also pose a risk:
  • Iodine-131.
  • Strontium-89.
  • Radioactive implanted seeds.
• Joint replacements, cardiac valves and portacaths are not generally considered cremation risks.

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Communication and documentation

26. Family discussion

• Where the cause is not immediately clear:
  • Contact the family.
  • Explain the proposed cause of death.
  • Ask whether they are aware of any recent symptoms.
  • Ask whether they have concerns regarding trauma, overdose or medical care.
  • Listen for new information that may alter the assessment.
• Do not ask the family to determine the cause.
• Clearly explain the medical opinion.
• Document:
  • Who was contacted.
  • Information provided.
  • Any concerns raised.
  • Whether concerns prompted coronial discussion.

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27. Discussion with other health professionals

• Contact relevant clinicians where necessary:
  • Treating specialist.
  • Hospital medical team.
  • Residential aged-care nursing staff.
  • Palliative-care team.
  • Ambulance officers.
  • Police.
• Ambulance rhythm strips or documentation may support:
  • Fatal arrhythmia.
  • Acute coronary event.
  • Respiratory deterioration.
• Document all relevant discussions.

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28. Medical-record entry

• Record:
  • Date and time notified of death.
  • Person who notified the practice.
  • Place and circumstances of death.
  • Date and time last seen alive.
  • Recent symptoms.
  • Relevant diagnoses.
  • Recent treatment.
  • Recent falls, trauma or surgery.
  • Presence or absence of suspicious circumstances.
  • Information received from staff, family, police or ambulance.
  • Whether the death was expected.
  • Whether the death was considered natural.
  • Whether coronial advice was sought.
  • Name of the person providing coronial advice.
  • Reason for completing or declining to complete the certificate.
  • Proposed Part I causal sequence.
  • Proposed Part II contributing conditions.
  • Approximate duration of each condition.
  • Cremation-risk assessment.
  • Family discussion.
  • Date certificate completed.
  • Destination of the completed certificate.
• Detailed documentation is particularly important where the doctor is uncertain or declines to issue the certificate.

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29. Final accuracy check

Before signing, confirm:

• Correct patient.
• Correct spelling of name.
• Correct date of birth.
• Correct date and time of death.
• Correct place of death.
• All required sections completed.
• No acronyms.
• No vague terminology.
• No unsupported diagnosis.
• No mode of dying used as the sole cause.
• Part I forms a logical causal chain.
• Part II contains only relevant contributing conditions.
• Durations are included.
• Recent procedures have been considered.
• Cremation risk has been addressed.
• Coronial reporting has been considered.
• The death is not being certified where reporting is mandatory.
• Your full name, title, contact details and completion date are included.

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30. Amendment after registration

• A death certificate may be amended after registration.
• Amendment may be required where:
  • A typographical error is identified.
  • A diagnosis was omitted.
  • Further clinical information becomes available.
  • The causal sequence was recorded incorrectly.
• The original certifying doctor or the coroner may amend the certificate.
• Where new information suggests the death should have been reported:
  • Notify the coroner promptly.
  • Document the new information and action taken