Home Office Advice to Medical Practitioners completing Cremation Forms B & C
1. This guidance provides advice to medical practitioners who are asked to complete cremation certificates in connection with applications for cremation. It has been prepared to complement advice issued to crematoria medical referees so that medical practitioners can be aware of and, so far as possible, meet referees’ expectations so that unnecessary delay to the authorisation of cremation can be avoided.
Cremation Certificates
2. Medical practitioners should be aware that some cremation authorities use non-statutory versions of forms B and C. Although these forms may be “personalised” for each crematorium, and may have marginal explanatory notes, forms which do not comply with the statutory requirements are not valid. If medical practitioners are in doubt, they should check with the superintendent of the crematorium.
Eligibility to Sign Forms B and C
Provisional and temporary registration
3. Regulation 9 of the Cremation Regulations requires the confirmatory medical certificate to be given by a registered medical practitioner of not less than 5 years’ standing. The Home Office takes the view that this requires a continuous period of registration at the relevant time. As far as limited registration is concerned, periods of temporary or provisional registration would not seem to disqualify a registered doctor from completing a confirmatory certificate, but it will be a matter for the medical referee to decide whether an inadequate length of full registration may be a factor to be taken into account in any particular case.
Overseas doctors
4. So far as overseas doctors are concerned, EC Directive 93/16 (recognition of medical qualifications) and the Agreement on the European Economic Area (EEA) dated 13 December 1993 (Annex VII) (mutual recognition of professional qualifications) required member States to recognise one another’s diplomas in medicine, subject to certain standards being fulfilled. Section 17 and Schedule 2 to the Medical Act 1983 implemented this by setting out a list of “primary European qualifications” which would be recognised in the UK in accordance with the directive (a list of the EEA member states is given at Annex A). It follows that a national of any EEA member state holding a primary European qualification is entitled to be registered in the UK as a fully registered medical practitioner. It is consistent with this approach that experience acquired under the primary European qualification outside the UK should be accorded equal respect. Accordingly, an overseas doctor who has a primary European qualification in an EEA member state will be eligible to sign a cremation Form C provided the qualification has been held for five years.
Corroboration of cause of death - deaths in hospital
5. Regulation 9 also requires that the registered medical practitioner who gives the confirmatory medical certificate should not be a relative of the deceased, or a partner of the doctor who has given the cremation certificate in Form B.
6. The purpose of requiring two independent doctors to complete separate forms B and C is to provide corroboration of the medical circumstances in which death took place. This is obviously enhanced by the doctors being truly independent of each other. It is understood that, in the past, it has been normal practice for doctors from different hospital units to sign forms B and C or, failing this, to arrange for a local GP to sign form C – but that these arrangements have lapsed in some instances. Medical Referees have been reminded that they should satisfy themselves that there is sufficient independence between the signatories of Forms B and C in all cases.
7. Similarly, where a junior hospital doctor has given the certificate in Form B, it is considered that the spirit of the Regulations requires that the doctor who signs the Form C should not have been in charge of the case, nor directly concerned in the patient’s treatment. Medical practitioners should be aware that criminal proceedings have been successfully brought against doctors who have falsely completed the forms.
Dentists
8. Dentists are not qualified to sign cremation certificates.
Completion of Forms and Certificates A, B and C
9. The most frequently occurring errors in the completion of certificates
are:-
(a) Failure to complete all questions in full
(b) Incorrect completion of forms
(c) Illegible handwriting; and
(d) Discrepancies between forms as to the date and time of death.
10. Certificates should be answered in full (ie questions should not be deleted) and completed legibly. Abbreviations for causes of death may cause difficulty where the abbreviation is unclear, unusual or ambiguous; in such cases, further enquiries of the doctor concerned are likely to be made. Signatures should be a hand-written signature, not an abbreviation or a stamp.
11. Certificates should also be completed by the certifying doctor, and not by another person on his or her behalf. The doctor issuing the confirmatory certificate should not seek to amend the certificate of the medical attendant, but record any differences (eg as to the cause of death) on his or her own certificate.
12. Nevertheless, a ‘no’ answer to any particular question is not regarded as necessarily fatal to an application, although such an answer may well provoke a need for further enquiry and in certain cases (eg as in paragraph 28 below) such enquiries are strongly recommended.
13. The following paragraphs address some other common issues.
Form B – Certificate of Medical Attendant
QUESTION 5: “ORDINARY MEDICAL ATTENDANT”
14. The ordinary medical attendant may normally be taken to be the deceased’s general practitioner. Where the deceased has been an in-patient in hospital for a short period of time, it may be better to regard the patient’s GP as the ordinary medical attendant, rather than the hospital doctor in attendance. (See also paragraph 7 above.)
QUESTION 6: “DID YOU ATTEND THE DECEASED DURING HIS OR HER LAST ILLNESS?”
15. The certifying medical attendant should have attended the deceased. In the primary care setting, a demonstrable prior period of care or the presence of the certifying practitioner at the death will usually meet this requirement. A general practitioner partner may be acceptable if he or she had seen the deceased outside the normally acceptable period (14 days) and the attending partner is unavailable, but the circumstances should be clearly recorded.
16. The minimum period of hospital care sufficient to meet the requirement may normally be 24 hours, unless it is a second or subsequent admission. If the coroner has been informed, but decided that he need not take jurisdiction, that fact should be recorded.
QUESTION 7: “WHEN DID YOU LAST SEE THE DECEASED ALIVE?”
17. The normal expectation is that the deceased will have been seen not more than 14 days before death; otherwise the coroner’s dispensation should be sought.
QUESTION 8: “HOW SOON AFTER DEATH DID YOU SEE THE BODY?”
18. If a post mortem examination has been conducted by the certifying medical attendant, this should be indicated here and the cause of death in Question 9 should be the findings of the examination. Where the qualifications in Question 8A can be met, then a confirmatory medical certificate (Form C) is not required. If a post mortem examination has been conducted by another person, details should be given in response to Question 11.
QUESTION 9: CAUSE OF DEATH
19. All sections of this question should be answered.
QUESTION 10: MODES OF DEATH
20. The terms often appear to be misunderstood. Syncope implies a sudden death occurring in minutes, but not necessarily unexpectedly, with a history of ischaemic heart or cerebro-vascular disease. Convulsions may indicate an unnatural death unless adequately explained by the cause of the death.
QUESTION 11: CAUSE, MODE AND DURATION OF DEATH
21. Both parts of the question should be completed.
22. Medical practitioners will need to have been present at some point during the period of the final mode of death in order to certify that the answer to Question 10 was based on their own observations. Question 11 also covers the cause of death, and the answer should indicate when this has been informed by other sources, eg patient history, operative procedures or medical or lay witnesses.
QUESTION 12: OPERATIONS
23. Any failure to include operative procedures which are of potential significance may call into question the reliability of the certificate.
QUESTIONS 13 AND 14: OTHERS PRESENT
24. Specific names (and contact details) will assist both the practitioner completing the confirmatory certificate and the medical referee.
QUESTIONS 15 AND 16: BACKGROUND AND CIRCUMSTANCES
25. These questions are intended to provide the certifying practitioner with the opportunity to confirm that there were no circumstances surrounding the death which might require further investigation.
Form C – Confirmatory Medical Certificate
26. The cause of death on the Form C does not need to be the same as the one given on the Form B, but any discrepancy should be explained.
27. Medical practitioners should note that the Home Office has long recommended that medical referees should not accept Form Cs unless the questions 1, 2 and 4 have been answered in the affirmative.
28. In addition, the Home Office considers that an affirmative answer to at least one of questions 5 to 8 should also be expected. Experience has shown that this need not introduce significant delay to the completion of the Form C or to the funeral arrangements. Nevertheless, Question 5 should be answered in the affirmative only if the signatory of Form C has seen and questioned a medical practitioner other than the signatory of Form B.
QUESTION 4: “HAVE YOU SEEN … THE MEDICAL PRACTITIONER?”
29. If the medical practitioners have not seen each other, Form C should be completed to show that the enquiries have been ‘adequate’.
30. In completing Form C, doctors should ensure that their registration details are supplied and that the handwriting is legible.
31. Medical referees will expect that the evidence offered on the certificates demonstrates sound clinical grounds for the cause of death given, and Forms B and C should be completed with this in mind.
Requirement for Confirmatory Medical Certificate – Form C
32. A Form C should only be completed where one is required under the Cremation Regulations. Form C is not required where:
a. A post mortem examination has been carried out by a relevant medical practitioner appointed by the Cremation Authority and who has issued a Form D;
b. A post mortem examination has been carried out and the cause of death certified by the coroner (Form E);
c. An inquest has been opened and the coroner has issued his Form E; or
d. The death occurred in hospital, the deceased was an in-patient there, and a post mortem has been carried out by a medical practitioner qualified to do so, and the medical attendant knows the results of the examination before issuing Form B.
33. If a Form C has been completed where there is no requirement for the certificate any fee paid may be required to be refunded.
Deaths Reportable to the Coroner
34. Medical practitioners are asked to ensure that the Coroner is notified if any suspicious circumstances come to his knowledge In cases where the Coroner has been consulted by the signatories of either Form B or Form C, but considers that his/her involvement is unnecessary, this should be recorded by the medical practitioner concerned.
Causes of death
35. Advice on the completion of medical certificates of cause of death acknowledges that ‘old age’ may be an acceptable cause in certain circumstances. Whether such a cause is acceptable for the purposes of cremation applications, having regard to the need to definitely ascertain the cause of death, is for consideration. Attribution to ‘old age’ commonly arises where the deceased may have been suffering from a number of conditions leading to death but where it may not be possible to decide which particular condition led to the death. The Home Office is unable to offer guidance on a matter which must ultimately be a clinical decision by the certifying doctor or doctors, who should satisfy themselves that ‘old age’ is an appropriate cause of death in all the circumstances, and that it is not used where the cause of death is properly “unascertained” and which should on that account be referred to the coroner.
Deaths Abroad
36. Where a person dies abroad and the body is repatriated to England or Wales for cremation, special arrangements apply. Medical practitioners are not qualified to complete cremation Forms B or C in relation to such deaths. Enquiries about such cases should be directed to the Home Office (or to the Coroner, if the circumstances indicate that the death ought to have been reported to the Coroner if it had occurred in England or Wales.
Anatomical Dissection
Body Parts
37. The cremation of body parts removed following a post mortem examination is subject to a procedure set out in Home Office circular 2/2000 and will not normally require involvement by medical practitioners other than pathologists.
Unidentified Remains
38. It is unlikely that applications for the cremation of unidentified remains will arise without the involvement of the coroner.
Cremation Contrary to Wishes
39. There is no longer any provision to prohibit the cremation of a deceased person in contradiction of any known wishes or written directions to the contrary. The decision how best to honour the wishes of the deceased in this matter is entirely an issue for the relative or executor applying for cremation.
Cremation of non-viable foetal remains
40. Foetal remains under 24 weeks of age are not subject to the provisions of the Cremation Act or Regulations, although most crematoria are understood to be prepared to cremate such remains at their discretion.
General
41. Medical Referees have been reminded that it is essential to ensure that no cremation takes place unless the relevant forms have been properly completed in accordance with the Regulations. Medical Referees have the statutory power to reject incompletely completed forms and may refuse to authorise cremation until the forms have been completed to their satisfaction. Medical referees also have the power to make any enquiry they may consider necessary about an application or certificate. Medical practitioners are requested to assist medical referees in the discharge of their duties by completing the cremation certificates fully and accurately, and by responding to any further enquiries as helpfully as possible.