Guidelines for Verifying Death
2015
Citation: Ministry of Health. 2015. Guidelines for Verifying Death.
Wellington: Ministry of Health.
Published in July 2015
by the Ministry of Health
PO Box 5013, Wellington 6145, New Zealand
ISBN 978-0-478-44848-1 (online)
HP 6221
This document is available at www.health.govt.nz
 This work is licensed under the Creative Commons Attribution 4.0 International licence. In essence, you are free to: share ie, copy and redistribute the material in any medium or format; adapt ie, remix, transform and build upon the material. You must give appropriate credit, provide a link to the licence and indicate if changes were made.
Contents
Purpose 4
Verification of death 4
The role of the Coroner 5
Reportable deaths 5
Reporting deaths to the Coroner 5
Medical Certificate of Cause of Death in relation to an illness 6
Clinical assessment to verify death 6
Detailed guidance for health practitioners 7
Education and practice support systems 8
Opt out decision 8
Stillbirth 8
Role of the funeral director 9
Reference documents 10
Purpose
This document provides guidance to health practitioners, employers, professional bodies, the police and the funeral industry on the process for verifying death. Medical practitioners, nurse practitioners, registered nurses, enrolled nurses, midwives, emergency medical technicians, paramedics and intensive care paramedics are authorised by the Chief Coroner to verify death, including deaths which meet the criteria for reporting to the Coroner. When a person dies, a number of steps need to be completed and different role related tasks undertaken.
Verification of death
Verification of death means the act of establishing that a person is dead and recording the time, place and date of that assessment. Verification of death is established through clinical assessment for the absence of signs of life. Unlike the Medical Certificate of Cause of Death (HP4720) verification of death does not have any legal status, does not require any opinion as to the cause of death and does not constitute authority for a body to be buried or cremated.
In many settings, especially in hospitals, a medical practitioner is immediately available and able to issue a Medical Certificate of Cause of Death after a person dies as the explainable result of an illness. In these cases it is not necessary to follow the process for verifying death described in this guideline.
In other situations where a medical practitioner is not immediately available to issue a Medical Certificate of Cause of Death, there can be unreasonable delays for family members of the deceased. In cases where the death was expected and is explainable as the result of an illness, for example, in aged care or palliative care settings, a funeral director may remove the body providing the medical practitioner who has agreed to issue a Medical Certificate of Cause of Death commits to do so within the legally specified time.
There is no legal requirement for death to be verified before a body is removed, however, in many cases the funeral industry expects that a health practitioner will verify death prior to the funeral director taking over the care of the body.
In most cases, the health practitioner who verifies death and documents the assessment will be doing so at the behest of the police who are acting as the Coroners’ agent – because a medical practitioner is not willing (or it is not appropriate) to issue a Medical Certificate of Cause of Death, and therefore the death is a coronial case. In any case where the death is reported to the Coroner, the police may prevent the body being removed, even when death is verified, in order to preserve the scene of death for further investigation.
The role of the Coroner
The role of the Coroner is to investigate reportable deaths to establish why, where, when and how the death occurred. The aim of the investigation is to establish the facts and to work out whether anything can be done differently to prevent future deaths in similar circumstances.
Reportable deaths
Deaths reported to the Coroner are defined in Section 13 of the Coroners Act 2006 and are:
deaths which are without known cause, suicide or unnatural or violent
deaths for which no Medical Certificate of Cause of Death is given
deaths during, or that appear to have been as a result of, a medical, surgical dental or similar operation or procedure or treatment – see s.13(1)(c)(ii and iii) Coroners Act 2006
deaths that occurred while a person was affected by an anaesthetic, or appear to have been the result of the administration of an anaesthetic or a medicine – s.13(1)(c)(iv and v)
deaths that occurred while the woman concerned was giving birth, or that appear to have been a result of that woman being pregnant or giving birth
deaths in official custody or care, including any person who died while subject to the following Acts:
the Alcoholism and Drug Addiction Act 1966
Children, Young Persons, and their Families Act 1989
Corrections Act 2004, the Crimes Act 1961
Intellectual Disability (Compulsory Care and Rehabilitation) Act 2003
Mental Health (Compulsory Assessment and Treatment) Act 1992
(www.legislation.govt.nz/act/public/2006/0038/latest/DLM377532.html).
As above, some deaths must be reported to the Coroner, but other deaths which are expected and explainable do not. A death does not need to be reported to the Coroner when a medical practitioner agrees to issue a Medical Certificate of Cause of Death, provided that the death is not otherwise reportable under s13(1) of the Coroners Act 2006. In such cases, the provisions of Section 46B of the Burial and Cremation Act 1964 apply.
Section 14 of the Coroners Act 2006 requires that any person who finds a body in New Zealand or learns of a death to which Section 13 of the Coroners Act 2006 applies must report the finding to the police. A pragmatic interpretation of the Act means that a person finding a body where the death is expected and explainable, and occurs in a setting such as aged care or palliative care, does not need to report finding the body to the police. However, in any sudden, unexpected death where the body is found and the cause of death is not established, including if a person is found dead at home, the police should be notified. It is the role of the police to determine whether the death is reported to the Coroner.
Where there is any doubt, the National Duty Coroner can determine whether a death is classified as reportable. Telephone 0800 266800.
Medical Certificate of Cause of Death in relation to an illness
Completion of the Medical Certificate of Cause of Death (HP4720) is separate to and completely different to the process for verifying death. The Medical Certificate of Cause of Death is a legal document which records the full details of the deceased, the circumstances of and cause of death. It can only be completed by a medical practitioner.
Section 46B of the Burials and Cremation Act 1964 requires that a Medical Certificate of Cause of Death is issued by a medical practitioner within 24 hours of the medical practitioner learning of the death, provided they are satisfied that the cause of death was the result of an illness and is not otherwise reportable.
The Medical Certificate of Cause of Death is required before a body can be embalmed, buried or cremated. It must not be issued for a reportable death.
Clinical assessment to verify death
A health practitioner can verify death when:
the body shows signs of rigor mortis incompatible with life, or
the body has visible injuries incompatible with life, or
the body shows signs of decomposition incompatible with life.
Alternatively, health practitioners can verify death once they have undertaken two assessments (a minimum of 10 minutes apart) to establish death. The health practitioner must confirm the following:
no signs of breathing for one minute
no palpable central pulse (femoral, carotid or brachial). In most circumstances this will require palpation for 5–10 seconds
no audible heart sounds
pupils dilated and unreactive to light
where available, a cardiac monitor or defibrillator is used and shows asystole.
Health practitioners must use the Coroners form (COR31) to document the assessment and record the details of the deceased including the date, time and place of the assessment. The COR31 is available from the police or the Duty Coroner’s office (National Initial Investigation Office) on 0800 266 800, or by emailing niio@justice.govt.nz
Detailed guidance for health practitioners
The clinical assessment described is for verifying death. It is not to be used to determine whether or not resuscitation attempts are futile because these two decisions are very different.
Death must be clear and unequivocal if the condition of the body is used to verify death.
A clinical assessment must occur if death is not clear and unequivocal.
The entire chest and abdomen should be exposed when examining the patient for signs of breathing and this examination must occur over an uninterrupted period of one minute.
Either the carotid or femoral site may be used when examining for a palpable central pulse. In infants aged up to one year palpation of the brachial pulse is recommended. No duration is specified for the palpation of a pulse, but there must be certainty that the pulse is not palpable. In most circumstances this will require palpation for 5–10 seconds.
Auscultation for heart sounds should occur over the expected site of the apex beat of the heart. In many people this will be over the fourth intercostal space in the mid-clavicular line.
The pupils must be dilated, but no pupil size is specified. The pupils must be unreactive to light and this requires a focal light source (eg, a torch) to be used.
The clinical assessment must be performed twice, with a minimum of 10 minutes between the two assessments. The reason for this is that the person may be in asystole for 5–10 minutes and then spontaneously develop return of a beating heart. This is sometimes called auto-resuscitation or the Lazarus reflex.
It is not compulsory to determine the cardiac rhythm, but this should be done following the second clinical assessment if a suitable monitor is present.
The person may be dead, but may not be in asystole at the time of the second clinical assessment. For example:
there may be slow broad complexes. In this case verification of death should be delayed until asystole is present
a person with a pacemaker may have electrical activity generated by the pacemaker for many hours after death. In this case it is appropriate to determine the person is dead, provided all of the other clinical criteria are met.
Education and practice support systems
Medical practitioners, nurse practitioners, registered nurses, enrolled nurses, midwives, emergency medical technicians, paramedics and intensive care paramedics are authorised by the Chief Coroner to verify death. The required technical expertise and skill is within these health practitioners’ scopes of practice.
Alongside technical expertise it is important health practitioners understand the legislation that guides their practice. In particular, when verifying death health practitioners must have a thorough understanding of the Health Practitioners Competency Assurance Act 2003, and the implications for practice in the Health and Disability Commissioner Code of Patient Rights 1996, the Coroners Act 2006, the Burial and Cremation Act 1964, Births, Deaths Marriages and Relationships Registration Act 1995 and the codes of ethics and professional boundaries for their practice.
Employers and organisations have a role to ensure health practitioners are supported to verify death through clinical governance systems which cover policy, professional development and clinical leadership.
Collaborative relationships between health practitioners in local areas will support a seamless service and promote best practice, whilst ensuring professional boundaries are well known and understood. It is essential that the Police, funeral directors, health practitioners and health care facilities establish well understood role responsibilities and pathways for responding to deaths.
Opt out decision
Health practitioners are required by the Health Practitioners Competence Assurance Act 2003 to only undertake those activities within their scope of practice and for which they have the required competence. While the competencies for verification of death are included within the named groups of health practitioners’ scope of practice, and the activity undertaken as part of their usual roles, verification of death is voluntary. Any health practitioner who is not willing, or does not feel competent to undertake the activity can defer to another health practitioner.
Stillbirth
Section 46A of the Burials and Cremations Act 1964 outlines who can sign the Medical Certificate of Causes of Foetal and Neonatal Death (HP4721) with regard to a stillbirth. Stillbirth is defined in the Births, Deaths Marriages and Relationship Registration Act 1995 as:
‘a dead foetus that at no time shows any signs of life and that weighed 400g or more when it was issued from the mother or issued from its mother after the 20th week of pregnancy’.
In most cases of stillbirth a medical practitioner will sign the Medical Certificate of Causes of Foetal and Neonatal Death. However, where a medical practitioner was not present at the birth or did not examine the baby, a midwife can sign to expedite burial or cremation.
Role of the funeral director
The funeral director is employed to provide advice and services for the family of a deceased person after death including:
transport of the body
registering the death
meeting the legal requirements for burial or cremation (including bookings for a cemetery or crematorium, and filing the necessary forms for cremation)
the embalming, care and presentation of the deceased’s body
placement of death notices and/or funeral notices in the paper
the funeral service.
In cases where the death was expected, for example, in aged care and other palliative settings, the funeral director may remove the body before the Medical Certificate of Cause of Death is issued. In such cases, the medical practitioner who has agreed to issue the Medical Certificate of Cause of Death must do so within the legally specified time. In all cases, the funeral director must receive a completed Medical Certificate of Cause of Death from the medical practitioner before a body is embalmed, buried or cremated.
Reference documents
Births, Deaths, Marriages and Relationships Registrations Act 1995
www.legislation.govt.nz/act/public/1995/0016/latest/DLM359369.html?search=ts_act%40bill%40regulation%40deemedreg_births_resel_25_a&p=1
Burials and Cremations Act. 1964
www.legislation.co.nz/act/public/1964/0075/latest/DLM355079.html
Competencies for enrolled nurses. 2012. Nursing Council of New Zealand
www.nursingcouncil.org.nz/Nurses/Scopes-of-practice/Enrolled-nurse
Competencies for registered nurses. 2007. Nursing Council of New Zealand
www.nursingcouncil.org.nz/Nurses/Scopes-of-practice/Registered-nurse
Competencies for the nurse practitioner scope of practice. 2008. Nursing Council of New Zealand
www.nursingcouncil.org.nz/Nurses/Scopes-of-practice/Nurse-practitioner
Competencies for entry to the register of midwives. 2007. Midwifery Council
www.midwiferycouncil.health.nz/images/stories/pdf/competencies%20for%20entry%20to%20the%20register%20of%20midwives%202007.pdf
Coroners Act. 2006.
www.legislation.co.nz/act/public/2006/0038/latest/DLM377057.html?search=qs_act%40bill%40regulation%40deemedreg_coroners+act_resel_25_h&p=1&sr=1
Health Practitioners Competence Assurance Act. 2003.
www.legislation.govt.nz/act/public/2003/0048/latest/DLM203312.html?src=qs
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