Death Summary

Medical certificate of cause of death and clinical summary

Patient Name

UHID

Age / Sex

Date of Admission

Date of Death

Time of Death

Ward / Bed

Admitting Consultant

Pronouncing Doctor

Part I — Direct sequence leading to death

a) Immediate cause

b) Due to / as a consequence of

c) Due to / as a consequence of

d) Underlying cause (if applicable)

Part II — Other significant conditions contributing to death

Admitting Diagnosis

Duration of Illness (Pre-admission)

Hospital Stay

ICU Stay

Ventilator Support

CPR Performed?

Mode of Death

Brought Dead?

Autopsy / Post-mortem Required?

Next of Kin Informed?

Medico-Legal Case?

Body Released to

I certify to the best of my knowledge that the above information is accurate and complete. This death was due to natural causes.

Certifying Doctor

Registration Number