Scotland’s Local Supervising Authorities
Maternal Death Guideline
Contents
Pages
Definitions
Responsibilities
2
3-4
Appendices
Appendix 1
Notification of maternal death to the LSAMO
Further Reading
Appendix 2
Appendix 3
Form F.89 Death under medical care
Death and the procurator fiscal
Guideline Written by: South East Scotland Supervisors of Midwives
Supervisors Quality Improvement Group
Date: February 2008
Approved by: Local Supervising Authority Midwifery Officer. Yvonne Bronsky
South East and West Region Supervisors Quality Improvement Group (SQIG)
Document Number: 6
Implemented October April 2008
Reviewed June 2010, December 2015
Review Date December 2018
Page 1 of 19
Maternal Death Guideline
Definition of a maternal death (International Classification of
Diseases (ICD code 10)
A maternal death is defined as the death of a woman while pregnant or within
42 days of termination of pregnancy, irrespective of the duration and the site
of the pregnancy, from any cause related to or aggravated by the pregnancy
or its management but not from accidental or incidental causes.
A Direct maternal death is defined as a death resulting from obstetric
complications of the pregnancy state (pregnancy, labour and puerperium),
from interventions, omissions, incorrect treatment, or from a chain of events
resulting from any of the above.
An Indirect maternal death is defined as a death that resulting from previous
existing disease, or disease that developed during pregnancy and which was
not due to direct obstetric causes, but which was aggravated by the
physiological affects of pregnancy. These include cases of self-harm as a
consequence of postnatal depression
A Coincidental death is defined as a death that occurs from unrelated causes
which happen to occur in the pregnancy or puerperium, i.e. some
malignancies, domestic violence, road traffic accidents, etc. They are also
important causes of death from the aspect of wider public health.
A Late death is defined as a death that occurs between 42 days and one year
after abortion, miscarriage or delivery that is due to direct or indirect
maternal causes. Late Coincidental deaths can sometimes also be important.
A Pregnancy-related death is defined as a death occurs whilst pregnant or
within 42 days of termination of pregnancy, irrespective of the cause of the
death.
South East and West Region Supervisors Quality Improvement Group (SQIG)
Document Number: 6
Implemented October April 2008
Reviewed June 2010, December 2015
Review Date December 2018
Page 2 of 19

In keeping with The Midwives Rules and Standards (NMC 2012)
Rule 10 - the on call supervisor must be notified that a maternal
death has occurred.
Responsibility for reporting a maternal death
A maternal death may occur in the community or in the hospital. The Enquiry
is initiated by the NHS HIS Confidential Enquiries into Maternal Death
(CEMD) administrator, who is usually informed of the maternal death by the
Registrar General or a health professional involved in the case. The
responsibility for notifying the Director of Public Health for the area in which
the woman resided should rest with the consultant, midwife, or general
practitioner who had overall responsibility for the woman’s care during
pregnancy; or with the consultant or general practitioner treating the woman
during her final illness if the death occurs within one year following the end of
her pregnancy. It does not matter if more than one professional notifies the
NHS HIS CEMD administrator as case ascertainment is more important than
duplication of notifications.
In the event of the baby dying in the uterus the following should be taken into
consideration:

The definition of a stillbirth does not include the removal of a dead baby
from its dead mother at post-mortem for the purpose of ascertaining
the cause of death. This is because the post-mortem is being carried
out on the mother rather than the baby. Therefore, registration of a
baby in these circumstances over 24 weeks gestation as a death is not
legally required. This advice has been given by Registrar General
(Office for National Statistics).

However, consideration must be shown to the wishes of the family. A
medical practitioner may issue a death certificate for the dead baby as
stillborn. Most Registrars of Births, Deaths and Marriages will comply
but local policies in this respect should be checked in order to prevent
confusion and further distress for the family.

As the majority of pathologists will remove the baby from the mother's
body at post-mortem it is sensible for the local stillbirth/neonatal death
procedure to be followed whether the baby is to be registered as a
death or not.

The Local Supervising Authority Midwifery Officer (LSAMO) must be
informed as soon as practically possible.
South East and West Region Supervisors Quality Improvement Group (SQIG)
Document Number: 6
Implemented October April 2008
Reviewed June 2010, December 2015
Review Date December 2018
Page 3 of 19
Responsibilities of the Supervisor of Midwives
The Supervisor of Midwives will ensure that appropriate support is offered to
the staff involved. Personnel such as Hospital Chaplain and Occupational
Health may support the Supervisor of Midwives with this.
Serious Untoward Incident Policy should be initiated and details of the
incident made available (A Root Cause Analysis (RCA) will be undertaken by
the Risk Management Team), a Supervisor of Midwives must be involved in
the RCA.
The medical records should be reviewed by the Supervisor of Midwives and a
complete summary of the case recorded. It is important to note the names of
all staff involved, particularly those staff that do not normally work within the
maternity unit.
The case notes and all documentation should be completed, photocopied and
secured at the first opportunity. There should be an early review of the
records: the midwifery care given should be reviewed by the Supervisor of
Midwives.
The death should be reported to the Local Supervising Authority Midwifery
Officer (LSAMO) as soon as practically possible initially verbally followed by
the maternal death proforma. Appendix 1.
The Supervisor of Midwives and LSAMO will liaise with the Head of Midwifery
with regards to the setting up of a debriefing event.
APPENDIX 1
Notification of Maternal Death to the LSAMO
South East and West Region Supervisors Quality Improvement Group (SQIG)
Document Number: 6
Implemented October April 2008
Reviewed June 2010, December 2015
Review Date December 2018
Page 4 of 19
Notifying unit
Details of woman
D.O.B
/
/
Name
Parity
+
Address
CHI No
Details on delivery/baby
Please circle
Date
/
/
SVD / Forceps / Vent / Assisted Breech Delivery /
Em LUSCS / El LUSCS
Mode
Birthweight (g)
M/F
Sex
LB / SB / NND
Condition
Details on death
/
/
weeks
If antenatal, gestation
Date
If postnatal, how long
Place
Hospital
other
/
home
days / weeks / months
/ If other, where
If hospital, name and
ward
Details on death (continued)
Cause
South East and West Region Supervisors Quality Improvement Group (SQIG)
Document Number: 6
Implemented October April 2008
Reviewed June 2010, December 2015
Review Date December 2018
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Tick if unknown
Summary of events surrounding death
South East and West Region Supervisors Quality Improvement Group (SQIG)
Document Number: 6
Implemented October April 2008
Reviewed June 2010, December 2015
Review Date December 2018
Page 6 of 19
Review of midwifery practice if relevant
Review
conducted
Conducted by
Yes
No
/
If no, reason
Name
Designation
Outcome of
review
Form completed by:
Name
Designation
Signature
/
/
Date of completion
South East and West Region Supervisors Quality Improvement Group (SQIG)
Document Number: 6
Implemented October April 2008
Reviewed June 2010
Review Date October 2016
Page 7 of 19
South East and West Region Supervisors Quality Improvement Group (SQIG)
Document Number: 6
Implemented October April 2008
Reviewed June 2010
Review Date October 2016
Page 8 of 19
South East and West Region Supervisors Quality Improvement Group (SQIG)
Document Number: 6
Implemented October April 2008
Reviewed June 2010
Review Date October 2016
Page 9 of 19
APPENDIX 3
DEATH AND THE PROCURATOR FISCAL
1. Duty of Procurator Fiscal to Enquire into Deaths
It is the duty of the Procurator Fiscal in the exercise of his function at common law and
under statute to enquire into certain categories of death. This is necessary not only in
order to minimise the risk of undetected homicide or other crime but also in pursuance of
the public interest to eradicate dangers to health and life, to allay public anxiety and to
ensure that full and accurate statistics are compiled. It is also necessary to secure and
preserve evidence relevant to the rights of interested parties which may vary with the
circumstances of the death.
In Scotland no other official has any duty in relation to enquiry into death comparable to that of the
Procurator Fiscal.
2. Deaths to be reported to the Procurator Fiscal
It is the duty of the appropriate Procurator Fiscal to enquire into all sudden, suspicious,
accidental, unexpected and unexplained deaths and in particular into all deaths resulting
from an accident in the course of employment or occupation, deaths while in legal
custody and deaths occurring in circumstances such as to give rise to serious public
concern. However, the Procurator Fiscal may enquire into any death brought to his notice
if he thinks it necessary to do so. Knowledge of such deaths will usually come to the
Procurator Fiscal through reports by the police, hospital doctors, or doctors in general
practice or through intimations from registrars or from relatives. Any death which the
circumstances or evidence suggest may fall into one or more of the following categories
must be reported to the Procurator Fiscal:(1) any death due to violent, suspicious or unexplained cause.
(2) any death involving fault or neglect on the part of another.
(3) possible or suspected suicide.
(4) any death resulting from an accident.
(5) any death arising out of the use of a vehicle including an aircraft, ship or train.
(6) any death by drowning.
(7) any death by burning or scalding, or as a result of a fire or explosion.
(8) certain deaths of children - any death of a newborn child whose body is found, any death from
sudden infant death syndrome (see Section 5 below), any death due to suffocation including
overlaying, any death of a foster child.
(9) any death at work, whether or not as a result of an accident.
(10) any death related to occupation, for example, industrial disease or poisoning. (See Appendix
1).
(11) any death as a result of abortion or attempted abortion.
South East and West Region Supervisors Quality Improvement Group (SQIG)
Document Number: 6
Implemented October April 2008
Reviewed June 2010
Review Date October 2016
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(12) any death as a result of medical mishap, and any death where a complaint is received which
suggests that medical treatment or the absence of treatment may have contributed to the death.
(See Section 3 below).
(13) any death due to poisoning or suspected poisoning, including prescription or non-prescription
drugs, other substances, gas or solvent fumes.
(14) any death due to notifiable infectious disease, or food poisoning.
(15) any death in legal custody.
(16) any death of a person of residence unknown, who died other than in a house.
(17) any death where a doctor has been unable to certify a cause.
Where the death is a result of food poisoning or an infectious disease the Procurator
Fiscal should consult the Director of Public Health for the area concerned before deciding
whether there should be further enquiry into the circumstances of the death (see
Appendix 2). In the case of death from industrial disease or poisoning the Health and
Safety Executive will be consulted.
3. Deaths Under Medical Care/Medical Mishap
(1) Certain deaths associated with the provision of medical care are to be reported to the
Procurator Fiscal. Most of these deaths represent an unfortunate outcome where every
reasonable care has been taken, but they may result from acts of either negligent
commission or omission on the part of medical or para-medical staff, or may be
associated with criminality. It is the duty of the Fiscal to enquire into deaths which fall
into the following categories, which are not to be regarded as exhaustive, viz:
(i) deaths which occur unexpectedly having regard to the clinical condition of the deceased prior
to his receiving medical care;
(ii) deaths which are clinically unexplained;
(iii) deaths seemingly attributable to a therapeutic or diagnostic hazard;
(iv) deaths which are apparently associated with lack of medical care;
(v) deaths which occur during the actual administration of general or local anaesthetic;
(vi) deaths which may be due to an anaesthetic;
(vii) deaths caused by the withdrawal of life sustaining treatment to patients in a persistent
vegetative state (see Section 17 below).
(2) "Medical care" includes surgical, anaesthetic, nursing or other kind of health care.
These deaths may be the result of diagnostic procedures (investigations or x-ray
procedures) or therapeutic procedures (whether surgical or as a result of medication oral, parenteral or inhalation administration of drug treatment). This includes deaths
possibly linked to defects in medicinal products or medical equipment or apparatus.
(3) Instructions have been given to hospitals, nursing homes and general practitioners that
where a patient has died in such circumstances the Procurator Fiscal must be informed
without delay. The responsibility for notification lies with the doctor concerned in the
care of the patient or the doctor called in at the time of death. The Procurator Fiscal
should be notified by telephone or otherwise as soon as possible after the occurrence and
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Reviewed June 2010
Review Date October 2016
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as soon as practicable thereafter on Form F89 signed by the doctor. Arrangements have
been made to distribute supplies of Form F89 to hospitals, nursing homes and general
practitioners. Further supplies may be obtained from the Procurator Fiscal.
If the deceased died after surgery and the doctor who is reporting the death to the
Procurator Fiscal has no knowledge of the surgery preceding the death, the Form F89
should not be completed by the reporting doctor without consultation with the surgeon
who conducted the operation or with a senior member of the surgical team to ascertain if
any particular matter should be brought to the attention of the Procurator Fiscal.
(4) On receipt of the Form F89, the Procurator Fiscal will consider whether it is
appropriate to request the doctor in charge of the case, and where appropriate other
doctors who have been involved in the treatment or investigation of the patient, to
provide a full written report detailing the circumstances leading up to and surrounding the
death.
(5) On receipt of a report the Procurator Fiscal may take the decision if he considers this
appropriate, to make no further enquiry. If he deems other action to be necessary, he will
obtain a report from a forensic pathologist and/or a consultant in the speciality concerned
(anaesthesia, cardiology, surgery, etc) or an appropriate general practitioner. They should
be independent of the medical institution or medical practitioner concerned. The decision
as to whether an autopsy is necessary will, as always, be taken by the Procurator Fiscal.
In many cases, an autopsy will form an important part of the evidence available for the
further enquiries. The forensic pathologist and specialist adviser should have full access
to the Form F89, any additional reports obtained by the Procurator Fiscal and to any
medical records, and it may be helpful for them to discuss with the physicians concerned
any aspect of the case which requires clarification.
(6) The Procurator Fiscal will ask the forensic pathologist and/or the independent
specialist adviser to provide a report considering objectively the standards of medical
care, the treatment given and
the availability and adequacy of the emergency steps taken. Where appropriate, any
deficiencies in the standards should be brought to the attention of the Procurator Fiscal.
(7) In particular the forensic pathologist and/or the independent specialist adviser will be
asked to direct his attention to the following points, viz:
(i) whether the patient was properly and sufficiently examined before the procedure;
(ii) whether all due precautions were observed in the performance of the procedure and the
selection and administration of any anaesthetic or medication;
(iii) whether there were any factors present which could have been discovered indicating that the
procedure would be attended with special risk to life.
(8) The Scottish Office Department of Health has informed Health Boards and Trusts that
if a death is not reported to the Procurator Fiscal but the Health Board or Trust
subsequently receives a complaint from the next of kin about the medical treatment given
to the deceased and the complaint contains a suggestion that the medical treatment may
have contributed to the death of the patient, then that death should be reported to the
Procurator Fiscal as soon as the complaint is received.
South East and West Region Supervisors Quality Improvement Group (SQIG)
Document Number: 6
Implemented October April 2008
Reviewed June 2010
Review Date October 2016
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4. Deaths of Persons Receiving Dental Treatment
The death of a person undergoing dental treatment will be reported to the Procurator
Fiscal by the dentist and/or anaesthetist concerned. The Procurator Fiscal will obtain a
report from a forensic pathologist and/or independent specialist adviser.
5. Sudden Infant Death Syndrome and Post Perinatal Infant Mortality
Procurators Fiscal must enquire into all cases of SIDS or 'Cot Death' but they will not
necessarily see the parents in all cases as this can cause additional strain for the family.
Should the parents express specific concerns about the circumstances of the death, or
should the Procurator Fiscal be of the view that it is appropriate to consider holding a
Fatal Accident Inquiry, the parents will be interviewed.
In dealing with such cases Procurators Fiscal will have regard to the following:(1) SIDS can be diagnosed only as the result of an autopsy. When a case of SIDS is suspected, an
autopsy must be conducted unless there are clear and compelling reasons for not doing so and
notwithstanding the views of relatives.
(2) Where practicable, autopsies will be conducted by a paediatric pathologist and, if there is a
suspicion of criminality and a two doctor autopsy is thought necessary, by a forensic pathologist in
association with a paediatric pathologist.
(3) As it is possible that tissue samples may be of value to the continuing medical research into the
cause or causes of cot death, the pathologists should be instructed to obtain samples of lung and
liver tissue from cot death victims.
(4) To provide support and assistance to general practitioners in such cases, a paediatrician
designated by the British Paediatric Association will be informed by the Procurator Fiscal of any
sudden infant death once SIDS has been established as the cause. Procurators Fiscal will intimate
to the appropriate paediatrician (listed at Appendix 3).
(5) Where requests for access to the autopsy report are received by Procurators Fiscal from
paediatricians or other members of the medical profession involved in counselling parents
following a cot death, a copy of the report will be provided. Where the request is received from
bereaved parents, it may be appropriate to suggest that a copy be given to their General
Practitioner, who could discuss its contents with them. If the parents do not want to involve their
GP, Procurators Fiscal may provide parents with a copy direct. However, if there is any
uncertainty as to whether the death is suspicious or an instance of SIDS, copies of reports will not
be made available until a decision has been reached regarding their possibility of criminal
proceedings, or any criminal proceedings are completed.
(6) To prevent unnecessary distress to parents, local procedures should be established in
consultation with the police and pathologists to obviate the necessity for formal identification of
the body prior to autopsy. Arrangements should be made, however, should the parents wish this as
a final opportunity to see their child. This should be done in as sympathetic surroundings as
possible.
(7) Procurators Fiscal should continue to cooperate fully with paediatricians and members of the
medical profession involved in research into post perinatal infant deaths (ie deaths of children
aged 7 - 365 days). Procurators Fiscal should send a copy of all autopsy reports of infants dying
between the ages of one week and one year to the Scottish Cot Death Trust.
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6. Control of a Dead Body
The Procurator Fiscal has a right and a duty to control the disposal of a dead body while
he makes enquiries into the death. Depending upon the circumstances he may decide to
leave the body where the death occurred, eg at home or in a hospital. He may decide to
have the body removed to a police or hospital mortuary or a specially designated
mortuary. He will require to decide in every case whether he will accept a medical
certificate as to the cause of death and release the body, or whether an autopsy is
necessary. When releasing a body the Procurator Fiscal requires to decide whether
cremation may be allowed to take place. There may be circumstances, for example a
homicide investigation where the Procurator Fiscal cannot allow cremation to take place
as it would lead to the destruction of evidence available from the body. If the Procurator
Fiscal has no objections in principle to a cremation, the matter then becomes one for the
Medical Referee to decide.
7. Decision to Instruct an Autopsy
An autopsy will not always be necessary. In many cases when the Procurator Fiscal first
hears of the death he will be advised that a death certificate has not been granted. If the
Procurator Fiscal is satisfied that death is due to natural causes and that there are no
elements of criminality or negligence, he will invite the deceased's own doctor or, if the
death occurred in hospital, the doctor concerned, to provide a certificate as to the cause of
death. If the doctor is unwilling to do so after consultation with the Procurator Fiscal, the
Procurator Fiscal will invite the police surgeon (if there is one and he is prepared to act)
to view the body and provide a certificate after consultation as he sees fit. The police
surgeon may then agree to certify the cause of death or, alternatively, may advise the
Procurator Fiscal that an autopsy should be carried out. In such cases a one doctor
autopsy will usually be sufficient.
If a deceased has died in hospital and the death does not appear to require any further
investigation on the part of the Procurator Fiscal the question of an autopsy to establish
the cause of death is a matter for the hospital
may be appropriate to suggest that a copy be given to their General Practitioner, who could discuss
its contents with them. If the parents do not want to involve their GP, Procurators Fiscal may
provide parents with a copy direct. However, if there is any uncertainty as to whether the death is
suspicious or an instance of SIDS, copies of reports will not be made available until a decision has
been reached regarding their possibility of criminal proceedings, or any criminal proceedings are
completed.
(6) To prevent unnecessary distress to parents, local procedures should be established in
consultation with the police and pathologists to obviate the necessity for formal identification of
the body prior to autopsy. Arrangements should be made, however, should the parents wish this as
a final opportunity to see their child. This should be done in as sympathetic surroundings as
possible.
(7) Procurators Fiscal should continue to cooperate fully with paediatricians and members of the
medical profession involved in research into post perinatal infant deaths (ie deaths of children
aged 7 - 365 days). Procurators Fiscal should send a copy of all autopsy reports of infants dying
between the ages of one week and one year to the Scottish Cot Death Trust.
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may then agree to certify the cause of death or, alternatively, may advise the Procurator
Fiscal that an autopsy should be carried out. In such cases a one doctor autopsy will
usually be sufficient.
If a deceased has died in hospital and the death does not appear to require any further
investigation on the part of the Procurator Fiscal the question of an autopsy to establish
the cause of death is a matter for the hospital.
Where a pathologist while conducting a one-doctor autopsy finds unexplained difficulties
or grounds for suspicion he should suspend the autopsy and report immediately to the
Procurator Fiscal in order that a second pathologist can be instructed.
In deciding whether or not to instruct an autopsy, the Procurator Fiscal will be influenced
by considerations of potential hazard, such as the danger of infection, to those who
require to be present. Where the deceased is considered to be in a high risk category, as a
possible carrier of HIV or Hepatitis viruses, an initial blood screen for the presence of
these viruses should be ordered. The test for the need to have a dissection will become
much more stringent should a positive result for any of the above viruses be obtained.
Where there is no possibility of criminal proceedings it may be sufficient to have an
external examination of the body by a pathologist, supplemented by toxicological
analysis of blood and/or tissue and of the contents of any relevant containers found at the
scene or elsewhere, for example hypodermic syringes.
8. Medical Research - Hospital Autopsy
The Procurator Fiscal is sometimes asked by doctors, especially hospital doctors, to
permit an autopsy in the interest of medical research or for some other medical reason,
although the cause or primary cause of death is known. In cases where the cause of death
has been ascertained without a dissection and the Procurator Fiscal does not otherwise
require an autopsy to be held it would not be appropriate for him to instruct one. In such
cases Procurators Fiscal may not have any objection to an autopsy, but doctors should
approach the next-of-kin to obtain their consent, making it clear the autopsy is not at the
instance of the Procurator Fiscal. However, if the autopsy conducted in such
circumstances reveals suspicion, it should be halted immediately and the Procurator
Fiscal informed. The results of autopsies conducted under an arrangement of this kind
must always be reported to Procurators Fiscal.
9. Choice of Medical Experts
It is the Procurator Fiscal who is responsible for deciding which pathologists to instruct in
any particular death and the number of specialists required, notwithstanding the
arrangements with universities. In some cases, it may be necessary to bring in a
pathologist with a particular skill, eg a neuropathologist in cases of head injury. It may be
desirable to instruct experts who are not pathologists, eg in cases of sexual assault where
an expert in obstetrics or gynaecology could be associated with the autopsy.
The Procurator Fiscal is also responsible for deciding the extent of investigation to be
made by way of forensic science. He will choose and instruct the experts whom he
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wishes to carry out the work, eg members of the police laboratory, staff of a hospital or
university department or an Inspector from the Health and Safety Executive. The
Procurator Fiscal will have selected and instructed the pathologists who are to perform
the autopsy. These pathologists may advise him of the need for further investigation by
way of forensic science but the decision as to such investigation will be made by the
Procurator Fiscal in the light of all the circumstances of the case which are known to him.
10. Deaths where there is a Possibility of Criminal Proceedings
In every case in which (a) there is a possibility that the death was caused or contributed to
by the commission of a criminal act, or (b) there is a possibility of criminal proceedings
in which it will be necessary to prove the fact and cause of death, an autopsy must be
carried out by two pathologists.
11. Identification of Body
In cases where there is the possibility of criminal proceedings care should be taken that,
where the identity of the deceased is know, there is corroborated evidence of
identification of the body to the pathologists. When death has occurred in hospital, it is
customary for the nurses who prepare and lay out the body to attach a bracelet to the
deceased unless he was already an in-patient whereupon it would have been attached at
admission.
12. Extent of Examination
In some deaths the Procurator Fiscal will require to give specific instructions as to what
steps are to be taken during and after an autopsy depending on the circumstances of the
case, eg the taking of blood and urine, hair, nail scraping or fingerprints of the deceased,
or the sampling of dirt, dust, etc at the locus, to compare with dirt, etc found on clothing
or the body. Photographs of specific wounds and marks of the body, examination of
wounds in relation to particular weapons or other objects and in relation to the deceased's
clothing, examination for fingerprints on the surface of the body in cases of manual
strangulation. It may be necessary to retain organs for additional expert examination, eg
the liver in suspected poisoning or drug abuse enquiries. For health reasons body organs,
stomach contents, blood and saliva samples and swabs stained with body fluid will be
retained by the examiner for a period of 21 days only, following service upon the accused
or his solicitor of a letter informing him that they will be destroyed unless the defence
indicate they wish to examine them or wish an extension to the 21 day period. Prior to
dissection it may be deemed necessary to carry out a full skeletal X-ray. This should
always be done if "battered baby syndrome" is suspected. A forensic odontologist may be
called in where bite marks are present.
13. Attendance at Autopsy
It is the Procurator Fiscal who is in charge of the inquiry during the autopsy and either he
or one of his deputes should attend the dissection in connection with a death which is a
suspected homicide. He will ensure that any medical problem or apparent contradiction in
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the pathological findings is further investigated to a solution and that all known nonmedical facts are properly investigated and explained by the pathologists. He must ensure
that the pathologists fully explore the findings to determine whether the non-medical
facts can be reconciled with the medical conclusions.
14. Human Tissue Act 1961
The Human Tissue Act 1961 provides inter alia for the use of parts of bodies for
therapeutic purposes. Section 1(5) states that no part of a body may be removed if the
Procurator Fiscal objects. Where there is reason to believe that the Procurator Fiscal may
require an autopsy or a Fatal Accident Inquiry to be held, no parts of a body should be
removed without his prior consent.
The Act applies mainly to removal of the kidneys, heart, liver and the cornea from the
eye. It is not vital that the cornea be removed immediately upon death and so no special
procedure is necessary. Other organs must, however, be removed very soon after death
and the medical authorities have been advised to inform the Procurator Fiscal as soon as
possible of any proposed transplant before death occurs. Where there is doubt about the
appropriate Procurator Fiscal, the initial contact will be made with the Procurator Fiscal
for the area in which the hospital is situated. He should then make enquiry to establish
who is the appropriate Procurator Fiscal to consent to the removal of parts of the body.
The appropriate Procurator Fiscal will then instruct immediate enquiry by the police into
the circumstances so he may decide whether to consent for his interest to the removal
when death occurs. Consent would never be given in a case which is likely to result in a
charge of murder. Where consent is given it is the responsibility of the Procurator Fiscal
to ensure that sufficient evidence is available for any subsequent criminal proceedings or
Fatal Accident Inquiry. It is necessary to establish that the death has not been caused or
contributed to by the transplant operation. If there is uncertainty as to whether the
retrieval operation could affect the evidence, the Procurator Fiscal should ask the
transplant coordinator to put him in touch with the senior transplant surgeon to discuss
the operation plans and any requirement for pathological investigation.
15. Where the Procurator Fiscal consents to the removal of parts of the body
The following is the procedure adopted in hospitals:Transplant surgery will not be commenced until the fact of death of the donor has been
established by two doctors independent of the transplant team. These doctors will, if
required, give evidence to that effect to prove that the death of the donor was not caused
by the transplant operation. The transplant surgeon will detail his operative procedure and
any other findings in the hospital records which will be available for the autopsy
pathologist should he wish to see them. The transplant surgeon will also be available for
court purposes, if required.
be available to prove that the transplant operation did not contribute to the death of the
donor. It is emphasised that the consent of the Procurator Fiscal is not of itself authority
for the removal of part of a body. The other requirements of the Human Tissue Act place
South East and West Region Supervisors Quality Improvement Group (SQIG)
Document Number: 6
Implemented October April 2008
Reviewed June 2010
Review Date October 2016
Page 17 of 19
an onus upon those seeking to implement the transplant procedure but the Procurator
Fiscal is not involved in this.
16. Anatomy Act 1984
The 1984 Act makes provision for the examination by dissection of a body for the
purposes of teaching or studying, or researching into, morphology. In any case where
there is reason to believe that the Procurator Fiscal may require a Fatal Accident Inquiry
or a post-mortem examination of the body, an anatomical examination as defined by the
1984 Act should not be carried out except with the Procurator Fiscal's consent. Whilst the
hospital or institute require the concurrence of the Procurator Fiscal, that is not
tantamount to authorisation. The approval of the next of kin will still be required.
17. Persistent Vegetative State: Withdrawal of Life Support Facilities
In light of the decision of the Inner House of the Court of Session in the case of Law
Hospital NHS Trust v Lord Advocate (1996 SLT 848), the Lord Advocate announced the
approach that will be adopted by the Crown when life sustaining treatment or medical
treatment is withdrawn or discontinued for patients who are incapable of consenting to
such withdrawal or discontinuation.
The Lord Advocate will not authorise the prosecution of a qualified medical practitioner
(or any person acting upon the instruction of such a practitioner) who, acting in good
faith and with the authority of the Court of Session, withdraws or otherwise causes to be
discontinued life sustaining treatment or other medical treatment from a patient in a
persistent, or permanent vegetative state (PVS), with the result that the patient dies.
In his opinion in the Law case, the Lord President stated that by means of application by
petition for the exercise of the parens patriae jurisdiction of the court, an area Health
Board or NHS Trust in whose care the patient is, or any relative of the patient, may seek
the withdrawal of treatment. The court decided it was not necessary to require such an
application in every case; the decision as to whether an application is necessary must rest
with those who will be responsible for carrying that intention into effect, having regard in
particular to the views of the patient's relatives and statements of policy issued by the
Lord Advocate.
It will be noted from the terms of the Lord Advocate's statement that the immunity from
prosecution does not automatically extend to medical practitioners who have not sought
and received the authority of the Court. The Lord Advocate has expressed the view,
however, that if doctors, and those acting on their instructions, were acting in accordance
with accepted medical practice, and had exercised the proper degree of care expected of
them, it would be very unlikely any prosecution in the public interest would be brought
against them.
Procurators Fiscal may require to consider instructing an autopsy when the withdrawal of
life sustaining treatment has resulted in the death of a person in a persistent vegetative
state. Such deaths should be reported to the Procurator Fiscal as they are deaths under
medical care.
South East and West Region Supervisors Quality Improvement Group (SQIG)
Document Number: 6
Implemented October April 2008
Reviewed June 2010
Review Date October 2016
Page 18 of 19
Clearly this is a growing area of medico - legal interest and may be subject to further
update in light of experience. Any such update will be circulated as required.
18. Asbestosis, Mesothelioma and Asbestos-Related Lung Cancer
Relatives of those who have died as a result of asbestosis, mesothelioma or asbestosrelated lung cancer have an interest in ensuring that evidence as to the cause of death is
available should they wish to make a claim in respect of the circumstances in which the
deceased was exposed to asbestos.
If the deceased's condition was conclusively diagnosed before his death, an autopsy may
not be necessary. Unless a lung biopsy has been undertaken prior to death which revealed
asbestos bodies, it is unlikely that a conclusive diagnosis will have been reached.
It should not be necessary for next of kin to attend at the mortuary for the purpose of
formal identification of the deceased. If the death has occurred in a hospice or hospital,
medical staff should be able to provide a link in the chain of identification. The
Procurator Fiscal will require to gather evidence about the deceased's employment record
which may be available from his medical records.
As in every case where an autopsy is instructed, the pathologist should send to the
deceased's GP a letter informing him that a post mortem examination has taken place and
giving him details of the cause of death.
APPENDICES 1, 2 AND 3 ARE AVAILABLE ON
HTTP://SKYE/DP/DOCS/LABS/DEATHPF.HTM
Dr R Nairn
Consultant Pathologist
Last reviewed: March 2002
South East and West Region Supervisors Quality Improvement Group (SQIG)
Document Number: 6
Implemented October April 2008
Reviewed June 2010
Review Date October 2016
Page 19 of 19