• Amend Code of Criminal Procedure outlining specific circumstances under which such notification to the Police is required and circumstances in which a mandatory autopsy is required

This is Part I of a multiple-part series. The second part, will be published in an upcoming issue of The Daily Morning

Amendments have been suggested to Sections 369-373 of the Code of Criminal Procedure to introduce the mandatory reporting of certain types of death by medical practitioners to the inquirer into sudden death/coroner (ISD).

The amendment suggests they should do so when they become aware of the deaths during their professional duties, clearly outlining the specific circumstances under which such notification to the Police is required and the circumstances in which a mandatory autopsy is required.

These recommendations were made in an opinion article on ‘Legal and statutory guidelines for medical death certification in home deaths: Insights from Sri Lanka’ which was authored by P. Appuhamy (attached to the Forensic Medicine and Toxicology Institute), R. Samaranayake and S.A. Gunawardena (both attached to the Colombo University's Medical Faculty's Forensic Medicine and Toxicology Department), and published in the Journal of Forensic Medicine, Science and Law's 16th Volume's First Issue, in June of this year.

The Health Ministry’s Annual Health Bulletin reported 52,000 deaths in all healthcare facilities in 2017. In addition, the Census and Statistics Department recorded 140,000 deaths during the same period. Accordingly, about 70% of deaths occurred outside healthcare facilities. This percentage includes deaths that occur at home.

In home deaths, through the Births and Deaths Registration (BDR) Act, No. 17 of 1951 as amended/Chapter 129, several officials, namely the medical practitioner who treated the deceased last, the Grama Niladhari, the inquirer into sudden death (ISD – a Government appointee who plays a similar role as the coroner), any Police officer, or estate superintendent (if the deceased is an employee of a plantation estate) are empowered to issue the medical certificate of the cause of death (COD) (MCCD). 

Out of the above officials, only the medical practitioner has medical training. The MCCD is a statutory document that is needed to obtain the death certificate (DC) from the BD Registrar. The DC is a vital document mandatory for various procedures, including the disposal of the body, and financial and legal transactions involving the deceased and family members. In a significant proportion of natural deaths occurring at home, the next of kin (NOK) of the deceased contact their general practitioner (GP) for the MCCD. However, there are instances where a/the GP is reluctant to provide the MCCD, leaving the family members with no choice but to take an alternate pathway to obtain the MCCD from ‘non-medical’ officials who are empowered to issue the MCCD. However, significant errors have been identified in the COD in the DC issued by officials such as the GN, which can affect families, mortality statistics, and public health research.

The inquest is important in providing valuable mortality statistics, for public safety, and justice. However, GPs tend to ‘under-report’ deaths to the ISD. Furthermore, a study in England found that the GPs correctly identified only 3% of all deaths that should have been reported to the ISD. Several factors can contribute to this, including a lack of knowledge about reportable deaths and family pressure to avoid an inquest procedure which can delay the funeral arrangements. Similarly, under-reporting can lead to serious consequences such as distorting the mortality statistics and unmasking potential public health issues such as outbreaks of disease and patterns of violence. 

These deficits highlight the necessity for the continuous education of GPs as a professional development strategy implemented by many countries to ensure a high-quality death registration system. 

Methodology 

Up to September of last year (2024), the Code Act, No. 15 of 1979 as amended (Sections 369-373), the BDR Act (S. 29-39), the Sri Lanka Medical Council (SLMC) Guidelines for Medical Practitioners and Dentists Medical Certification of Death (2016 - Guidelines regarding certificates of the COD – pages three-five), the SLM Ordinance, No. 26 of 1927 as amended (Sections 29 and 33), and the Justice Ministry circulars (13/2018) and (3/2008) on mandatory post-mortem (PM) on maternal deaths, and indications for mandatory PMs, respectively, are the statutory legislations, Acts, amendments, and ethical guidelines which contain legal and/or ethical provisions related to the certification, reporting, investigation, and registration of death in Sri Lanka. 

Discussion 

Professional guidelines and laws in SL

The statutory procedure related to the issuing of an MCCD is detailed in the BDR Act. “In the event of the death of any person who has been attended during his/her last illness by a medical practitioner, a certificate in duplicate, substantially in the form J set out in the schedule, stating to the best of his/her knowledge and belief the cause of the death, shall be forthwith issued without fee or reward by such practitioner to the person required under this Act to give information.”

The SLMC released a guideline in 2004 related to issuing MCs. This guideline incorporates the above legal provisions and criteria that need to be fulfilled to issue an MCCD. In 2021, the Health Ministry issued a ‘Handbook for Sri Lankan Doctors on COD Certification’, which includes procedural details as well as theoretical aspects of writing the COD based on the World Health Organisation’s guidelines. Accordingly, to issue an MCCD, the medical practitioner should ensure that: The COD is known; the COD is natural; the doctor is the attending physician of the last illness that has led to the death of the deceased; the doctor has treated the deceased recently; and the doctor has viewed the body.

Based on these guidelines, several thematic elements are discussed in the form of a stakeholder flowchart on navigating home death certification, that are relevant to GPs. 

Home death – the deceased had taken treatment from a GP – the GP reviews the medical records – the GP issues the MCCD to the NOK in B12 – the DC is issued by the BD Registrar.

Home death – the deceased had taken treatment from a GP – the GP is unable to give a COD – the GP or NOK informs the Police – ISD.

Home death – the NOK informs the Police and the Police informs the ISD – the ISD establishes a COD in natural circumstances after the review of the medical records and a PM is not held/a PM is held by a forensic pathologist and the COD is stated in the H 1328 issued to the ISD after the PM – the ISD completes the B18 form and sends to the BD Registrar – the DC is issued by the BD Registrar.  

Mandatory autopsy – maternal deaths, deaths due to accidents, suicides, deaths due to shooting, and deaths where the cause is unknown. 

The MCCD should be issued by a medical practitioner

Here, the term ‘medical practitioner’ refers to a doctor who treats the deceased individual, working in public or private hospitals, including GPs practicing within the community. Sri Lanka has a healthcare system that is a combination of allopathic and indigenous medical practices, and there is often a cross-utilisation of both types for the same illness. However, in terms of the BDR Act, only allopathic doctors or apothecaries who are registered in the SLMC are legally allowed to provide MCCDs. 

This has been further ratified in Section 37 of the Medical Ordinance. For more than a century, GPs have played a predominant role in the primary healthcare sector of Sri Lanka, and a large proportion of these GPs cater to a specific community throughout their career. Recent attempts to improve the primary healthcare system have also introduced specialist family physicians affiliated with State hospitals. Therefore, especially in home deaths, GPs have the primary legal responsibility to issue an MCCD.

A GP who refuses to issue an MCCD without a valid reason could be penalised through Section 65 of the BDR Act, which states that “Every medical practitioner who neglects or refuses to issue a certificate as required by Section 31 shall be guilty of an offence and shall be liable to a fine". However, this would apply only to deaths that occur due to natural illnesses for which the GP had treated the deceased.

The doctor should be the attending physician of the last illness of the deceased and have treated the deceased recently

In well-established GP health systems in developed countries, the patient is registered in the health institution, and the GP is a registered practitioner of the institution. The patient nominates the GP as his/her regular GP. Thus, with a clear therapeutic relationship, the GP is bound to issue the MCCD to patients registered under the GP.

Although the term ‘attended’ can present a degree of confusion, particularly as it is not clearly defined in the guideline, it means a doctor who had cared for the patient during the illness that led to the death. Moreover, the death declaration form (form B33 of the Government Press) has highlighted that “the medical practitioner who treated the deceased must complete this form”. 

However, in today’s context of complex and multidisciplinary healthcare, most illnesses are treated by a combination of doctors, in which the GP may have played a minor part in the treatment or only been a referral point. When the GP has access to the relevant medical records and is familiar with the deceased’s medical history, investigations, and treatment, the GP can issue an MCCD if the GP is certain of the progression of the illness. 

However, there should be a recent encounter of the patient with the relevant GP before the demise. The GP responsible for the deceased person’s medical care during their last illness should be adequately convinced as to the COD, and that no other circumstances are present that require the death to be reported to the ISD. Even when a deceased’s GP is absent or unavailable, another GP in the practice can complete the DC, provided that they have sufficient information to do so, and the death is not required to be reported to the ISD.

On the other hand, if the GP only attended to the deceased during their final moments or was called after death and just certified the death, they cannot give an MCCD due to insufficient knowledge, as the GP should have treated the last illness that had led to the death. Therefore, the GP should not issue the MCCD in an “unattended death” where the GP has not been involved in the patient’s care.

Similarly, there are no clear guidelines regarding the duration acceptable for ‘treated the deceased recently’ in Sri Lanka, which creates a degree of confusion, particularly as the term ‘recently’ is not clearly defined. However, many guidelines from developed countries have defined this duration.

This can be as long as six months, indicating that even with a regular patient, if the patient was not treated at the specified time, an MCCD cannot be issued. The concept here is that the doctor who treated the patient should know the extent of the disease, its complications, the patient’s response to the treatment, etc.

The doctor is the attending physician of the last illness that has led to the death of the deceased

It is also necessary to ensure that the death is due to the most recent illness for which the deceased was treated by the GP. These apply even to patients with chronic illnesses, as the COD may still be different. Understandably, to issue an MCCD in an illness, a competent GP should be able to consider if death is a likely outcome of that illness or its treatment. If a patient dies who is on treatment for a non-fatal condition like a simple upper respiratory tract infection or osteoarthritis of the knee, the GP would not be able to determine the COD, as the death is unexpected. Thus, the GP needs to refer this to the ISD for an inquest.

The MCCD should be issued in a specific format

The statutory form to be used by GPs when issuing an MCCD is given in the BDR Act as form J. The same form is commonly known as form B12, as per its reference number given by the Government Press. The local guideline highlighted the importance of issuing the MCCD on the B12 form rather than on their personal letterheads or blank sheets. Furthermore, as per the BDR Act, the B12 form must be provided to the NOK in duplicate. Printed B12 forms can be obtained at the Registrar's Office of the DS.

The MCCD should be issued without a fee or reward

The BDR Act clearly states that the MCCD should be issued as an honourable service, and that the MCCD cannot be charged a professional fee nor receive any form of reward or benefit. This law should also apply to private hospitals where they charge for issuing the MCCD and include that in the hospital bill, disregarding the BDR Act.

The issue of the MCCD to a relative

In many countries, the GP is unable to issue an MCCD if the deceased is a close relative of the GP. This is to prevent issues related to conflict of interest and ensure the objectivity of the process. However, no statutory provision in Sri Lanka bars a doctor from issuing an MCCD to a relative, friend, or neighbour if the GP has been directly involved in that person’s care during the last illness. However, this may pose specific ethical and legal challenges. It may raise conflict of interest issues and even allegations of improper conduct, as well as medical negligence, if suspicions are raised regarding the death.

The COD given in the MCCD should be valid and defendable

It is understood that a GP is not expected to determine the COD with complete certainty. However, the GP needs to be able to determine the COD based on the understanding of the illness and the patient’s medical history, recent investigation findings, and the circumstances surrounding the death. When the COD is uncertain, reasonable steps should be taken to obtain sufficient information to determine the COD, which include reviewing the medical records and contacting other health professionals involved in the recent care of the deceased. If the GP is still unable to ascertain the COD after all such steps have been taken, then, the death must be reported to the ISD. 

If any legal issue arises regarding the death in the future, the MCCD can be subjected to legal scrutiny. If the opinion of the GP does not hold up under the adversarial cross-examination in court, this could raise doubts about the GP's competence. The penalty for providing false information in the MCCD is substantial. As per Section 68 of the BDR Act, any individual who issues a false certificate will be liable to a fine and a term of rigorous imprisonment for a maximum of seven years. Similarly, as per Section 33 of the Medical Ordinance, if a medical practitioner is found guilty of making a false statement to register a birth, death, or stillbirth or obtain a certificate, their name may be removed from the register. Therefore, the GP is expected to provide a rational, evidence-based opinion on the COD, which should be justified based on the medical records and clinical features.

The COD should be known, and the circumstances of death should be natural

The GP responsible for the patient's care should thoroughly review the medical records and the relevant facts before issuing an MCCD. The GP must have convincing evidence to support the opinion that the death is due to natural circumstances. A natural death is defined as a death related to an internal bodily event not influenced by external occurrences. Thus, a death caused by pneumonia, infections, cancer, stroke, or heart disease is classified as a natural death from a medical point of view. Unnatural deaths are homicides, accidents, suicides, poisoning, medical errors, and drug overdose. Sometimes, it can be difficult to determine whether an individual's death is simply 'natural' or ‘unnatural’ due to the multi-factorial nature of deaths in people who are undergoing treatment for diseases. Wherever death has an association with an external factor, either due to the fault of the patient or a third party, it should be considered unnatural. It is important to remember that sometimes, deaths that are clinically perceived to be natural may legally be considered unnatural. Examples include a patient bedridden following a motor vehicle accident, dying from pneumonia several months after the event, or a patient dying of renal failure from chronic exposure to a toxic substance.

The body should be viewed before issuing a MCCD

The final criterion in the SLMC guidelines is that the GP must conduct an external examination of the body. Although a medical diagnosis of the COD cannot be established with the external examination, it provides additional information to serve the judicial process and public interest. The external examination is an important screening process to prevent the concealment of deaths due to violence or negligence. 

Reviews have shown several instances where homicides have been missed or overlooked during medical death certification. Ideally, the external examination must be carried out with the body of the deceased completely undressed and all regions of the body, including all body orifices, the back, and especially the head and the neck, visible. 

However, this can be a difficult task for obvious reasons. Regardless, a GP is expected to view the body with this level of scrutiny. Therefore, the GP must use his/her good sense and judgement and take adequate precautions to satisfy himself/herself that the circumstances are natural and clear. Furthermore, if the history or medical records do not indicate a likely natural COD, the GP may be unable to establish the likely COD. 

Thus, as per the CPC Act and the guidelines, when the COD is unknown or if a person dies suddenly when in apparent good health, an inquest must be held.