Today’s correspondent, although from NSW, wonders about some issues raised in a news story from Western Australia – ‘Perth doctor claims man placed in body bag and taken to morgue while still alive’ 9News (Online), 6 October 2022. The gist of the story is that a registered nurse determined a patient had died and the patient’s body was transferred to the morgue. A doctor was later called upon to sign a death certificate.
When the body bag was unzipped, the doctor was stunned by what he saw. Reid’s eyes were open and there was fresh blood from a cut to an arm.
The other arm was over his right shoulder.
“I believe the frank blood from a new skin tear, arm position and eye signs were inconsistent with a person who was post-mortem on arrival at the morgue,” the doctor told the coroner last week.
The doctor claimed he was asked to date the death certificate to accord with the nurses determination that the patient was dead but he refused to do that. The issues were then referred to the Coroner and ‘the Corruption and Crime Commission … because any direction to backdate a death certificate could be deemed serious misconduct by a public officer.’
My correspondent says:
In NSW, both paramedics employed by NSW ambulance and certain registered nurses can ‘confirm life extinct.’ I am unsure whether the spokesperson for the AMA WA is unaware/incorrect or it is different in WA.
I am surprised that the doctor is taking ‘eyes open’ (I’ve seen plenty of deceased in this manner) a ‘fresh cut’ and ‘arm position’ as evidence another health professional has made an error. Does the reporting err on the side of doctors are right because they are doctors?
One other point. The MCCD [Medical Certificate of Cause of Death] is also something that to my understanding is “backdated”. It can be issued within 48 hours of death after a Verification of Death (VOD) is completed by a paramedic/authorised RN, where the doctor may not view the patient at all but go on known patient history and the VOD.
There is a difference between determining that a person has died – that life is extinct, and determining the cause of death.
I have written about Queensland Paramedics – Recognition of Life Extinct (ROLE) (August 22, 2014). We don’t need to go into details of the role of an RN or paramedic in WA to resolve the issues here. We can assume for the sake of the argument that an RN should be competent to tell whether a patient is, or is not, dead and that the RN certifying life extinct was consistent with the hospital policy and the RN’s scope of practice. That is not, however the issue.
Does the reporting err on the side of doctors are right because they are doctors?
I’m not a journalist and this is not a journalism blog so take what follows with a grain of cynical salt – but if the reporting errs on the side of the doctor (in this case) is right it’s because it’s not much of a story otherwise. Conflict is the story – so I’m sure they would err on the side of the nurse is right if a nurse went public with a story of a doctor’s error.
But, having said that, I don’t think the article does assume the doctor is correct. The article reports what happened – the doctor opened the body bag, the doctor was concerned about what he saw, the doctor reported the matter as he should. Reporting that this is what happened is surely good journalism particularly where it happened in a public hospital and there must be significant public interest in the conduct of the hospital. But even the heading – the place for sub-editorial click bait – doesn’t say ‘person put in morgue alive’ – it says that a doctor claims this is what happened.
As for the statement:
I am surprised that the doctor is taking ‘eyes open’ (I’ve seen plenty of deceased in this manner) a ‘fresh cut’ and ‘arm position’ as evidence another health professional has made an error…
My correspondent acknowledged that ‘… the facts are relatively unknown (other than reporting by a media organisation)’and it is important to bear that in mind. The journalist has to summarise the story and we don’t know exactly what the doctor saw or did to form his opinion. But even if the evidence is incomplete or insufficient to establish an error that does not mean a doctor should not make a report to allow an agency – like the coroner – to look into it. A person does not need to be satisfied beyond reasonable doubt before raising concerns.
A Medical Certificate of Cause of Death is a certificate required under relevant registration legislation. In Western Australia the Births, Deaths and Marriages Registration Act 1998 (WA) s 44 says:
Doctor to provide certificate of cause of death unless the death is reportable to a coroner
In the case of a person’s death other than a still-birth or a neonatal death, the doctor who —
(a) was responsible for the person’s medical care immediately before the death; or
(b) examined the person’s deceased body,
must, within 48 hours after the person’s death —
(c) certify, in an approved form, the cause of the death; and
(d) give the certificate to the person who is responsible under section 42 for notifying the Registrar of the death.
The doctor does not have to give a certificate if he or she has a reasonable excuse for not doing so (s 44(4)(b)) or if the doctor is required to report the death to the coroner (s 44(5)).
The Coroners Act 1996 (WA) s 17(3) says that a doctor must report the death to a coroner if:
(a) the death is or may be a reportable death; or
(b) the doctor is unable to determine the cause of death; or
(c) in the opinion of the doctor, the death has occurred under any suspicious circumstances.
In the circumstances one can see why a doctor would not sign a certificate. If, on the examination of the body, the doctor forms the view that the person may not have been dead when placed in a body bag and then in the morgue, that doctor could not certify the cause of death – was it the patient’s underlying disease; hypothermia; asphyxiation? The doctor would also rightly conclude that ‘the death has occurred under any suspicious circumstances’. An autopsy is required to determine the cause of death and to answer the doctor’s concerns, but the doctor could not, in those circumstances, sign a MCCD.
Back-dating the form
No-one should ever back date a form – but that can mean different things. I am unable to find a copy of the WA MCCD online but I assume it has a place for a doctor to sign and date it. That date should always be the date on which the form is signed. I would also assume that the form has a place to record the date of the person’s death.
An information sheet published by Avant, a medical indemnity insurer (Death certificates – Western Australia (2015)) says:
At times, you may be required to sign a death certificate for a patient you don’t know or have not seen for a while. There is no legal requirement for you to have had recent contact with the patient, but you do need to have enough information based on the history (e.g. review of the medical records or discussion with the treating doctor) or an examination to provide a cause of death.
It also says:
In Western Australia, there is no requirement to sight the body for the MCCD.
It is not ‘backdating’ the form to put that date of death as an earlier date than the date the form was signed. That is the record of what happened –on a given date the doctor is certifying that he or she is satisfied that the patient died on an earlier date.
But you can see in this case why the doctor would not do that. He examined the patient on a given day and was sure he was dead then, but the doctor was not sure the patient was dead on the day he was taken to the morgue. Writing the date of death as the earlier date would have been quite wrong and would have been ‘backdating’. It would be the doctor saying he was satisfied that the patient was dead on that earlier date when in fact he was only satisfied that the patient was dead on the date of the examination. Given the doctor was not satisfied that it was correct, pressuring the doctor to certify the patient was dead on that earlier date would also be quite wrong and possibly corrupt if the motivation was to protect the hospital or staff from adverse consequences.
The law in WA appears consistent with my correspondent’s comment that:
The MCCD [Medical Certificate of Cause of Death] … can be issued within 48 hours of death after a Verification of Death (VOD) is completed by a paramedic/authorised RN, where the doctor may not view the patient at all but go on known patient history and the VOD.
However, that cannot be right if the doctor does not think the history given, or the verification of death was correct. In that case he or she could not issue the MCCD but must report the matter to the coroner, as happened here. The best they can say is ‘the patient was dead when I examined them, but I cannot be sure when they died’ in which case the only date they can put is the date of their examination.
To ‘backdate’ a form is to sign it and date it as if it was signed on an earlier date. To date it with the date it was signed, but on the form to say the date of death was an earlier day, is not to back date the form. In this case however for the doctor to say the death occurred on the earlier day would be to ‘backdate’ his opinion; the doctor knew the patient was dead on the day he examined the body, but could not certify that the person was dead on an earlier date as clearly, he was not satisfied that was the case. There could be no justification for writing the earlier date as the date of death in those circumstances.
Is the doctor correct? Legally he was clearly correct to do what he did.
Is he correct about the date of death? We cannot say, that will be up to the coroner to determine.
This blog is made possible with generous financial support from the Australasian College of Paramedicine, the Australian Paramedics Association (NSW), Natural Hazards Research Australia, NSW Rural Fire Service Association and the NSW SES Volunteers Association. I am responsible for the content in this post including any errors or omissions. Any opinions expressed are mine, and do not necessarily reflect the opinion or understanding of the donors.