A patient dies in hospital. He had a stroke three months ago which left him bed-bound, and he died of pneumonia. How should Part I of the death certificate read? ANSWER: work from the IMMEDIATE cause backwards to the UNDERLYING cause. Line (a) Pneumonia ← immediate cause Line (b) Immobility Line (c) Cerebrovascular accident ← UNDERLYING cause, last line The UNDERLYING cause is the condition that started the sequence, and it is what national mortality statistics count. Its position on the last used line is therefore not a formality. PART II would carry contributing conditions that were not part of this chain — for example diabetes impairing healing.

Why is "cardiac arrest" unacceptable as a cause of death? ANSWER: because it is a MODE of dying, not a cause. Every death involves the heart stopping. Writing "cardiac arrest" states only that the person died — it conveys no information about WHY. The certificate asks what caused the heart to stop. SAME ERROR: "respiratory failure", "asystole", "brain death", "old age". CONSEQUENCE: a certificate completed this way corrupts national mortality statistics and may conceal a cause that should have been investigated.

You examine a man with injuries after an alleged assault. Which of the following belongs in your notes? A. "Entry wound on the left arm" B. "Defence injuries to both forearms" C. "4 cm linear laceration, left forearm, 6 cm distal to the elbow crease, clean edges" D. "Injuries consistent with assault" ANSWER: C. Why: it DESCRIBES — site measured from a fixed landmark, size, shape and the character of the edges. It states what you observed. A, B and D are INTERPRETATIONS of how the injuries were caused. They are frequently wrong, they are the court's job rather than yours, and once written into a legal file they acquire an authority they do not deserve — potentially contributing to a wrongful conviction or acquittal.

A colleague asks you to estimate the age of a bruise from its colour for a police report. What is the correct response? ANSWER: decline — colour is an unreliable guide to the age of a bruise. Bruises of identical age look different depending on depth, site, skin tone and individual variation. The traditional colour sequence is not supported well enough to testify to. WHY IT MATTERS: it is one of the first things a competent lawyer will challenge, and a doctor who has testified to it can be shown to have claimed more than medicine can deliver — which undermines the rest of their evidence. CORRECT APPROACH: describe the colour as observed, and do not convert it into a time.

Which of these deaths may you certify yourself? A. A man who dies of complications of a femoral fracture sustained in an assault four months ago B. A woman found dead at home with no known illness C. A man with known metastatic lung cancer who dies on the ward as expected D. A patient who dies during an operation ANSWER: C — the expected death of a patient whose cause you know. Why the others must be REFERRED: A: the death is UNNATURAL. It remains so even though the causative event was four months ago. B: UNEXPLAINED — "I do not know why this person died" is a referral, not a guess. D: death during or shortly after a procedure. THE PRESSURE TO GET THIS WRONG IS REAL: the family wants to proceed with the funeral and referral means delay. Certifying a plausible cause to spare them can conceal a crime and is a serious professional offence.

What four elements must be proved for a claim of clinical negligence to succeed, and which most often defeats a claim? ANSWER: 1. DUTY of care existed. 2. BREACH — care fell below the standard of a reasonably competent doctor in that role. 3. CAUSATION — the breach caused the harm. 4. HARM recognised by law. CAUSATION most often defeats a claim. A poor outcome following imperfect care is not sufficient if the outcome would have happened anyway — a bad result is not by itself evidence of a bad doctor. WHAT ACTUALLY PREVENTS CLAIMS: good records, early honest explanation and a genuine apology. Families frequently say they went to law because nobody would tell them what had happened.

A police officer asks you for a patient's clinical details. What governs your response? ANSWER: confidentiality still applies. It is not absolute, but a request from the police is not by itself authority to disclose. DISCLOSURE IS JUSTIFIED WHERE: - the patient consents, OR - the law requires it, OR - there is a sufficiently serious risk to others. IF YOU MUST DISCLOSE: give the MINIMUM necessary, record what you disclosed and the reason, and take advice if there is any doubt. RELATED POINT ON EXAMINATION: a person brought by the police is still a patient and may refuse. Explain what the examination involves and where the findings will go BEFORE starting — consent given without knowing a report goes to a third party is not informed.