COVID 19 GLOBAL

[fygjam]

39 minutes ago, roobob said:

lol.... lets look at a couple of the names....lol

..... a Japanese pianist...lol

Izumi Kimura - Wikipedia

Hesham Nassar...a Youtuber...lol

Hesham Nassar - YouTube

Dear oh dear..... the laugh of the day... these two would not even qualify as glorified teachers let alone get a grant......555

Comedy gold......🤣 🤣 🤣

cheers

Oh dear, laugh of the day is correct.

Who doesn't know how to refine a search in a search engine?

https://www.google.com/search?q=Izumi+Kimura+university+of+tokyo&spell=1&sa=X&ved=2ahUKEwiWjc6Cu4n2AhXDUGwGHSdwCrYQBSgAegQIARAy&biw=2560&bih=1309

Now see if you can find the correct Hesham Nasser, you obviously need the practice.

The google roob..

Tell us how the number of papers each has published compares to your endeavors.

 

 

 

 

 

[lazarus]

1 hour ago, fygjam said:

Actually nothing like that academic study...

Just because it hasn't been peer reviewed doesn't mean it is wrong.

But I suggest you go and read the actual paper rather than a report by the dreadful media about the paper.

Thanks, I'll wait and see if the new variant in fact does pose a significant threat. There will be more variants and more studies, yet IMO the world needs two things to happen...

1) continue with an aggressive universal vaccine program globally.

2) shore up existing health care capabilities to deal with not only Covid but the next epidemic to come down the track...as that's a given.

[fygjam]

11 minutes ago, lazarus said:

Thanks, I'll wait and see if the new variant in fact does pose a significant threat. There will be more variants and more studies, yet IMO the world needs two things to happen...

1) continue with an aggressive universal vaccine program globally.

2) shore up existing health care capabilities to deal with not only Covid but the next epidemic to come down the track...as that's a given.

Yep, yep and yep.

And that was a suggestion that "every you" should read the paper rather than go by a media report.

 

 

Edited February 18, 2022 by fygjam

[Kathmandu]

11 hours ago, Krapow said:

 

This 'story' is like the worst of the media scaremongering pish. 

It's been shown to be no more danger in Countries like Denmark where it's dominant. Indeed Denmark were that worried, they continued to ease all restrictions, sane as the UK where it's been for ages as well. 

The media has a lot to answer for during this debacle, whipping up hysteria in the Karen's. 

Check the numbers again, my friend. Denmark has continued to record more COVID-19 cases per capita than nearly anywhere else in the world, and both COVID hospitalizations and deaths have shot up by about a third.

[Krapow]

34 minutes ago, Kathmandu said:

Check the numbers again, my friend. Denmark has continued to record more COVID-19 cases per capita than nearly anywhere else in the world, and both COVID hospitalizations and deaths have shot up by about a third.

Well no, this is how things gets 'misinterpreted' shall we say. 

The reason case numbers have went up in Denmark is because they lifted all restrictions 3weeks ago. The 'New variant' that some are reporting as some new deadly threat, has been in Denmark for ages, likewise S.Africa. If it was the cause of a rise in cases, deaths etc, it would have happened ages ago. It didn't, as it's not the case. 

Denmark are also currently actually at pains to point out the numbers being used in regards to hospitalisations and deaths by lefty leaning advocates, are those WITH covid, not BECAUSE OF covid. Big difference, especially Omicron being so transmissible. It's been shown that over  half of hospitalisations and deaths in the UK recorded as Covid were actually due to something completely unrelated, they just happened to test positive in hospital as it was rife, over half!  It'll be the same in Denmark.

Now there is even the usual UK Lefty lockdown zealots weighing in with the Lefty Danish counterparts coming out with the same shite they did in the UK, and were proven wrong every time. Had we listened to them at the start of Omicron in Nov/Dec we'd probably only be coming out of a incredibly damaging in all sorts of ways, and completely unnecessary lockdown. 

This 'New deadly variant' is just the usual media scaremongering and being jumped on by the usual politically motivated 'experts'. 

[Golfingboy]

A huge number of police, most dressed in riot gear, have moved in to hopefully put an end to the Ottawa protests. Some truckers have even driven away voluntarily to start clearing the streets, so I feel like it’s almost over. 
 

I support democracy and right to protest, but most Canadians are in agreement it’s gone too far. It’s been 3 weeks, this was not 500 people marching on a Sunday afternoon. The chief of police resigned over this, due to criticism over his “inaction”. 
 

Still, even if I don’t agree with people blocking streets in my nation’s capital, I don’t like seeing them being manhandled,dragged away and handcuffed. Just not an easy situation to deal with all around, I mean bank accounts are starting to be frozen, Bin Laden-style, for those funding this movement. Oh well……

 

[fygjam]

Good to see. A welcome return of the wingnut "they died with Covid not of Covid" denial.

 

[forcebwithu]

10 hours ago, fygjam said:

Oh dear, laugh of the day is correct.

Who doesn't know how to refine a search in a search engine?

https://www.google.com/search?q=Izumi+Kimura+university+of+tokyo&spell=1&sa=X&ved=2ahUKEwiWjc6Cu4n2AhXDUGwGHSdwCrYQBSgAegQIARAy&biw=2560&bih=1309

Now see if you can find the correct Hesham Nasser, you obviously need the practice.

The google roob..

Tell us how the number of papers each has published compares to your endeavors.

Roob's post is a great example of confirmation bias. Types in a search based on name only, sees what he wants to see and goes no further.

All one would have to due to confirm the search results were maybe a bit off is add something as simple as the word "virology" after the name and the return would look quite different.

[Krapow]

4 hours ago, fygjam said:

Good to see. A welcome return of the wingnut "they died with Covid not of Covid" denial.

 

Denial?

The irony of that and what you just posted is obviously way beyond your intellect or grasp of what's currently going on.  But then you and ilk only see it through your overall Lefty viewpoint. 

It's a fact, been shown in plenty of recent studies as such, especially with Omicron being so rife. It's even gets It's own weekly 'mention' in internal intelligence emails that get sent to all our PH teams in work from hospital consultants stating the percentage of people in hospital who are in for something completely unrelated but just happened to test positive for Covid as it was rife, very mild for the vast, vast majority, but rife all the same. Likewise for deaths unrelated to Covid but had tested positive for Covid. Real time data so we know what's actually going on. Everyone gets tested for covid on arrival to hospital for whatever reason. 

But you know better, eh!

Oh, and try and grow a set of balls and actually quote me next time.

[galenkia]

12 minutes ago, Krapow said:

Denial?

The irony of that and what you just posted is obviously way beyond your intellect or grasp of what's currently going on.  But then you and ilk only see it through your overall Lefty viewpoint. 

It's a fact, been shown in plenty of recent studies as such, especially with Omicron being so rife. It's even gets It's own weekly 'mention' in internal intelligence emails that get sent to all our PH teams in work from hospital consultants stating the percentage of people in hospital who are in for something completely unrelated but just happened to test positive for Covid as it was rife, very mild for the vast, vast majority, but rife all the same. Likewise for deaths unrelated to Covid but had tested positive for Covid. Real time data so we know what's actually going on. Everyone gets tested for covid on arrival to hospital for whatever reason. 

But you know better, eh!

Oh, and try and grow a set of balls and actually quote me next time.

Mate at work, his mum is an undertaker. She was told early on that all bodies that test positive are automatically classed as COVID deaths, no matter the actual cause of death. So while many people did die from it, the figures are far from accurate. 

And many were said to have caught it in hospital whilst being admitted for something unrelated. 

Of course, the high figures ensures that most people comply with the lock down rules. Which I guess was the aim of the Government,to try and control the situation. Nothing breeds compliance like fear of death. 

[roomark]

14 minutes ago, galenkia said:

Mate at work, his mum is an undertaker. She was told early on that all bodies that test positive are automatically classed as COVID deaths, no matter the actual cause of death. So while many people did die from it, the figures are far from accurate. 

And many were said to have caught it in hospital whilst being admitted for something unrelated. 

Of course, the high figures ensures that most people comply with the lock down rules. Which I guess was the aim of the Government,to try and control the situation. Nothing breeds compliance like fear of death. 

Thank f**k they seem to be playing ball and have or are dropping everything in U.K now been a long old time and from my experience of Omicron anyway it couldn't knock a wank out 🤣🤣🤣🤣

[Krapow]

40 minutes ago, galenkia said:

Mate at work, his mum is an undertaker. She was told early on that all bodies that test positive are automatically classed as COVID deaths, no matter the actual cause of death. So while many people did die from it, the figures are far from accurate. 

And many were said to have caught it in hospital whilst being admitted for something unrelated. 

Of course, the high figures ensures that most people comply with the lock down rules. Which I guess was the aim of the Government,to try and control the situation. Nothing breeds compliance like fear of death. 

Omicron has changed everything. 

Around this time last year there was up to 2000 deaths a day in the UK, it was Delta, much more severe but thankfully not as transmissible. 

Now it's the reverse, Omicron and this 'New variant' of it is much more transmissible but much less severe. Which if you look at the big picture, is great news in many ways. f**k sake France were posting near half a million daily cases a few weeks ago, country or health service didn't collapse. Omicron!

The 'mention' in the weekly data reports to PH teams from hospital is a new thing, only started in December when the hospitals seen a substantial number, enough to continually point it out, were arriving at hospital for something completely unrelated to Covid then tested on arrival and found to be positive, as Omicron was absolutely rife but many times with little or no symptoms. Likewise people dying from something unrelated but had tested positive for Omicron which had no bearing on their death, as it was rife. 

I repeat, Omicron has changed everything. That's not denial. Denial is not accepting Omicron has changed things.

Myself and my wife had Omicron in January. We tested when we got what we thought was a slight cold, it was positive. We wouldn't have tested had we felt the same last January, as the guidance for testing and what the symptoms were was different then, it was Delta. I worked from home as usual, my wife didn't go to work as per the isolation rules, but she felt fine to do so. We are both fully vaccinated with our boosters. 

As anyone who has read any of my posts on here from the start of Covid will know, I'm certainly not in denial. Indeed I was the one stating at the start if anyone still thought this was flu or wasn't going to get very bad very quick, they weren't paying attention. 

By the same token I stated vaccines would be the way out of this, and due to their success I didn't think there would be another full lockdown down, whilst arguing last year to keep restrictions until every adult had been offered the chance to get fully vaccinated, which I'm glad to Gov did. 

Denial no, views and opinions evolved as the situation has evolved, as IMO most reasonable,  sensible people would do. 

[fygjam]

1 hour ago, Krapow said:

Denial?

The irony of that and what you just posted is obviously way beyond your intellect or grasp of what's currently going on.  But then you and ilk only see it through your overall Lefty viewpoint. 

It's a fact, been shown in plenty of recent studies as such, especially with Omicron being so rife. It's even gets It's own weekly 'mention' in internal intelligence emails that get sent to all our PH teams in work from hospital consultants stating the percentage of people in hospital who are in for something completely unrelated but just happened to test positive for Covid as it was rife, very mild for the vast, vast majority, but rife all the same. Likewise for deaths unrelated to Covid but had tested positive for Covid. Real time data so we know what's actually going on. Everyone gets tested for covid on arrival to hospital for whatever reason. 

But you know better, eh!

Oh, and try and grow a set of balls and actually quote me next time.

Ok, you're quoted. Happy now?

But seeing as your so close to the coal face perhaps you could acquaint us with the requirements for doctors signing death certificates.

Are doctors required to apportion the cause of a persons death, say 10% old age, 20% heart, 30% smoking, 40% cancer etc.

Or

Are doctors required to list a single cause of death which, in the doctors expert opinion, is the primary reason that the deceased is deceased.

Now I'm going to go out on a limb here and say I suspect it is the latter. Thus those where the cause of death is listed as Covid, died because of Covid and not because they died with Covid.

If you have information to the contrary then you should be blowing the whistle on those miscreants corrupting the official  statistics.

 

While I have your attention.

In an earlier post I supplied the link to the study of the BA.2 variant. I have read the paper and for the life of me I couldn't detect the "pishy" bits. Maybe you could point them out for me. Perhaps it's my Lefty viewpoint but it looked like a fairly standard research paper to me.

What we did.

How we did it.

What we found.

Our conclusions.

I will agree that to solely rely on the popular media for Covid facts, you're being a fool to yourself and a burden to others. That's why I try to look behind the media. Imagine relying for information on The Today Show and Karl Stefanovic.

 

 

[john luke]

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/877302/guidance-for-doctors-completing-medical-certificates-of-cause-of-death-covid-19.pdf
 

  Guidance for doctors completing Medical Certificates of Cause of Death in England and Wales
FOR USE DURING THE EMERGENCY PERIOD ONLY
1. The purposes of death certification ...................................................................2
2. Who should certify the death?...........................................................................2
3. Referring deaths to the coroner.........................................................................3
4. How to complete the cause of death section.....................................................4
4.1 Sequence leading to death, underlying cause and contributory causes...........4 4.2 Results of investigations awaited .....................................................................7 4.3 Avoid ‘old age’ alone ........................................................................................7 4.4 Never use ‘natural causes’ alone .....................................................................8 4.5 Avoid organ failure alone..................................................................................8 4.6 Avoid physical and mental conditions which are not fatal in themselves..........9 4.7 Avoid terminal events, modes of dying and other vague terms ........................9 4.8 Never use abbreviations or symbols ..............................................................10
5. Specific causes of death .................................................................................10 5.1 Stroke and cerebrovascular disorders............................................................10 5.2 Neoplasms .....................................................................................................10 5.3 Diabetes mellitus............................................................................................12 5.4 Deaths involving infections and communicable diseases...............................12 5.5 Injuries and external causes...........................................................................15 5.6 Substance misuse..........................................................................................15
In an emergency period of the COVID-19 pandemic there is a relaxation of previous legislation concerning completion of the medical certificate cause of death (MCCD) by medical practitioners (referred to for the remainder of this document as doctor). The important changes occur in Sections 2 and 3 of this guidance. You should use standard guidance outside of the emergency period.
This guidance is intended to complement the notes for doctors in the front of every book of MCCDs. Those instructions remain current and doctors should familiarise themselves with the MCCD notes and consult them if they are in any doubt about whether, or how, to certify a death.
Those medical practitioners who have been appointed as medical examiners and also those appointed as medical examiner officers can provide resource to the death certification process where required in a period of emergency.
F66 Guidance

1. The purposes of death certification
Prompt and accurate certification of death is essential as it serves a number of functions. A medical certificate of cause of death (MCCD) enables the deceased’s family to register the death. This provides a permanent legal record of the fact of death and enables the family to arrange disposal of the body, and to settle the deceased’s estate.
A doctor who attended the deceased during their last illness has a legal responsibility to complete a MCCD and arrange for the transmission (electronic recommended) of it to the relevant registrar as soon as possible to enable the registration to take place this duty may be discharged through another doctor who may complete an MCCD in an emergency period. Deaths are required by law to be registered within 5 days of their occurrence unless there is to be a coroner’s post mortem or an inquest.
After registering the death, the family is provided with a certified copy of the register entry (“death certificate”), which includes an exact copy of the cause of death information that you give. This provides them with an explanation of how and why their relative died. It also gives them a permanent record of information about their family medical history, which may be important for their own health and that of future generations. For all of these reasons it is extremely important that you provide clear, accurate and complete information about the diseases or conditions that caused your patient’s death in a timely manner.
Information from death certificates is used to measure the relative contributions of different diseases to mortality. Statistical information on deaths by underlying cause is important for monitoring the health of the population, designing and evaluating public health interventions, recognising priorities for medical research and health services, planning health services, and assessing the effectiveness of those services. Death certificate data are extensively used in research into the health effects of exposure to a wide range of risk factors through the environment, work, medical and surgical care, and other sources.
In the emergency period, the registrar will accept a scanned (or photographed) and emailed copy of the completed MCCD. The email must be sent from a secure email address (for example NHS.net) to a secure email address (for example .gov.uk). The list of qualified informants includes a funeral director (where they are acting on behalf of the family). If the MCCD is scanned and emailed the original signed form should be securely retained and delivered to the registrar as soon as possible after the emergency period (this should be discussed and agreed with the registration service).
2. Who should certify the death?
In an emergency period, any doctor can complete the MCCD, when it is impractical for the attending doctor to do so. This may, for example, be when the attending doctor is self-isolating, unwell, or has pressure to attend patients. In these circumstances, it may be practical to allow a medical examiner or recently retired doctor returning to work to complete the MCCD.
There is no clear legal definition of “attended”, but it is generally accepted to mean a doctor who has cared for the patient during the illness that led to death and so is familiar with the patient’s medical history, investigations and treatment. For the purposes of the emergency period, the attendance may be in person, via video/visual consultation, but not audio (e.g. via telephone). The certifying doctor should also have

access to relevant medical records and the results of investigations. There is no provision in the emergency period to delegate this statutory duty to any non-medical practitioner.
Where the certifying doctor has not seen the deceased before death they should delete the words last seen alive by me on.
If the deceased has been seen before death by a doctor but not the certifying doctor, as well as signing the MCCD they should include the name of that doctor on the MCCD.
In hospital, there may be several doctors in a team caring for the patient. It is ultimately the responsibility of the consultant in charge of the patient's care to ensure that the death is properly certified. Any subsequent enquiries, such as for the results of post- mortem or ante-mortem investigations, will be addressed to the consultant.
In general practice, more than one GP may have been involved in the patient’s care and so be able to certify the death. In the emergency period, the same provisions to enable any doctor to certify the death prevail in general practice.
If no doctor has attended the deceased within 28 days of death (including video/visual consultation) or the deceased was not seen after death by a doctor, the MCCD can still be completed. However, the registrar will be obliged to refer the death to the coroner before it can be registered. In these circumstances, the coroner may instruct the registrar to accept the certifying doctor’s MCCD for registration.
Where a cause of death cannot be ascertained, the death cannot be certified, and the doctor should refer the death directly to the coroner with any supporting information. The coroner may from this information determine no investigation is needed and inform the registrar that the death can be registered. This information will be used for mortality statistics, but the death will be legally “uncertified” if the coroner does not investigate and make a determination as to the cause of death. However, once the registrar has received the coroner’s notification the death may be registered.
3.
• •
Referring deaths to the coroner
Covid-19 is an acceptable direct or underlying cause of death for the purposes of completing the Medical Certificate of Cause of Death
Covid-19 is not a reason on its own to refer a death to a coroner under the Coroners and Justice Act 2009.
 • That Covid-19 is a notifiable disease under the Health Protection (Notification) Regulations 2010 does not mean referral to a coroner is required by virtue of its notifiable status.
Medical practitioners are required to certify causes of death “to the best of their knowledge and belief”. Without diagnostic proof, if appropriate and to avoid delay, medical practitioners can circle ‘2’ in the MCCD (“information from post-mortem may be available later”) or tick Box B on the reverse of the MCCD for ante-mortem investigations. For example, if before death the patient had symptoms typical of COVID- 19 infection, but the test result has not been received, it would be satisfactory to give ‘COVID-19’ as the cause of death, tick Box B and then share the test result when it

becomes available. In the circumstances of there being no swab, it is satisfactory to apply clinical judgement.
Doctors and registrars of births and deaths have a legal obligation to report certain categories of deaths to the coroner before they can be registered. These include deaths where there is reason to suspect, the death was unnatural, unexplained, violent or where the death occurs in prison or otherwise in state detention. Deaths occurring during an operation, or before full recovery from an anaesthetic should also be referred In addition, there will always be cases which may on one view be ‘natural’ which have some other element (e.g. neglect concerns) which brings them within the orbit of the coroner. Deaths for which the cause is not known must be reported to the coroner. In the emergency period, if no doctor has attended the deceased within 28 days of death (including video/visual consultation) or the deceased was not seen after death by a doctor, the death must be referred to the coroner.
Strictly speaking, the law requires that an MCCD should be completed even when a death has been referred to the coroner. In practice, if the coroner has decided to order a post-mortem examination and/or to hold an inquest, he may tell a doctor not to complete the MCCD. However, the coroner can only legally certify the cause of death if he has investigated it through autopsy, inquest or both. This means that, if the coroner decides not to investigate, the registrar will need to obtain an MCCD from a doctor who attended the deceased before the death can be registered. This may cause inconvenience to you and the family, if you have not already provided one. This will avoid the death having to be registered as uncertified.
When a death is referred, it is up to the coroner to decide whether or not it should be investigated further. It is very important that the coroner is given all of the facts relevant to this decision. The doctor should discuss the case with the coroner before issuing an MCCD if at all uncertain whether he or she should certify the death. This allows the coroner to make enquiries and decide whether or not any further investigation is needed, before the family tries to register the death. The coroner may decide that the death can be registered from the doctor's MCCD. For example, around 60% of deaths with fractured neck of femur mentioned on the certificate are registered from the original MCCD following referral to the coroner (2016 figures). Omitting to mention on the certificate conditions or events that contributed to the death in order to avoid referral to the coroner is unacceptable and a breach of the doctor’s legal obligations. If these come to light when the family registers the death, the registrar will be obliged to refer it to the coroner. If the fact emerges after the death is registered, an inquest may still be held.
4. How to complete the cause of death section
 • COVID-19 is an acceptable direct or underlying cause of death for the purposes of completing the Medical Certificate of Cause of Death
• COVID-19 is not a reason on its own to refer a death to a coroner under the Coroners and Justice Act 2009.
• That COVID-19 is a notifiable disease under the Health Protection (Notification) Regulations 2010 does not mean referral to a coroner is required by virtue of its notifiable status.

Medical practitioners are required to certify causes of death “to the best of their knowledge and belief”. Without diagnostic proof, if appropriate and to avoid delay, medical practitioners can circle ‘2’ in the MCCD (“information from post-mortem may be available later”) or tick Box B on the reverse of the MCCD for ante-mortem investigations. For example, if before death the patient had symptoms typical of COVID- 19 infection, but the test result has not been received, it would be satisfactory to give ‘COVID-19’ as the cause of death, tick Box B and then share the test result when it becomes available. In the circumstances of there being no swab, it is satisfactory to apply clinical judgement.
As previously mentioned, doctors are expected to state the cause of death to the best of their knowledge and belief; they are not expected to be infallible. Even without any changes to the law, there is increased scrutiny of death certification and patterns of mortality by local and national agencies as a result of the Shipman Inquiry. Suspicions may be raised if death certificates appear to give inadequate or vague causes of death. For example, if a patient dies under the care of an orthopaedic surgeon, it might be expected that some orthopaedic condition contributed to the death and so this condition would be mentioned in part I or part II of the certificate. Similarly, it would be surprising if a patient was being treated in an acute hospital, but no significant disease or injury at all was mentioned on their death certificate.
The level of certainty as to the cause of death varies. What to do, depending on the degree of certainty or uncertainty about the exact cause of death, is discussed below.
4.1 Sequence leading to death, underlying cause and contributory causes
The MCCD is set out in two parts, in accordance with World Health Organisation (WHO) recommendations in the International Statistical Classification of Diseases and Related Health Problems (ICD). You are asked to start with the immediate, direct cause of death on line Ia, then to go back through the sequence of events or conditions that led to death on subsequent lines, until you reach the one that started the fatal sequence. If the certificate has been completed properly, the condition on the lowest completed line of part I will have caused all of the conditions on the lines above it. This initiating condition, on the lowest line of part I will usually be selected as the underlying cause of death, following the ICD coding rules. WHO defines the underlying cause of death as “a) the disease or injury which initiated the train of morbid events leading directly to death, or b) the circumstances of the accident or violence which produced the fatal injury”. From a public health point of view, preventing this first disease or injury will result in the greatest health gain. Most routine mortality statistics are based on the underlying cause. Underlying cause statistics are widely used to determine priorities for health service and public health programmes and for resource allocation. Remember that the underlying cause may be a longstanding, chronic disease or disorder that predisposed the patient to later fatal complications.
You should also enter any other diseases, injuries, conditions, or events that contributed to the death, but were not part of the direct sequence, in part two of the certificate. The conditions mentioned in part two must be known or suspected to have contributed to the death, not merely be other conditions which were present at the time.

Examples of cause of death section from MCCDs (including example of COVID-19 as underlying cause of death):
Cause of death the disease or condition thought to be the underlying cause should appear in the lowest completed line of part I
I
    (a) Disease or condition Interstitial pneumonitis leading directly to death
(b) other disease or condition,
if any, leading to I(a) COVID-19
(c) other disease or condition, primary adenocarcinoma of ascending colon if any, leading to I(b)
   II Other significant conditions Contributing to death but not related to the
disease or condition
causing it
diabetes mellitus
   Cause of death the disease or condition thought to be the underlying cause should appear in the lowest completed line of part I
I
II.
The colon cancer on line 1(c) led directly to the liver metastases on line 1(b), which ruptured, causing the fatal haemorrhage on 1(a). Adenocarcinoma of the colon is the underlying cause of death.
Cause of death the disease or condition thought to be the underlying cause should appear in the lowest completed line of part I
I
II Other significant conditions Contributing to death but not related to the disease or condition causing it
  (a) Disease or condition Intraperitoneal haemorrhage leading directly to death
(b) other disease or condition,
if any, leading to I(a) Ruptured metastatic deposit in liver
(c)other disease or condition,
if any, leading to I(b) primary adenocarcinoma of ascending colon
Other significant conditions Contributing to death but not
related to the disease or condition causing it
Non-insulin dependent diabetes
          (a) Disease or condition Cerebral infarction leading directly to death
 (b) other disease or condition, Thrombosis of basilar artery if any, leading to I(a)
 (c) other disease or condition, Cerebrovascular atherosclerosis if any, leading to I(b)
      
(In subsequent examples, to save space, the layout of the MCCD has not been reproduced. All examples are taken from actual MCCDs of deaths in England and Wales).
In some cases, a single disease may be wholly responsible for the death. In this case, it should be entered on line Ia.
Example:
Ia. Meningococcal septicaemia
Meningococcal septicaemia is the underlying cause of this death.
• More than three conditions in the sequence
The MCCD in use in England and Wales currently has 3 lines in part I for the sequence leading directly to death. If you want to include more than 3 steps in the sequence, you can do so by writing more than one condition on a line, indicating clearly that one is due to the next.
Example:
Ia. Post-transplant lymphoma
Ib. Immunosuppression following renal transplant 15 years ago
Ic. Glomerulonephrosis due to insulin dependent diabetes mellitus
II. Recurrent urinary tract infections
Insulin dependent diabetes with renal complications is the underlying cause.
• More than one disease may have led to death
If you know that your patient had more than one disease or condition that was compatible with the way in which he or she died, but you cannot say which was the most likely cause of death, you should include them all on the certificate. They should be written on the same line and you can indicate that you think they contributed equally by writing “joint causes of death” in brackets.
Examples:
Ia. Cardiorespiratory failure
Ib. Ischaemic heart disease and chronic obstructive airways disease
Ic.
II. Osteoarthritis
Ia. Hepatic failure
Ib. liver cirrhosis
Ic. Chronic hepatitis C infection and alcoholism (joint causes of death)
II.
Where more than one condition is given on the lowest used line of part 1, ONS will use the internationally agreed mortality coding rules in ICD-10 to select the underlying cause for routine mortality statistics.
Since 1993, ONS also code all the other conditions mentioned on the certificate. These multiple cause of death data are used by ONS in a variety of routine and ad hoc analyses, and can be made available for research in some circumstances. Multiple

cause data provides useful additional information on the mortality burden associated with diseases that are not often selected as the main cause of death. For example, conditions that are very often complications of another disease or its treatment, such as deep vein thrombosis / pulmonary embolism or health care associated infections should rarely be the underlying cause of death. Their contribution to mortality is better estimated from multiple cause data. In contrast to the above, if you do not know that your patient actually had any specific disease compatible with the mode and circumstances of death, you must refer the death to the coroner. For example, if your patient died after the sudden onset of chest pain that lasted several hours and you have no way of knowing whether he or she may have had a myocardial infarct, a pulmonary embolus, a thoracic aortic dissection, or another pathology, it is up to the coroner to decide what investigations to pursue.

4.2 Results of investigations awaited
If in broad terms you know the disease that caused your patient’s death, but you are awaiting the results of laboratory investigation for further detail, you need not delay completing the MCCD. For example, a death can be certified as bacterial meningitis once the diagnosis is firmly established, even though the organism may not yet have been identified. Similarly, a death from cancer can be certified as such while still awaiting detailed histopathology. This allows the family to register the death and arrange the funeral. However, you should indicate clearly on the MCCD that information from investigations might be available later. You can do this by circling ‘2’ on the front of the MCCD for autopsy information, or by ticking box ‘B’ on the back of the certificate for results of investigations initiated ante-mortem. It is important for public health surveillance to have this information on a national basis; for example, to know how many meningitis and septicaemia deaths are due to meningococcus, or to other bacterial infections. The registrar will write to the certifying doctor if a GP, or to the patient’s consultant for hospital deaths, with a form requesting further details to be returned to ONS.
4.3 Avoid ‘old age’ alone
Old age, ‘senility’ or ‘frailty of old age’ should only be given as the sole cause of death in very limited circumstances. These are that:
• You have personally cared for the deceased over a long period (years, or many months)
• You have observed a gradual decline in your patient's general health and functioning
• You are not aware of any identifiable disease or injury that contributed to the death
• You are certain that there is no reason that the death should be reported to the
coroner
You may mention old age or frailty as a contributory cause, especially if it explains the severe effect of a condition that is not usually fatal. If the immediate cause of death was Covid-19 or its consequences, and the patient had no specific pre-existing health conditions, but appears to have been especially vulnerable to Covid-19 or its effects because of old age or frailty, it is appropriate to state old age or frailty as contributing to the death.
You should bear in mind that coroners, crematorium referees, registrars and organisations that regulate standards in health and social care, may ask you to support your statement with information from the patient's medical records and any investigations that might have a bearing on the cause of death. You should also be aware that the patient’s family may not regard old age as an adequate explanation for their relative’s death and may request further investigation.
It is unlikely that patients would be admitted to an acute hospital if they had no apparent disease or injury. It follows that deaths in acute hospitals are unlikely to fulfil the conditions above. You can specify old age as the underlying cause of death, but you should also mention in part one or part two, as appropriate, any medical or surgical conditions that may have contributed to the death.

Examples:
Ia. 1Pathological fractures of femoral neck and thoracic vertebrae
Ib. Severe osteoporosis
Ic. Old age
II. Fibrosing alveolitis
Ia. Old age Ib.
Ic.
II. Non-insulin dependent diabetes mellitus, essential hypertension and diverticular disease
Ia. Hypostatic pneumonia
Ib. Dementia
Ic. Old age
II.
While there is no statutory age limit or restriction on referring to ‘old age’, a death certified as due to old age or senility alone will usually be referred to the coroner, unless the deceased was 80 or older, all the conditions listed above are fulfilled and there is no other reason that the death should be referred. Similar terms, such as ‘frailty of old age’, will be treated in the same way.
4.4 Never use ‘natural causes’ alone
The term “natural causes” alone, with no specification of any disease on a doctor's MCCD, is not sufficient to allow the death to be registered without referral to the coroner. If you do not have any idea what disease caused your patient's death, it is up to the coroner to decide what investigations may be needed.
4.5 Avoid organ failure alone
Do not certify deaths as due to the failure of any organ without specifying the disease or condition that led to the organ failure. Failure of most organs can be due to unnatural causes, such as poisoning, injury or industrial disease. This means that the death will have to be referred to the coroner if no natural disease responsible for organ failure is specified.
Examples:
Ia. Renal failure
Ib. Necrotising-proliferative nephropathy
Ic. Systemic lupus erythematosus
II. Raynaud's phenomenon and vasculitis
Ia. Liver failure
Ib. Hepatocellular carcinoma
Ic. Chronic Hepatitis B infection
II. Congestive cardiac failure Essential hypertension

Conditions such as renal failure may come to medical attention for the first time in frail, elderly patients in whom vigorous investigation and treatment may be contraindicated, even though the cause is not known. When such a patient dies, you are advised to discuss the case with the coroner before certifying. If the coroner is satisfied that no further investigation is warranted, the registrar can be instructed to register the death based on the information available on the MCCD. The registrar cannot accept an MCCD that gives only organ failure as the cause of death without explicit instruction from the coroner.
4.6 Avoid physical and mental conditions which are not fatal in themselves
Long-term physical disabilities, mental health problems and learning difficulties (also known as learning disabilities or intellectual disabilities) are rarely sufficient medical explanation of the death in themselves. If such a condition is considered to be relevant, the more immediate mechanism(s) or train of events leading to death must be made clear.
Example (1): A person with learning difficulties may develop aspiration pneumonia. Aspiration pneumonia should be given as the immediate cause of death; the person's learning difficulties could be included in Part 2 of the certificate if thought to be a contributory factor, but not in Part 1, as having learning difficulties does not form a direct sequence of events to having pneumonia.
Example (2): A congenital syndrome which causes learning difficulties may also cause an organ defect which can lead to premature death. The organ failure should then be included in the certificate.
A description such as ‘learning difficulties’ should not be the only cause of death. You may give a degenerative condition such as Alzheimer’s disease as the only cause of death if the mechanism by which it caused death is unclear but it is fully supported by the clinical history as the underlying cause.
4.7 Avoid terminal events, modes of dying and other vague terms
Terms that do not identify a disease or pathological process clearly are not acceptable as the only cause of death. This includes terminal events, or modes of dying such as cardiac or respiratory arrest, syncope or shock. Very vague statements such as cardiovascular event or incident, debility or frailty are equally unacceptable. ‘Cardiovascular event’ could be intended to mean a stroke or myocardial infarction. It could, however, also include cardiac arrest or fainting, or a surgical or radiological procedure. If no clear disease can be identified as the cause of death, referral to the coroner will be necessary.

4.8 Never use abbreviations or symbols
Do not use abbreviations on death certificates. Their meaning may seem obvious to you in the context of your patient and their medical history, but it may not be clear to others. For example, does a death from “MI” refer to myocardial infarction or mitral incompetence? Is “RTI” a respiratory or reproductive tract infection, or a road traffic incident? The registrar should not accept a certificate that includes any abbreviations. (The only exceptions, which the registrar can accept, are HIV and AIDS for human immunodeficiency virus infection and acquired immune deficiency syndrome). You, or the patient's consultant, may be required to complete a new certificate with the conditions written out in full, before the death can be registered. This is inconvenient for you and for the family of the deceased. The same applies to medical symbols.
5. Specific causes of death
5.1 Stroke and cerebrovascular disorders
Give as much detail about the nature and site of the lesion as is available to you. For example, specify whether the cause was haemorrhage, thrombosis or embolism, and the specific artery involved, if known. Remember to include any antecedent conditions or treatments, such as atrial fibrillation, artificial heart valves, or anticoagulants that may have led to cerebral emboli or haemorrhage. Avoid the term “cerebrovascular accident” and consider using terms such as “stroke” or “cerebral infarction” if no more specific description can be given.
Examples:
Ia. Subarachnoid haemorrhage
Ib. Ruptured aneurysm of anterior communicating artery
Ic.
II.
Ia. Intraventricular haemorrhage
Ib. Warfarin anticoagulation
Ic. atrial fibrillation
II.
5.2 Neoplasms
Malignant neoplasms (cancers) remain a major cause of death. Accurate statistics are important for planning care and assessing the effects of changes in policy or practice. Where applicable, you should indicate whether a neoplasm was benign, malignant, or of uncertain behaviour. Please remember to specify the histological type and anatomical site of the cancer.
Example:
Ia. Carcinomatosis
Ib. Small cell carcinoma of left main bronchus
Ic. Heavy smoker for 40 years

II. Hypertension, cerebral arteriosclerosis, ischaemic heart disease.
You should make sure that there is no ambiguity about the primary site if both primary and secondary cancer sites are mentioned. Do not use the terms “metastatic” or “metastases” unless you specify whether you mean metastasis to, or metastasis from, the named site.
Examples:
Ia. Intraperitoneal haemorrhage
Ib. Metastases in liver
Ic. From primary adenocarcinoma of ascending colon
II. Non-insulin dependent diabetes mellitus
Ia. Pathological fractures of left shoulder, spine and shaft of right femur
Ib. Widespread skeletal secondaries
Ic. primary adenocarcinoma of breast
II. Hypercalcaemia
Ia. Lung metastases
Ib. From testicular teratoma
Ic.
II.
If you mention two sites that are independent primary malignant neoplasms, make that clear.
Example:
Ia. Ib. Ic.
II.
Massive haemoptysis
Primary small cell carcinoma of left main bronchus
Primary adenocarcinoma of prostate
If a patient has widespread metastases, but the primary site could not be determined, you should state this clearly.
Example:
Ia multiple organ failure
Ib. poorly differentiated metastases throughout abdominal cavity
Ic. unknown primary site
II.
If you do not yet know the cancer type and are expecting the result of histopathology,
11

indicate that this information may be available later by initialing box 'B' on the back of the certificate. You, or the consultant responsible for the patient's care, may be sent a letter requesting this information at a later date.
In the case of leukaemia, specify whether it is acute, sub-acute or chronic, and the cell type involved.
Example:
Ia. Neutropenic sepsis
Ib. Acute myeloid leukaemia
Ic.
II.
Ia. Haemorrhagic gastritis
Ib. Chronic lymphatic leukaemia
1c.
II. Myocardial ischaemia, valvular heart disease
5.3 Diabetes mellitus
Always remember to specify whether your patient’s diabetes was insulin dependent / Type I, or non-insulin dependent / Type II. If diabetes is the underlying cause of death, specify the complication or consequence that led to death, such as ketoacidosis.
Examples:
Ia. End-stage renal failure
Ib. Diabetic nephropathy
Ic. Insulin dependent diabetes mellitus
II.
Ia. Septicaemia - fully sensitive staphylococcus aureus
Ib. Gangrene of both feet due to peripheral vascular disease
Ic. Non-insulin-dependent diabetes mellitus
II. Ischaemic heart disease
5.4 Deaths involving infections and communicable diseases
Mortality data is important in the surveillance of infectious diseases, as well as monitoring the effectiveness of immunisation and other prevention programmes. If the patient's death involved a notifiable disease, you have a statutory duty to notify the proper officer for the area, unless the case has already been notified. This is normally a consultant in communicable disease control (CCDC) in your local Health Protection Team (HPT). If you are not sure whether a case is notifiable, you can get advice from
  • That Covid-19 is a notifiable disease under the Health Protection (Notification) Regulations 2010 does not mean referral to a coroner is required by virtue of its notifiable status.
• If you are aware that a virology test for Covid-19 has been carried out, state the result if known, for example ‘Covid-19 (positive test)’. However, certification should not be delayed to await the availability of test results.

your local HPT who will also advise on appropriate microbiological investigations. Further information about notification and surveillance of infectious diseases is available at https://www.gov.uk/government/collections/notifications-of-infectious-diseases-noids In deaths from infectious disease, you should state the manifestation or body site, e.g. pneumonia, pyelonephritis, hepatitis, meningitis, septicaemia, or wound infection. You should also specify, giving as much detail as is available:
• The infecting organism, e.g. pneumococcus, influenza A virus, meningococcus
• Antibiotic resistance, if relevant, e.g. meticillin resistant Staphylococcus
aureus (MRSA), or multiple drug resistant mycobacterium tuberculosis
• The source and/or route of infection, if known, e.g. food poisoning, needle sharing, contaminated blood products, post-operative, community or hospital acquired, or health care associated infection.
Example:
Ia. Bilateral pneumothoraces
Ib. Multiple bronchopulmonary fistulae
Ic. Extensive, cavitating pulmonary tuberculosis (smear and culture positive)
II. Iron deficiency anaemia; ventilator associated pseudomonas pneumonia
You need not delay completing the certificate until laboratory results are available, provided you are satisfied that the death need not be referred to the coroner. You should indicate, by ticking box 'B' on the back of the certificate, that further information may be available later. A letter may then be sent to you, or to the patient's consultant, requesting this information.
Failure to specify the infecting organism can lead to unnecessary investigation. For example, deaths are sometimes certified as being due to spinal or paraspinal abscess, without stating the organism(s) involved. These are then coded as tuberculosis following the ICD index and rules, which can lead to unnecessary efforts by the local CCDC to investigate the case.
Remember to specify any underlying disease that may have suppressed the patient's immunity or made them more susceptible to the infection that led to the death.
5.4.1 Health care associated infections
It is a matter for your clinical judgment whether a condition the patient had at death, or in the preceding period, contributed to their death, and so whether it should be included on the MCCD. However, families may be surprised if you do not include something that they believe contributed to their relative's death. ONS receives frequent queries from a wide range of sources about mortality related to health care associated infections, and complaints about the quality of information given about them on death certificates. Where infection does follow treatment, including surgery, radiotherapy, antineoplastic, immunosuppressive, antibiotic or other drug treatment for another disease, remember to specify the treatment and the disease for which it was given.
If a health care associated infection was part of the sequence leading to death, it should be in part I of the certificate, and you should include all the conditions in the sequence of events back to the original disease being treated.
 
Examples:
Ia. clostridium difficile pseudomembranous colitis
Ib. multiple antibiotic therapy
Ic. community acquired pneumonia with severe sepsis
II. immobility, Polymyalgia Rheumatica, Osteoporosis
Ia. bronchopneumonia (hospital acquired Meticillin Resistant Staph aureus)
Ib. multiple myeloma
Ic.
II. chronic obstructive airways disease
If your patient had an HCAI which was not part of the direct sequence, but which you think contributed at all to their death, it should be mentioned in part II
Ia. Carcinomatosis and renal failure
Ib. Adenocarcinoma of the prostate
Ic.
II. Chronic obstructive airways disease and catheter associated Escherichia coli urinary tract infection
5.4.2 Pneumonia
Pneumonia may present in previously fit adults, but often it occurs as a complication of another disease affecting the lungs, mobility, immunity, or swallowing. Pneumonia may also follow other infections and may be associated with treatment for disease, injury or poisoning, especially when ventilatory assistance is required. Remember to specify, where possible, whether it was lobar or bronchopneumonia and whether primarily hypostatic, or related to aspiration and the organism involved. You should include the whole sequence of conditions and events leading up to it. If known, specify whether the pneumonia was hospital or community acquired. If it was associated with mechanical ventilation, or invasive treatment, this should be clearly stated.
Example:
Ia. pneumococcal pneumonia
Ib. Influenza A
Ic.
II. Ischaemic heart disease
If you report bronchopneumonia, remember to include in the sequence in part I any predisposing conditions, especially those that may have led to paralysis, immobility, depressed immunity or wasting, as well as chronic respiratory conditions such as chronic bronchitis.
Example:
Ia. bronchopneumonia
Ib. immobility and wasting
Ic. Alzheimer’s disease
II.

5.5 Injuries and external causes
All deaths involving any form of injury or poisoning must be referred to the coroner. If the death is not one that must be certified by the coroner and s/he instructs you, as the patient’s clinician, to certify, remember to include details as to how the injury occurred and where it happened, such as at home, in the street, or at work.
Example:
Ia. Pulmonary embolism
Ib. Fractured neck of femur
Ic. Tripped on loose floor rug at home
II. Left sided weakness and difficulty with balance since haemorrhagic stroke 5 years ago; hemiarthroplasty 2 days after fracture
Remember to state clearly if a fracture was pathological, that is due to an underlying disease process such as a metastasis from a malignant neoplasm or osteoporosis.
5.6 Substance misuse
Deaths from diseases related to chronic alcohol or tobacco use need not be
referred to the coroner, provided the disease is clearly stated on the MCCD.
Example:
Ia. Ib. Ic.
II.
Ia. Ib. Ic.
II.
Carcinomatosis
Bronchogenic carcinoma upper lobe left lung Smoked 30 cigarettes a day
Chronic bronchitis and ischaemic heart disease.
hepatic encephalopathy alcoholic liver cirrhosis
difficult to control insulin dependent diabetes
Deaths due to acute or chronic poisoning, by any substance, and deaths involving drug dependence or misuse of substances other than alcohol and tobacco must be referred.
The General Register Office for England and Wales, which is part of Her Majesty’s Passport Office, is responsible for legislation relating to the registration of births, marriages, civil partnerships and deaths (www.gro.gov.uk/). Registration information is passed to the Office for National Statistics (ONS) who publish a wide range of mortality statistics (www.statistics.gov.uk) under the theme of ‘Health and Care’. ONS also distribute the registration information to the Department of Health, other government departments, WHO and other international organisations, the NHS, local authorities and academics. For more information email [email protected]
Coroners, forensic and general pathologists, general practitioners and medical specialists, epidemiologists and public health specialists, crematorium referees, the Coroner’s Society, Ministry of Justice , ONS, Department of Health and Identity and Passport Service contributed to the development of this guidance through the Death Certification Advisory Group (DCAG).
    

 

[roomark]

41 minutes ago, john luke said:

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/877302/guidance-for-doctors-completing-medical-certificates-of-cause-of-death-covid-19.pdf
 

  Guidance for doctors completing Medical Certificates of Cause of Death in England and Wales
FOR USE DURING THE EMERGENCY PERIOD ONLY
1. The purposes of death certification ...................................................................2
2. Who should certify the death?...........................................................................2
3. Referring deaths to the coroner.........................................................................3
4. How to complete the cause of death section.....................................................4
4.1 Sequence leading to death, underlying cause and contributory causes...........4 4.2 Results of investigations awaited .....................................................................7 4.3 Avoid ‘old age’ alone ........................................................................................7 4.4 Never use ‘natural causes’ alone .....................................................................8 4.5 Avoid organ failure alone..................................................................................8 4.6 Avoid physical and mental conditions which are not fatal in themselves..........9 4.7 Avoid terminal events, modes of dying and other vague terms ........................9 4.8 Never use abbreviations or symbols ..............................................................10
5. Specific causes of death .................................................................................10 5.1 Stroke and cerebrovascular disorders............................................................10 5.2 Neoplasms .....................................................................................................10 5.3 Diabetes mellitus............................................................................................12 5.4 Deaths involving infections and communicable diseases...............................12 5.5 Injuries and external causes...........................................................................15 5.6 Substance misuse..........................................................................................15
In an emergency period of the COVID-19 pandemic there is a relaxation of previous legislation concerning completion of the medical certificate cause of death (MCCD) by medical practitioners (referred to for the remainder of this document as doctor). The important changes occur in Sections 2 and 3 of this guidance. You should use standard guidance outside of the emergency period.
This guidance is intended to complement the notes for doctors in the front of every book of MCCDs. Those instructions remain current and doctors should familiarise themselves with the MCCD notes and consult them if they are in any doubt about whether, or how, to certify a death.
Those medical practitioners who have been appointed as medical examiners and also those appointed as medical examiner officers can provide resource to the death certification process where required in a period of emergency.
F66 Guidance

1. The purposes of death certification
Prompt and accurate certification of death is essential as it serves a number of functions. A medical certificate of cause of death (MCCD) enables the deceased’s family to register the death. This provides a permanent legal record of the fact of death and enables the family to arrange disposal of the body, and to settle the deceased’s estate.
A doctor who attended the deceased during their last illness has a legal responsibility to complete a MCCD and arrange for the transmission (electronic recommended) of it to the relevant registrar as soon as possible to enable the registration to take place this duty may be discharged through another doctor who may complete an MCCD in an emergency period. Deaths are required by law to be registered within 5 days of their occurrence unless there is to be a coroner’s post mortem or an inquest.
After registering the death, the family is provided with a certified copy of the register entry (“death certificate”), which includes an exact copy of the cause of death information that you give. This provides them with an explanation of how and why their relative died. It also gives them a permanent record of information about their family medical history, which may be important for their own health and that of future generations. For all of these reasons it is extremely important that you provide clear, accurate and complete information about the diseases or conditions that caused your patient’s death in a timely manner.
Information from death certificates is used to measure the relative contributions of different diseases to mortality. Statistical information on deaths by underlying cause is important for monitoring the health of the population, designing and evaluating public health interventions, recognising priorities for medical research and health services, planning health services, and assessing the effectiveness of those services. Death certificate data are extensively used in research into the health effects of exposure to a wide range of risk factors through the environment, work, medical and surgical care, and other sources.
In the emergency period, the registrar will accept a scanned (or photographed) and emailed copy of the completed MCCD. The email must be sent from a secure email address (for example NHS.net) to a secure email address (for example .gov.uk). The list of qualified informants includes a funeral director (where they are acting on behalf of the family). If the MCCD is scanned and emailed the original signed form should be securely retained and delivered to the registrar as soon as possible after the emergency period (this should be discussed and agreed with the registration service).
2. Who should certify the death?
In an emergency period, any doctor can complete the MCCD, when it is impractical for the attending doctor to do so. This may, for example, be when the attending doctor is self-isolating, unwell, or has pressure to attend patients. In these circumstances, it may be practical to allow a medical examiner or recently retired doctor returning to work to complete the MCCD.
There is no clear legal definition of “attended”, but it is generally accepted to mean a doctor who has cared for the patient during the illness that led to death and so is familiar with the patient’s medical history, investigations and treatment. For the purposes of the emergency period, the attendance may be in person, via video/visual consultation, but not audio (e.g. via telephone). The certifying doctor should also have

access to relevant medical records and the results of investigations. There is no provision in the emergency period to delegate this statutory duty to any non-medical practitioner.
Where the certifying doctor has not seen the deceased before death they should delete the words last seen alive by me on.
If the deceased has been seen before death by a doctor but not the certifying doctor, as well as signing the MCCD they should include the name of that doctor on the MCCD.
In hospital, there may be several doctors in a team caring for the patient. It is ultimately the responsibility of the consultant in charge of the patient's care to ensure that the death is properly certified. Any subsequent enquiries, such as for the results of post- mortem or ante-mortem investigations, will be addressed to the consultant.
In general practice, more than one GP may have been involved in the patient’s care and so be able to certify the death. In the emergency period, the same provisions to enable any doctor to certify the death prevail in general practice.
If no doctor has attended the deceased within 28 days of death (including video/visual consultation) or the deceased was not seen after death by a doctor, the MCCD can still be completed. However, the registrar will be obliged to refer the death to the coroner before it can be registered. In these circumstances, the coroner may instruct the registrar to accept the certifying doctor’s MCCD for registration.
Where a cause of death cannot be ascertained, the death cannot be certified, and the doctor should refer the death directly to the coroner with any supporting information. The coroner may from this information determine no investigation is needed and inform the registrar that the death can be registered. This information will be used for mortality statistics, but the death will be legally “uncertified” if the coroner does not investigate and make a determination as to the cause of death. However, once the registrar has received the coroner’s notification the death may be registered.
3.
• •
Referring deaths to the coroner
Covid-19 is an acceptable direct or underlying cause of death for the purposes of completing the Medical Certificate of Cause of Death
Covid-19 is not a reason on its own to refer a death to a coroner under the Coroners and Justice Act 2009.
 • That Covid-19 is a notifiable disease under the Health Protection (Notification) Regulations 2010 does not mean referral to a coroner is required by virtue of its notifiable status.
Medical practitioners are required to certify causes of death “to the best of their knowledge and belief”. Without diagnostic proof, if appropriate and to avoid delay, medical practitioners can circle ‘2’ in the MCCD (“information from post-mortem may be available later”) or tick Box B on the reverse of the MCCD for ante-mortem investigations. For example, if before death the patient had symptoms typical of COVID- 19 infection, but the test result has not been received, it would be satisfactory to give ‘COVID-19’ as the cause of death, tick Box B and then share the test result when it

becomes available. In the circumstances of there being no swab, it is satisfactory to apply clinical judgement.
Doctors and registrars of births and deaths have a legal obligation to report certain categories of deaths to the coroner before they can be registered. These include deaths where there is reason to suspect, the death was unnatural, unexplained, violent or where the death occurs in prison or otherwise in state detention. Deaths occurring during an operation, or before full recovery from an anaesthetic should also be referred In addition, there will always be cases which may on one view be ‘natural’ which have some other element (e.g. neglect concerns) which brings them within the orbit of the coroner. Deaths for which the cause is not known must be reported to the coroner. In the emergency period, if no doctor has attended the deceased within 28 days of death (including video/visual consultation) or the deceased was not seen after death by a doctor, the death must be referred to the coroner.
Strictly speaking, the law requires that an MCCD should be completed even when a death has been referred to the coroner. In practice, if the coroner has decided to order a post-mortem examination and/or to hold an inquest, he may tell a doctor not to complete the MCCD. However, the coroner can only legally certify the cause of death if he has investigated it through autopsy, inquest or both. This means that, if the coroner decides not to investigate, the registrar will need to obtain an MCCD from a doctor who attended the deceased before the death can be registered. This may cause inconvenience to you and the family, if you have not already provided one. This will avoid the death having to be registered as uncertified.
When a death is referred, it is up to the coroner to decide whether or not it should be investigated further. It is very important that the coroner is given all of the facts relevant to this decision. The doctor should discuss the case with the coroner before issuing an MCCD if at all uncertain whether he or she should certify the death. This allows the coroner to make enquiries and decide whether or not any further investigation is needed, before the family tries to register the death. The coroner may decide that the death can be registered from the doctor's MCCD. For example, around 60% of deaths with fractured neck of femur mentioned on the certificate are registered from the original MCCD following referral to the coroner (2016 figures). Omitting to mention on the certificate conditions or events that contributed to the death in order to avoid referral to the coroner is unacceptable and a breach of the doctor’s legal obligations. If these come to light when the family registers the death, the registrar will be obliged to refer it to the coroner. If the fact emerges after the death is registered, an inquest may still be held.
4. How to complete the cause of death section
 • COVID-19 is an acceptable direct or underlying cause of death for the purposes of completing the Medical Certificate of Cause of Death
• COVID-19 is not a reason on its own to refer a death to a coroner under the Coroners and Justice Act 2009.
• That COVID-19 is a notifiable disease under the Health Protection (Notification) Regulations 2010 does not mean referral to a coroner is required by virtue of its notifiable status.

Medical practitioners are required to certify causes of death “to the best of their knowledge and belief”. Without diagnostic proof, if appropriate and to avoid delay, medical practitioners can circle ‘2’ in the MCCD (“information from post-mortem may be available later”) or tick Box B on the reverse of the MCCD for ante-mortem investigations. For example, if before death the patient had symptoms typical of COVID- 19 infection, but the test result has not been received, it would be satisfactory to give ‘COVID-19’ as the cause of death, tick Box B and then share the test result when it becomes available. In the circumstances of there being no swab, it is satisfactory to apply clinical judgement.
As previously mentioned, doctors are expected to state the cause of death to the best of their knowledge and belief; they are not expected to be infallible. Even without any changes to the law, there is increased scrutiny of death certification and patterns of mortality by local and national agencies as a result of the Shipman Inquiry. Suspicions may be raised if death certificates appear to give inadequate or vague causes of death. For example, if a patient dies under the care of an orthopaedic surgeon, it might be expected that some orthopaedic condition contributed to the death and so this condition would be mentioned in part I or part II of the certificate. Similarly, it would be surprising if a patient was being treated in an acute hospital, but no significant disease or injury at all was mentioned on their death certificate.
The level of certainty as to the cause of death varies. What to do, depending on the degree of certainty or uncertainty about the exact cause of death, is discussed below.
4.1 Sequence leading to death, underlying cause and contributory causes
The MCCD is set out in two parts, in accordance with World Health Organisation (WHO) recommendations in the International Statistical Classification of Diseases and Related Health Problems (ICD). You are asked to start with the immediate, direct cause of death on line Ia, then to go back through the sequence of events or conditions that led to death on subsequent lines, until you reach the one that started the fatal sequence. If the certificate has been completed properly, the condition on the lowest completed line of part I will have caused all of the conditions on the lines above it. This initiating condition, on the lowest line of part I will usually be selected as the underlying cause of death, following the ICD coding rules. WHO defines the underlying cause of death as “a) the disease or injury which initiated the train of morbid events leading directly to death, or b) the circumstances of the accident or violence which produced the fatal injury”. From a public health point of view, preventing this first disease or injury will result in the greatest health gain. Most routine mortality statistics are based on the underlying cause. Underlying cause statistics are widely used to determine priorities for health service and public health programmes and for resource allocation. Remember that the underlying cause may be a longstanding, chronic disease or disorder that predisposed the patient to later fatal complications.
You should also enter any other diseases, injuries, conditions, or events that contributed to the death, but were not part of the direct sequence, in part two of the certificate. The conditions mentioned in part two must be known or suspected to have contributed to the death, not merely be other conditions which were present at the time.

Examples of cause of death section from MCCDs (including example of COVID-19 as underlying cause of death):
Cause of death the disease or condition thought to be the underlying cause should appear in the lowest completed line of part I
I
    (a) Disease or condition Interstitial pneumonitis leading directly to death
(b) other disease or condition,
if any, leading to I(a) COVID-19
(c) other disease or condition, primary adenocarcinoma of ascending colon if any, leading to I(b)
   II Other significant conditions Contributing to death but not related to the
disease or condition
causing it
diabetes mellitus
   Cause of death the disease or condition thought to be the underlying cause should appear in the lowest completed line of part I
I
II.
The colon cancer on line 1(c) led directly to the liver metastases on line 1(b), which ruptured, causing the fatal haemorrhage on 1(a). Adenocarcinoma of the colon is the underlying cause of death.
Cause of death the disease or condition thought to be the underlying cause should appear in the lowest completed line of part I
I
II Other significant conditions Contributing to death but not related to the disease or condition causing it
  (a) Disease or condition Intraperitoneal haemorrhage leading directly to death
(b) other disease or condition,
if any, leading to I(a) Ruptured metastatic deposit in liver
(c)other disease or condition,
if any, leading to I(b) primary adenocarcinoma of ascending colon
Other significant conditions Contributing to death but not
related to the disease or condition causing it
Non-insulin dependent diabetes
          (a) Disease or condition Cerebral infarction leading directly to death
 (b) other disease or condition, Thrombosis of basilar artery if any, leading to I(a)
 (c) other disease or condition, Cerebrovascular atherosclerosis if any, leading to I(b)
      
(In subsequent examples, to save space, the layout of the MCCD has not been reproduced. All examples are taken from actual MCCDs of deaths in England and Wales).
In some cases, a single disease may be wholly responsible for the death. In this case, it should be entered on line Ia.
Example:
Ia. Meningococcal septicaemia
Meningococcal septicaemia is the underlying cause of this death.
• More than three conditions in the sequence
The MCCD in use in England and Wales currently has 3 lines in part I for the sequence leading directly to death. If you want to include more than 3 steps in the sequence, you can do so by writing more than one condition on a line, indicating clearly that one is due to the next.
Example:
Ia. Post-transplant lymphoma
Ib. Immunosuppression following renal transplant 15 years ago
Ic. Glomerulonephrosis due to insulin dependent diabetes mellitus
II. Recurrent urinary tract infections
Insulin dependent diabetes with renal complications is the underlying cause.
• More than one disease may have led to death
If you know that your patient had more than one disease or condition that was compatible with the way in which he or she died, but you cannot say which was the most likely cause of death, you should include them all on the certificate. They should be written on the same line and you can indicate that you think they contributed equally by writing “joint causes of death” in brackets.
Examples:
Ia. Cardiorespiratory failure
Ib. Ischaemic heart disease and chronic obstructive airways disease
Ic.
II. Osteoarthritis
Ia. Hepatic failure
Ib. liver cirrhosis
Ic. Chronic hepatitis C infection and alcoholism (joint causes of death)
II.
Where more than one condition is given on the lowest used line of part 1, ONS will use the internationally agreed mortality coding rules in ICD-10 to select the underlying cause for routine mortality statistics.
Since 1993, ONS also code all the other conditions mentioned on the certificate. These multiple cause of death data are used by ONS in a variety of routine and ad hoc analyses, and can be made available for research in some circumstances. Multiple

cause data provides useful additional information on the mortality burden associated with diseases that are not often selected as the main cause of death. For example, conditions that are very often complications of another disease or its treatment, such as deep vein thrombosis / pulmonary embolism or health care associated infections should rarely be the underlying cause of death. Their contribution to mortality is better estimated from multiple cause data. In contrast to the above, if you do not know that your patient actually had any specific disease compatible with the mode and circumstances of death, you must refer the death to the coroner. For example, if your patient died after the sudden onset of chest pain that lasted several hours and you have no way of knowing whether he or she may have had a myocardial infarct, a pulmonary embolus, a thoracic aortic dissection, or another pathology, it is up to the coroner to decide what investigations to pursue.

4.2 Results of investigations awaited
If in broad terms you know the disease that caused your patient’s death, but you are awaiting the results of laboratory investigation for further detail, you need not delay completing the MCCD. For example, a death can be certified as bacterial meningitis once the diagnosis is firmly established, even though the organism may not yet have been identified. Similarly, a death from cancer can be certified as such while still awaiting detailed histopathology. This allows the family to register the death and arrange the funeral. However, you should indicate clearly on the MCCD that information from investigations might be available later. You can do this by circling ‘2’ on the front of the MCCD for autopsy information, or by ticking box ‘B’ on the back of the certificate for results of investigations initiated ante-mortem. It is important for public health surveillance to have this information on a national basis; for example, to know how many meningitis and septicaemia deaths are due to meningococcus, or to other bacterial infections. The registrar will write to the certifying doctor if a GP, or to the patient’s consultant for hospital deaths, with a form requesting further details to be returned to ONS.
4.3 Avoid ‘old age’ alone
Old age, ‘senility’ or ‘frailty of old age’ should only be given as the sole cause of death in very limited circumstances. These are that:
• You have personally cared for the deceased over a long period (years, or many months)
• You have observed a gradual decline in your patient's general health and functioning
• You are not aware of any identifiable disease or injury that contributed to the death
• You are certain that there is no reason that the death should be reported to the
coroner
You may mention old age or frailty as a contributory cause, especially if it explains the severe effect of a condition that is not usually fatal. If the immediate cause of death was Covid-19 or its consequences, and the patient had no specific pre-existing health conditions, but appears to have been especially vulnerable to Covid-19 or its effects because of old age or frailty, it is appropriate to state old age or frailty as contributing to the death.
You should bear in mind that coroners, crematorium referees, registrars and organisations that regulate standards in health and social care, may ask you to support your statement with information from the patient's medical records and any investigations that might have a bearing on the cause of death. You should also be aware that the patient’s family may not regard old age as an adequate explanation for their relative’s death and may request further investigation.
It is unlikely that patients would be admitted to an acute hospital if they had no apparent disease or injury. It follows that deaths in acute hospitals are unlikely to fulfil the conditions above. You can specify old age as the underlying cause of death, but you should also mention in part one or part two, as appropriate, any medical or surgical conditions that may have contributed to the death.

Examples:
Ia. 1Pathological fractures of femoral neck and thoracic vertebrae
Ib. Severe osteoporosis
Ic. Old age
II. Fibrosing alveolitis
Ia. Old age Ib.
Ic.
II. Non-insulin dependent diabetes mellitus, essential hypertension and diverticular disease
Ia. Hypostatic pneumonia
Ib. Dementia
Ic. Old age
II.
While there is no statutory age limit or restriction on referring to ‘old age’, a death certified as due to old age or senility alone will usually be referred to the coroner, unless the deceased was 80 or older, all the conditions listed above are fulfilled and there is no other reason that the death should be referred. Similar terms, such as ‘frailty of old age’, will be treated in the same way.
4.4 Never use ‘natural causes’ alone
The term “natural causes” alone, with no specification of any disease on a doctor's MCCD, is not sufficient to allow the death to be registered without referral to the coroner. If you do not have any idea what disease caused your patient's death, it is up to the coroner to decide what investigations may be needed.
4.5 Avoid organ failure alone
Do not certify deaths as due to the failure of any organ without specifying the disease or condition that led to the organ failure. Failure of most organs can be due to unnatural causes, such as poisoning, injury or industrial disease. This means that the death will have to be referred to the coroner if no natural disease responsible for organ failure is specified.
Examples:
Ia. Renal failure
Ib. Necrotising-proliferative nephropathy
Ic. Systemic lupus erythematosus
II. Raynaud's phenomenon and vasculitis
Ia. Liver failure
Ib. Hepatocellular carcinoma
Ic. Chronic Hepatitis B infection
II. Congestive cardiac failure Essential hypertension

Conditions such as renal failure may come to medical attention for the first time in frail, elderly patients in whom vigorous investigation and treatment may be contraindicated, even though the cause is not known. When such a patient dies, you are advised to discuss the case with the coroner before certifying. If the coroner is satisfied that no further investigation is warranted, the registrar can be instructed to register the death based on the information available on the MCCD. The registrar cannot accept an MCCD that gives only organ failure as the cause of death without explicit instruction from the coroner.
4.6 Avoid physical and mental conditions which are not fatal in themselves
Long-term physical disabilities, mental health problems and learning difficulties (also known as learning disabilities or intellectual disabilities) are rarely sufficient medical explanation of the death in themselves. If such a condition is considered to be relevant, the more immediate mechanism(s) or train of events leading to death must be made clear.
Example (1): A person with learning difficulties may develop aspiration pneumonia. Aspiration pneumonia should be given as the immediate cause of death; the person's learning difficulties could be included in Part 2 of the certificate if thought to be a contributory factor, but not in Part 1, as having learning difficulties does not form a direct sequence of events to having pneumonia.
Example (2): A congenital syndrome which causes learning difficulties may also cause an organ defect which can lead to premature death. The organ failure should then be included in the certificate.
A description such as ‘learning difficulties’ should not be the only cause of death. You may give a degenerative condition such as Alzheimer’s disease as the only cause of death if the mechanism by which it caused death is unclear but it is fully supported by the clinical history as the underlying cause.
4.7 Avoid terminal events, modes of dying and other vague terms
Terms that do not identify a disease or pathological process clearly are not acceptable as the only cause of death. This includes terminal events, or modes of dying such as cardiac or respiratory arrest, syncope or shock. Very vague statements such as cardiovascular event or incident, debility or frailty are equally unacceptable. ‘Cardiovascular event’ could be intended to mean a stroke or myocardial infarction. It could, however, also include cardiac arrest or fainting, or a surgical or radiological procedure. If no clear disease can be identified as the cause of death, referral to the coroner will be necessary.

4.8 Never use abbreviations or symbols
Do not use abbreviations on death certificates. Their meaning may seem obvious to you in the context of your patient and their medical history, but it may not be clear to others. For example, does a death from “MI” refer to myocardial infarction or mitral incompetence? Is “RTI” a respiratory or reproductive tract infection, or a road traffic incident? The registrar should not accept a certificate that includes any abbreviations. (The only exceptions, which the registrar can accept, are HIV and AIDS for human immunodeficiency virus infection and acquired immune deficiency syndrome). You, or the patient's consultant, may be required to complete a new certificate with the conditions written out in full, before the death can be registered. This is inconvenient for you and for the family of the deceased. The same applies to medical symbols.
5. Specific causes of death
5.1 Stroke and cerebrovascular disorders
Give as much detail about the nature and site of the lesion as is available to you. For example, specify whether the cause was haemorrhage, thrombosis or embolism, and the specific artery involved, if known. Remember to include any antecedent conditions or treatments, such as atrial fibrillation, artificial heart valves, or anticoagulants that may have led to cerebral emboli or haemorrhage. Avoid the term “cerebrovascular accident” and consider using terms such as “stroke” or “cerebral infarction” if no more specific description can be given.
Examples:
Ia. Subarachnoid haemorrhage
Ib. Ruptured aneurysm of anterior communicating artery
Ic.
II.
Ia. Intraventricular haemorrhage
Ib. Warfarin anticoagulation
Ic. atrial fibrillation
II.
5.2 Neoplasms
Malignant neoplasms (cancers) remain a major cause of death. Accurate statistics are important for planning care and assessing the effects of changes in policy or practice. Where applicable, you should indicate whether a neoplasm was benign, malignant, or of uncertain behaviour. Please remember to specify the histological type and anatomical site of the cancer.
Example:
Ia. Carcinomatosis
Ib. Small cell carcinoma of left main bronchus
Ic. Heavy smoker for 40 years

II. Hypertension, cerebral arteriosclerosis, ischaemic heart disease.
You should make sure that there is no ambiguity about the primary site if both primary and secondary cancer sites are mentioned. Do not use the terms “metastatic” or “metastases” unless you specify whether you mean metastasis to, or metastasis from, the named site.
Examples:
Ia. Intraperitoneal haemorrhage
Ib. Metastases in liver
Ic. From primary adenocarcinoma of ascending colon
II. Non-insulin dependent diabetes mellitus
Ia. Pathological fractures of left shoulder, spine and shaft of right femur
Ib. Widespread skeletal secondaries
Ic. primary adenocarcinoma of breast
II. Hypercalcaemia
Ia. Lung metastases
Ib. From testicular teratoma
Ic.
II.
If you mention two sites that are independent primary malignant neoplasms, make that clear.
Example:
Ia. Ib. Ic.
II.
Massive haemoptysis
Primary small cell carcinoma of left main bronchus
Primary adenocarcinoma of prostate
If a patient has widespread metastases, but the primary site could not be determined, you should state this clearly.
Example:
Ia multiple organ failure
Ib. poorly differentiated metastases throughout abdominal cavity
Ic. unknown primary site
II.
If you do not yet know the cancer type and are expecting the result of histopathology,
11

indicate that this information may be available later by initialing box 'B' on the back of the certificate. You, or the consultant responsible for the patient's care, may be sent a letter requesting this information at a later date.
In the case of leukaemia, specify whether it is acute, sub-acute or chronic, and the cell type involved.
Example:
Ia. Neutropenic sepsis
Ib. Acute myeloid leukaemia
Ic.
II.
Ia. Haemorrhagic gastritis
Ib. Chronic lymphatic leukaemia
1c.
II. Myocardial ischaemia, valvular heart disease
5.3 Diabetes mellitus
Always remember to specify whether your patient’s diabetes was insulin dependent / Type I, or non-insulin dependent / Type II. If diabetes is the underlying cause of death, specify the complication or consequence that led to death, such as ketoacidosis.
Examples:
Ia. End-stage renal failure
Ib. Diabetic nephropathy
Ic. Insulin dependent diabetes mellitus
II.
Ia. Septicaemia - fully sensitive staphylococcus aureus
Ib. Gangrene of both feet due to peripheral vascular disease
Ic. Non-insulin-dependent diabetes mellitus
II. Ischaemic heart disease
5.4 Deaths involving infections and communicable diseases
Mortality data is important in the surveillance of infectious diseases, as well as monitoring the effectiveness of immunisation and other prevention programmes. If the patient's death involved a notifiable disease, you have a statutory duty to notify the proper officer for the area, unless the case has already been notified. This is normally a consultant in communicable disease control (CCDC) in your local Health Protection Team (HPT). If you are not sure whether a case is notifiable, you can get advice from
  • That Covid-19 is a notifiable disease under the Health Protection (Notification) Regulations 2010 does not mean referral to a coroner is required by virtue of its notifiable status.
• If you are aware that a virology test for Covid-19 has been carried out, state the result if known, for example ‘Covid-19 (positive test)’. However, certification should not be delayed to await the availability of test results.

your local HPT who will also advise on appropriate microbiological investigations. Further information about notification and surveillance of infectious diseases is available at https://www.gov.uk/government/collections/notifications-of-infectious-diseases-noids In deaths from infectious disease, you should state the manifestation or body site, e.g. pneumonia, pyelonephritis, hepatitis, meningitis, septicaemia, or wound infection. You should also specify, giving as much detail as is available:
• The infecting organism, e.g. pneumococcus, influenza A virus, meningococcus
• Antibiotic resistance, if relevant, e.g. meticillin resistant Staphylococcus
aureus (MRSA), or multiple drug resistant mycobacterium tuberculosis
• The source and/or route of infection, if known, e.g. food poisoning, needle sharing, contaminated blood products, post-operative, community or hospital acquired, or health care associated infection.
Example:
Ia. Bilateral pneumothoraces
Ib. Multiple bronchopulmonary fistulae
Ic. Extensive, cavitating pulmonary tuberculosis (smear and culture positive)
II. Iron deficiency anaemia; ventilator associated pseudomonas pneumonia
You need not delay completing the certificate until laboratory results are available, provided you are satisfied that the death need not be referred to the coroner. You should indicate, by ticking box 'B' on the back of the certificate, that further information may be available later. A letter may then be sent to you, or to the patient's consultant, requesting this information.
Failure to specify the infecting organism can lead to unnecessary investigation. For example, deaths are sometimes certified as being due to spinal or paraspinal abscess, without stating the organism(s) involved. These are then coded as tuberculosis following the ICD index and rules, which can lead to unnecessary efforts by the local CCDC to investigate the case.
Remember to specify any underlying disease that may have suppressed the patient's immunity or made them more susceptible to the infection that led to the death.
5.4.1 Health care associated infections
It is a matter for your clinical judgment whether a condition the patient had at death, or in the preceding period, contributed to their death, and so whether it should be included on the MCCD. However, families may be surprised if you do not include something that they believe contributed to their relative's death. ONS receives frequent queries from a wide range of sources about mortality related to health care associated infections, and complaints about the quality of information given about them on death certificates. Where infection does follow treatment, including surgery, radiotherapy, antineoplastic, immunosuppressive, antibiotic or other drug treatment for another disease, remember to specify the treatment and the disease for which it was given.
If a health care associated infection was part of the sequence leading to death, it should be in part I of the certificate, and you should include all the conditions in the sequence of events back to the original disease being treated.
 
Examples:
Ia. clostridium difficile pseudomembranous colitis
Ib. multiple antibiotic therapy
Ic. community acquired pneumonia with severe sepsis
II. immobility, Polymyalgia Rheumatica, Osteoporosis
Ia. bronchopneumonia (hospital acquired Meticillin Resistant Staph aureus)
Ib. multiple myeloma
Ic.
II. chronic obstructive airways disease
If your patient had an HCAI which was not part of the direct sequence, but which you think contributed at all to their death, it should be mentioned in part II
Ia. Carcinomatosis and renal failure
Ib. Adenocarcinoma of the prostate
Ic.
II. Chronic obstructive airways disease and catheter associated Escherichia coli urinary tract infection
5.4.2 Pneumonia
Pneumonia may present in previously fit adults, but often it occurs as a complication of another disease affecting the lungs, mobility, immunity, or swallowing. Pneumonia may also follow other infections and may be associated with treatment for disease, injury or poisoning, especially when ventilatory assistance is required. Remember to specify, where possible, whether it was lobar or bronchopneumonia and whether primarily hypostatic, or related to aspiration and the organism involved. You should include the whole sequence of conditions and events leading up to it. If known, specify whether the pneumonia was hospital or community acquired. If it was associated with mechanical ventilation, or invasive treatment, this should be clearly stated.
Example:
Ia. pneumococcal pneumonia
Ib. Influenza A
Ic.
II. Ischaemic heart disease
If you report bronchopneumonia, remember to include in the sequence in part I any predisposing conditions, especially those that may have led to paralysis, immobility, depressed immunity or wasting, as well as chronic respiratory conditions such as chronic bronchitis.
Example:
Ia. bronchopneumonia
Ib. immobility and wasting
Ic. Alzheimer’s disease
II.

5.5 Injuries and external causes
All deaths involving any form of injury or poisoning must be referred to the coroner. If the death is not one that must be certified by the coroner and s/he instructs you, as the patient’s clinician, to certify, remember to include details as to how the injury occurred and where it happened, such as at home, in the street, or at work.
Example:
Ia. Pulmonary embolism
Ib. Fractured neck of femur
Ic. Tripped on loose floor rug at home
II. Left sided weakness and difficulty with balance since haemorrhagic stroke 5 years ago; hemiarthroplasty 2 days after fracture
Remember to state clearly if a fracture was pathological, that is due to an underlying disease process such as a metastasis from a malignant neoplasm or osteoporosis.
5.6 Substance misuse
Deaths from diseases related to chronic alcohol or tobacco use need not be
referred to the coroner, provided the disease is clearly stated on the MCCD.
Example:
Ia. Ib. Ic.
II.
Ia. Ib. Ic.
II.
Carcinomatosis
Bronchogenic carcinoma upper lobe left lung Smoked 30 cigarettes a day
Chronic bronchitis and ischaemic heart disease.
hepatic encephalopathy alcoholic liver cirrhosis
difficult to control insulin dependent diabetes
Deaths due to acute or chronic poisoning, by any substance, and deaths involving drug dependence or misuse of substances other than alcohol and tobacco must be referred.
The General Register Office for England and Wales, which is part of Her Majesty’s Passport Office, is responsible for legislation relating to the registration of births, marriages, civil partnerships and deaths (www.gro.gov.uk/). Registration information is passed to the Office for National Statistics (ONS) who publish a wide range of mortality statistics (www.statistics.gov.uk) under the theme of ‘Health and Care’. ONS also distribute the registration information to the Department of Health, other government departments, WHO and other international organisations, the NHS, local authorities and academics. For more information email [email protected]
Coroners, forensic and general pathologists, general practitioners and medical specialists, epidemiologists and public health specialists, crematorium referees, the Coroner’s Society, Ministry of Justice , ONS, Department of Health and Identity and Passport Service contributed to the development of this guidance through the Death Certification Advisory Group (DCAG).
    

 

Christ John I've just gone dizzy 🤣

[Mr. Smooth]

^^^^^

FFS....you mean if a bloke took a wack to the temple from a 7 iron and that blow sent him to his final reward at the St. Peter Royal and Ancient, the doctor needs to read through all that gibberish to list the cause of death?

 

[roobob]

18 hours ago, fygjam said:

Oh dear, laugh of the day is correct.

Who doesn't know how to refine a search in a search engine?

https://www.google.com/search?q=Izumi+Kimura+university+of+tokyo&spell=1&sa=X&ved=2ahUKEwiWjc6Cu4n2AhXDUGwGHSdwCrYQBSgAegQIARAy&biw=2560&bih=1309

Now see if you can find the correct Hesham Nasser, you obviously need the practice.

The google roob..

Tell us how the number of papers each has published compares to your endeavors.

 

 

 

 

 

lol.....you have come up with the trifecta in spreading your false news.....lol

Your "experts" are a glorified teacher with no scientific papers published...a Japanese piano player....and a You tuber...lol.

Your on a roll.... keep them coming.... 🤣 🤣 🤣

cheers

[Krapow]

41 minutes ago, fygjam said:

Ok, you're quoted. Happy now?

But seeing as your so close to the coal face perhaps you could acquaint us with the requirements for doctors signing death certificates.

Are doctors required to apportion the cause of a persons death, say 10% old age, 20% heart, 30% smoking, 40% cancer etc.

Or

Are doctors required to list a single cause of death which, in the doctors expert opinion, is the primary reason that the deceased is deceased.

Now I'm going to go out on a limb here and say I suspect it is the latter. Thus those where the cause of death is listed as Covid, died because of Covid and not because they died with Covid.

If you have information to the contrary then you should be blowing the whistle on those miscreants corrupting the official  statistics.

 

While I have your attention.

In an earlier post I supplied the link to the study of the BA.2 variant. I have read the paper and for the life of me I couldn't detect the "pishy" bits. Maybe you could point them out for me. Perhaps it's my Lefty viewpoint but it looked like a fairly standard research paper to me.

What we did.

How we did it.

What we found.

Our conclusions.

I will agree that to solely rely on the popular media for Covid facts, you're being a fool to yourself and a burden to others. That's why I try to look behind the media. Imagine relying for information on The Today Show and Karl Stefanovic.

 

 

Sigh!

In the UK the daily reported covid deaths get presented as such - 'Deaths for any reason within 28 days of a positive Covid test'. 

Fact, they actually now tell you that each day. 

Now, have a wee think about that, or get an adult to explain it to you.

Anything else, see my post after the one where you thankfully grew a set and quoted me, instead of being a little snide. I'm currently on holiday out enjoying myself. You can carry on being whipped up into hysteria all you want, some of us are just getting on and enjoying life now. Omicron has changed everything, no matter If some are in denial or can't accept that. 

No idea what you're going about, about a link you posted to me. Though if it's about Omicron or the 'new/not so new variant' of it, you can continue being a Karen all you want. Your partisan Lefty viewpoint dictates how you see and continue to see things, you seek confirmation bias. 

No idea what the Today Show or Karl whatever is, never heard of either. Most of my info I get from Health Consultants I work with who have pretty much been doing nothing else but Covid for the past two years, nevermind their whole working life being involved in Public Health issues. 

Now, this all started with your snide remark, and while I appreciate your life must be pretty boring that you can be bothered continually involving yourself in these tedious 'back and forths' on this thread, mine isn't! 

Crack on Karen, I'm away to the pool, which isn't a bed temp for Feb, maybe then a sauna, decide what a la carte to go to later. Here for another good few days, I'll leave you to it, toodle pip ...

[Kathmandu]

14 hours ago, Krapow said:

Well no, this is how things gets 'misinterpreted' shall we say. 

The reason case numbers have went up in Denmark is because they lifted all restrictions 3weeks ago.

Well, the Johns Hopkins study, quoted earlier in this thread and latched onto by our deniers on the board said that lockdowns and other mitigation efforts had no effect. Are you now saying that it did have an effect?

 

14 hours ago, Krapow said:

The 'New variant' that some are reporting as some new deadly threat, has been in Denmark for ages, likewise S.Africa. If it was the cause of a rise in cases, deaths etc, it would have happened ages ago. It didn't, as it's not the case. 

Ages? It's been 2 months. We are only now seeing the results and it does not look good. Plenty of folks die from Covid and hang on for a lot longer than that.

14 hours ago, Krapow said:

Denmark are also currently actually at pains to point out the numbers being used in regards to hospitalisations and deaths by lefty leaning advocates, are those WITH covid, not BECAUSE OF covid. Big difference, especially Omicron being so transmissible.

So they would have died anyway? What part did Covid play? As I understand it, Covid can lead to some really nasty outcomes, especially with those that have pre-existing conditions. Sans Covid they probably would have survived.

14 hours ago, Krapow said:

 Big difference, especially Omicron being so transmissible.

Now you're making some sense. The sheer number of cases has led to an increase in deaths. We see that here in the USA and elsewhere.

 

[Kathmandu]

43 minutes ago, Mr. Smooth said:

^^^^^

FFS....you mean if a bloke took a wack to the temple from a 7 iron and that blow sent him to his final reward at the St. Peter Royal and Ancient, the doctor needs to read through all that gibberish to list the cause of death?

 

 

40 minutes ago, roobob said:

lol.....you have come up with the trifecta in spreading your false news.....lol

Your "experts" are a glorified teacher with no scientific papers published...a Japanese piano player....and a You tuber...lol.

Your on a roll.... keep them coming.... 🤣 🤣 🤣

cheers

Didn't take long for the peanut gallery to weigh in. 

Gotta hand it to you guys, it's cheap entertainment!! lol

[KWA]

1 hour ago, fygjam said:

Are doctors required to apportion the cause of a persons death, say 10% old age, 20% heart, 30% smoking, 40% cancer etc.

Or

Are doctors required to list a single cause of death which, in the doctors expert opinion, is the primary reason that the deceased is deceased.

Now I'm going to go out on a limb here and say I suspect it is the latter. Thus those where the cause of death is listed as Covid, died because of Covid and not because they died with Covid.

The one time that Google could have saved you from looking foolish and you failed to use it.

Covid is a notifiable disease and must be mentioned (if present in the last 28 days) on the death certificate.  Even if it's not in this section there's another bit particularly for notifiable diseases.

[galenkia]

1 hour ago, Mr. Smooth said:

^^^^^

FFS....you mean if a bloke took a wack to the temple from a 7 iron and that blow sent him to his final reward at the St. Peter Royal and Ancient, the doctor needs to read through all that gibberish to list the cause of death?

 

He better hope he don't test positive as he will have died from COVID. Nobody seems to have died from old age, clinical illness etc in the last 2 years. 

[Nightcrawler]

I think it is far too early to start doing Post Mortems only the Covid pandemic as the patient (Covid ) is still very much alive.

What was done or should have been, what worked and what didn't work will probably be the subject of discussion for sometime to come, but none of actual know with any certainly at this stage.

Blame the Media,blame Governments, blame Scientists, blame Social Media, blame the People, blame big Biotech etc etc etc

We all have access to information, or disinformation and make a choice as to which we want  to believe, often based on our own preconceived notions or ideas.

Places like Denmark and Hong Kong are going back to Lockdown and Covid restrictions as their numbers grow,whilst places such as UK have lifted most restrictions. 

Personally,I look at it this way...............

Whilst I have my own opinions, but I am not a qualified expert in virology, I am not a politician, I am not a conspiracy theorists nor a freedom fighter for civil liberties. 

I think that it is pretty futile a this stage to argue over the handling of a Virus which is still at large and affecting large numbers of people across to he globe. We cannot simply assume to hat it's all over. But we must hope that it is. We must also hope that further more deadly and infectious strains of the virus do not emerge. We simply don't know. 

What I do know. Without to he need to quote Media or scientific research,is that PEOPLE are responsible for the spread of contagious viruses. They come knocking at our door. 

What is obvious,is that Covid relies on human contact to grow and survive.  Lockdowns worked as an interim solution for reducing numbers of infected people,which in turn would reduce the numbers of hospitalisations and deaths related to Covid symptoms, particularly during the first two waves of Covid. 

Omicron and it's sub variant are now the most common and less potent that previous strains. Therefore,whilst infections are still high, the symptoms are less damaging,especially for those who have been vaccinated. 

We are living with the virus, but different countries are at different stages and Covid looks like it will be here to stay for some time. But during that time. However long that may be. New treatments are and will be developed to treat severe cases in the most vulnerable, whilst herd immunity continues in others.

What happens if more mutations occur that are more severe and worst than Delta? The answer is that none of us really know

That is not doom and gloom, it is just a possible scenario that we should not ignore. 

For now it seems likely that we can live with Omicron and that it's infection rates and associated deaths and hospitalisations with gradually reduce across the world. 

In my opinion,we should rejoice as restrictions are lifted, but not take them for granted. It's not over until it's over.

We were asked to make sacrifices, whether that be vaccination, wearing face protections, self isolation and social distancing etc. Most of us have complied, one way or another.

Let's hope that all of these things have been  worthwhile  doing at the time or currently, and I think they were or still are, to different degrees. Nothing to do with politics either. 

[bob lt]

9 minutes ago, galenkia said:

He better hope he don't test positive as he will have died from COVID. Nobody seems to have died from old age, clinical illness etc in the last 2 years. 

I don't suppose it will make much difference to him.

"When you're dead, you're dead. That's it."   Marlene Dietrich.

Or to quote Guy Martin  

[Krapow]

45 minutes ago, Kathmandu said:

Well, the Johns Hopkins study, quoted earlier in this thread and latched onto by our deniers on the board said that lockdowns and other mitigation efforts had no effect. Are you now saying that it did have an effect?

 

Ages? It's been 2 months. We are only now seeing the results and it does not look good. Plenty of folks die from Covid and hang on for a lot longer than that.

So they would have died anyway? What part did Covid play? As I understand it, Covid can lead to some really nasty outcomes, especially with those that have pre-existing conditions. Sans Covid they probably would have survived.

Now you're making some sense. The sheer number of cases has led to an increase in deaths. We see that here in the USA and elsewhere.

 

Okay, last post on this, as clearly some are either unwilling or incapable of judging a situation on it's own merits, not from a left or right, partisan viewpoint.

1) No idea why you're posting to me about the John Hopkins article, I didn't pass comment on that. Well actually I do know why you are, but it just reinforces what I said about some being incapable of seeing past everything having to be left or right. 

For clarity, I didn't pass comment as clearly it was not true, and anyone who genuinely thinks lockdowns had no impact on reducing infections and deaths, is off their head! 

2) Well actually it's longer than 2 months, it near the end of Feb, and the 'new variant' was already dominant in Denmark by early Jan. But no matter, with it being so transmissible the impact would have been seen quite a while before now. It was the full opening up 3 weeks ago that caused the spike, as any full opening up would do, as has been seen in the UK. Though again, when you use percentages when the actual numbers are so low, it looks more dramatic and no doubt done for effect. Go look at the average actual weekly deaths in Denmmark for people with Covid. Small would be an understatement.

3) Already answered this above.

4) Sure if you have more infections you'll have more deaths, and with any infection that can kill. But Omicron is very mild for the vast, vast majority of people. The reaction to it has to proportional. 

I remember saying in December that I didn't see any justification for another lockdown for Omicron, nor did I think one would happen, at least in the UK. You then called me gullible. 

Now, having a nice strawberry virgin mojito by the pool. You crazy kids can continue arguing all you want, I fully understood and agreed with the covid restrictions placed on us before, Indeed got into many arguments with the likes of Bruce Mango and similar about them, the old scoundrel, I love him really. But again, Omicron has changed things, so my viewpoint has also changed, as IMO any rational chap of sound mind and not blinkered by partisan stances would do, look at any given situation rationally. 

Lar gone.