CLINICAL GUIDELINES

Title :
Certification of Death
Process Owner(s) : Document No :
CMB-GP-CERTIFICATION OF
Divisional Chairmen DEATH-01
Effective Date :
02 Jan 2008
Review Date :
02 Jan 2008
Approval : Revision No :
Chairman, Medical Board 1.0
Any hardcopy, printed or photocopied, is considered an uncontrolled copy, unless it is the original, signed-off version.

1.0 Objectives

1.1 To provide guidelines with regards to the procedure for certification of death and the cases
that should be reported to the Coroner.

2.0 Scope

2.1 This policy defines the actions and responsibilities of all medical and nursing staff in
certifying death and in determining cases to be referred to the Coroner.

3.0 Definition

3.1 MOH : Ministry of Health

3.2 TTSH : Tan Tock Seng Hospital

3.3 CCOD : Certificate of Cause of Death

3.4 MO : Medical Officer

3.5 HIV : Human Immunodeficiency Virus

3.6 ED : Emergency Department

3.7 Natural Death : Natural death is defined as :

a. absence of contribution by unnatural or iatrogenic event

b. absence of death preceded by trauma, violence, poisoning other
suspious circumstances

3.8 HO : House Officer

3.9 MO(NTS) : Medical Officer (Non Traditional Source)

3.10 HOD : Head of Department

3.11 IMH : Institute of Mental Health

Page 1 of 8
 Title: Document No. :
Certification of Death CMB-GP-CERTIFICATION OF DEATH-01

3.12 Attending : The doctor who has managed and is following up on the patient and
doctor thus has knowledge of the patients condition. Doctors who managed
the patient in the ward but did not follow-up on the patient after
discharge are not considered as attending doctors. MOs who follow-up
on the patient at the MO clinics are also not considered as attending
doctors.

3.13 GP : General Practitioner

4.0 Reference

4.1 Section 19(1) of the Registration of Births and Deaths Act, Chapter 267 of the Singapore
Statute Revised Edition 1985 states that,

Every medical practitioner, upon the death of any person who has during his last illness
been attended by that medical practitioner, shall sign and deliver within 12 hours of the
death, to one of the persons required by this Act to furnish particulars of the death, or to any
deputy of the local registration area within which the death has occurred, a certificate in
prescribed form.

4.2 The MOH Directives (Professional Circular No. 6/2002) states that,

The certificate of cause of death should only be issued when the cause of death is known
AND the cause is natural. If a death has been the result of or has been contributed by an
unnatural event (eg. surgical complication, a fall prior to admission), then the case should be
referred to the Coroner. It is a requirement under the Criminal Procedure Code that all cases
where the cause of death could not be ascertained should be referred to the Coroner.

4.3 Section 22(1)(b) of the Criminal Procedure Code states that,

Every person aware of any sudden or unnatural death by violence or of any death under
suspicious circumstances or of the body of any person being found dead without its being
known how that person came by death, shall, in the absence of reasonable excuse, the
burden of proving which shall lie upon the person so aware, forthwith give information to the
officer-in-charge of the nearest police station or to a police officer of the commission or
intention or of the sudden, unnatural or violent death or death under suspicious
circumstances or of the finding of the dead body, as the case may be.

4.4 Registration of Birth and Death Act

4.5 Section 308, Section 310, Section 315 of the Criminal Procedure Code, Chapter 68

4.6 WI-NUR-GEN-009 Management of Death (Coroners Case)

4.7 WI-NUR-GEN-010 Management of Death (Non-Coroners Case)

4.8 QP-HGS-MOR-004 Issuing of Death Documents

4.9 Form B Certificate of Cause of Death

4.10 MH 20:04/02 Guidelines For the Collection, Removal and Disposal of

Bodies of Deceased HIV Infected Persons

Page 2 of 8
 Title: Document No. :
Certification of Death CMB-GP-CERTIFICATION OF DEATH-01

5.0 Policy

5.1 HOs are not allowed to certify death and complete the CCOD.

5.2 MO grade and above with full medical registration with SMC are allowed to certify death and
complete CCOD. (referred hereafter in this policy as the certifying medical officer).

5.3 MO grade and above with conditional medical registration with SMC are allowed to certify
death and complete CCOD upon approval by HOD. (referred hereafter in this policy as the
certifying medical officer).

5.4 MO (NTS) with temporary medical registration with SMC are allowed to certify death and
complete CCOD upon approval by HOD. (referred hereafter in this policy as the certifying
medical officer).

5.5 Clinical Fellows on temporary medical registration with SMC are allowed to certify death and
complete CCOD upon approval by HOD. (referred hereafter in this policy as the certifying
medical officer).

5.6 Before making a death certification, the certifying medical officer must:

a. be satisfied that death has occurred

b. know the cause of death
c. reasonably sure based on available information that death is not unnatural, as defined
earlier.

5.7 The officer certifying death is required to make statements when filling in the various forms
in the course of his duties. Such statements must be true to the best of his knowledge,
information and belief. Failure to observe this rule may result in a breach of the law, leading
to serious consequences.

5.8 The doctor must determine whether the deceased is a police case or not. If it is, the death
must be made a Coroners case.

5.9 The doctor must also determine the cause of death and whether the cause is natural or
unnatural. If unnatural, the death must be made a Coroners case. An unnatural death
includes cases where suspicious circumstances surrounds events leading to patients death,
regardless of whether the eventual cause of death is a natural or known one.

5.10 When the death has been due to natural causes, the CCOD should be issued within 12
hours of death and the case summary completed as soon as possible. The CCOD should
then be forwarded to the Deputy Registrar of Births and Deaths attached to the hospital,
who will then issue a certificate of death to the relatives.

5.11 Where the certifying medical officer is able to sign the CCOD, he must never refuse to do so
with a view to coercing the relatives to consent to an autopsy or getting an autopsy to be
ordered by the Coroner.

5.12 The certifying medical officer should not sign the CCOD without viewing the body.

5.13 When the cause of death cannot be clearly determined, the doctor should not sign the death
certificate. He should seek advice from senior staff.

Page 3 of 8
 Title: Document No. :
Certification of Death CMB-GP-CERTIFICATION OF DEATH-01

5.14 Another clinical staff of at least Registrar Grade should countercheck the accuracy of
certification.

5.15 After certification, a doctor of the next higher grade should make the record of death in the
appropriate section of the case notes with signed verification. However, there is no need for
verification by another senior doctor if the certificate of death is issued by an Associate
Consultant and above.

5.16 The Nursing Officer or Staff Nurse in charge of the ward should countercheck the particulars
and status (whether it was made a police case or not), of the deceased patient.

6.0 Guidelines

6.1 Completion of Certificate of Cause of Death

6.1.1 A death certificate serves as a permanent record of the death of an individual and
provides important personal information about the deceased and about the
circumstances and cause of death. It is also a legal document stating the cause
of death of the deceased. The law requires medical practitioners to fill in the
CCOD correctly.

6.1.2 The disease conditions must be filled in legibly in block letters and full.

6.1.3 The CCOD consists of two parts:

Part I is for reporting the sequence of events leading to death, proceeding

backwards from the final disease or condition resulting in death.

Part II contains other significant conditions, which contributed to death but did not
lead to the underlying cause.

Part I : Cause of Death Section

6.1.4 Only one cause is to be entered on each line of Part I :

Line 1(a) Immediate Cause of Death

This is the final disease or condition directly causing the death. This must be a
definitive cause of death and does not mean the mode or mechanism of dying,
eg. Cardiorespiratory failure, senility, cardiac or respiratory arrest.

Line 1(b) and (c) due to (as a consequence of)

In line 1(b) report the disease condition, if any, that gave rise to the immediate
cause of death. This is the underlying cause of death. If this in turn resulted from
a further condition, record that condition on line (c).

6.1.5 The medical certifier must ensure that conditions in 1(b) and 1(c) are related to
the condition in 1(a).

6.1.6 The medical certifier has the responsibility to select and record the sequence of
medical conditions, which was responsible for death as according to his/her best
medical opinion. No entry, however, is necessary in lines (b) and (c) of the cause
of death section, if the disease or condition directly leading to death stated in line
(a), on its own, fully describes the train of events which led to the death.

Page 4 of 8
 Title: Document No. :
Certification of Death CMB-GP-CERTIFICATION OF DEATH-01

6.1.7 Vague causes such as Senile Debility, Senile Dementia and Old Age are NOT
acceptable as causes of death.

Part II : Other Significant Conditions

6.1.8 Part II should record other important diseases or conditions that were present at
the time of death and that have contributed to the death but did not play the major
role in causing the death in Part I.

6.1.9 The doctor is reminded that it is not necessary to list all antemortem morbid
conditions. Only those which significantly contribute to the death should be listed.

6.1.10 Cause of an unnatural nature such as fractures, subdural haemorrhage injuries,

asphyxia (except asphyxia neonatorum) should not appear on CCODs as these
are deemed reportable to the Coroner.

6.2 Cases that should be Reported to the Coroner

6.2.1 The last section of the CCOD requires the doctor to certify that the death was due
to natural causes. If the cause of death is unnatural, the death has to be reported
to the Coroner for certification.

6.2.2 If a death had been the result of or contributed by an unnatural event (e.g.
surgical complication, fall prior to admission), the death should not be signed up,
however proximate or remote in time between the causative/contributory event
and the time of death.

6.2.3 The following is a list of causes of death, which should be reported to the
Coroner. This list is not intended to be exhaustive. This includes death from:
a) suicide or homicide;

b) burns and scalds;

c) domestic, industrial, road or any other accident;

d) drowning;

e) asphyxia, e.g. hanging, choking on food or vomitus (this includes cases of

aspiration pneumonia developed after inhalation of foreign bodies);

f) assault;

g) electrocution and lightning strike;

h) septicaemia, gangrene, tetanus or oesteomyelitis following an injury;

perforation of gastrointestinal tract by foreign bodies;

i) poisoning in all forms from drugs (due to over dosage, adverse drug
reaction, anaphylaxis, idiosyncrasy, addiction, acute-alcoholic intoxication);

j) food poisoning;

k) carbon monoxide poisoning;

Page 5 of 8
 Title: Document No. :
Certification of Death CMB-GP-CERTIFICATION OF DEATH-01

l) industrial diseases (such as pneumoconiosis, and cases where the

occupation of the deceased appears to have contributed to the death)

Other examples of unnatural deaths include death :

a) in a person who apparently in good health previously, but dies suddenly and
unexpectedly;
b) under suspicious circumstances;
c) regarding whom Police have been making investigations, e.g. Police cases
in hospitals;
d) in a person brought in dead to the hospital; when the cause of death is not
known and unnatural causes cannot be excluded;
e) just after the admission doctor has seen the person, when definite diagnosis
is not made;
f) in a person who has not been identified;
g) resulting from medical or surgical procedures, such as an operation,
anaesthetic procedure, transfusion or other invasive procedures;
h) due to childbirth;
i) from pregnancy (where there is a suspicion that it is not due to natural
causes, in a case of abortion or any form of criminal interference of
pregnancy);
j) in an institution where patients are or may be detained such as prisons,
detention centres, government old folk homes (not private old folk homes
where admission is voluntary); and
k) from want, neglect or exposure.

6.2.4 There does not exist a 24 hour rule whereby all admissions or post- operative
deaths within 24 hours require mandatory reporting as Coroners cases.

6.2.5 The doctor certifying the cause of death should exercise due care and
professional judgement in the issuance of a CCOD. The doctor should issue the
CCOD when he is confident to do so. If there is any doubt, the senior staff should
be consulted.

6.2.6 Once a case has been reported to the State Coroner, its status cannot be
changed except by consent of the forensic pathologist and/or the State Coroner.
The Coroner and the forensic pathologist will discuss the case and determine
whether an autopsy is necessary. If the Coroner is completely satisfied that death
is due to a natural cause based on the deceaseds medical history, a CCOD will
be issued without an autopsy. If there is doubt as to the cause of death or trauma
before death, the Coroner is empowered to authorize an autopsy.

6.3 Patient who Die while Undergoing Investigations or Treatment at Another Hospital

6.3.1 Patients who die while they are being transported in the hospital ambulance to
another hospital should be brought back to TTSH and the body handled
according to TTSH existing policy for such cases.

Page 6 of 8
 Title: Document No. :
Certification of Death CMB-GP-CERTIFICATION OF DEATH-01

6.3.2 When a patient, who has been accompanied by a doctor and nurse, dies while
awaiting or having investigations/treatment done in another hospital, the
accompanying doctor should follows these guidelines:

(a) Pronounce the patient dead after resuscitation has failed.

(b) Decide whether to declare the case a Coroners case. In this case, the
hospitals Police Post should be informed immediately and the protocol for
handling Coroners cases followed.
(c) For non-Coroners cases, a CCOD should be issued.
(d) Make a complete record of the event in the patients case notes.
(e) Make a summary report of the death for the ED doctor of the hospital
where the death occurred (to help the ED doctor deal with enquiries from
the deceaseds relatives).
(f) Inform the specialist in charge of the patient of the death and seek his
advice where necessary.
6.4 Certification of Death for Discharged Patients
6.4.1 For terminally ill inpatients who may wish to be discharged to spend their last
few moments at home, doctors should provide a good and detailed discharge
summary to the family. The family should be advised, at the time of discharge,
to pass the discharge summary either to their GP or police for the death
certification and the issue of CCOD upon the patients demise.

6.4.2 In situations where the patient was brought in dead to ED or had died in the ED,
ED will ascertain the name of the attending doctor by verification from the patient/
relatives and contact the attending doctor to view the body and review the case.
The attending doctor will decide whether to issue the CCOD after reviewing the
case. If there is no attending doctor, the death will be made a Coroners case.

6.4.3 After office hours on occasions when the attending doctor is not on-call: (i) the
death will be made a Coroners case or (ii) ED will inform the family to
approach their GP, if any, who managed the patient.

6.4.4 If even a single element of doubt exists that prevents the attending doctor
from issuing the CCOD, the doctor can still assist the relatives by providing a
medical report detailing the salient points regarding the patients condition, to
give to the Police Investigation Officer (IO).

6.4.5 The hospital should also enable the doctors and forensic death investigators
at the Centre of Forensic Medicine (HSA) to contact Health Information
Services (HIS) to access medical information regarding deceased persons who
have previously been under the care of the hospital. Where possible, HIS
should be available for referencing in mornings between 8 to 10 am on all days
of the year.

6.5 Certification of Death in Non-coronial or Academic Post-mortems

6.5.1 If the academic post-mortem had been requested by a clinician, the
pathologist should communicate the findings of the post-mortem
examination to the requesting clinician.

Page 7 of 8
 Title: Document No. :
Certification of Death CMB-GP-CERTIFICATION OF DEATH-01

6.6 Certification of Death of IMH patients transferred to TTSH

6.6.1 All inpatient deaths in IMH are considered Coroners Cases as IMH does not
have the capacity to certify deaths.

6.6.2 IMH inpatients who are not under detention, must be discharged first before
being admitted to other hospitals. They are therefore, no longer regarded as IMH
patients if they die in other hospitals and are therefore, not subjected to point
6.6.1

6.6.3 According to IMH internal procedures for the referral of detained patients to other
hospitals, IMH staff would make a copy of the patients detention order, which
would then accompany the referral letter. The police will escort the patients on
Section 308 and 310 whilst Cisco guard will escort the patients on Section 315.
Therefore, in the rare event that a detained patient is referred to TTSH, all the
necessary documents should be in place. However in the event that the detention
order is missing, IMHs Emergency / Admission room would be able to supply the
patients ward of origin. The IMH Nursing Officer / Staff Nurse of the ward would
be able to forward a copy of the detention order.

6.7 Amendments to the CCOD

6.7.1 Any amendments to the CCOD have to be in accordance with the Registration of
Birth and Death Act.
6.7.2 A statutory declaration setting forth the nature of the error and the facts of the
case, and made by two doctors required by the Registration of Birth and Death
Act to give information concerning the death with reference to which the error
was made, is required to be submitted to the Registrar of Birth and Death.
6.7.3 A prescribed fee has to be paid by the person requiring the error to be corrected
in the CCOD.
6.7.4 Please contact Mortuary Services Office at Tel: 6357 8196 for clarifications
regarding the process on amendments to the CCOD.

Page 8 of 8