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Submission Received

Medical Certificate of cause of Perinatal Death V9
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What to do next

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2.
Print and sign the form
3.
Provide it to the funeral director (or other person organising the disposal of the remains).

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User Verification

Medical Certificate of cause of Perinatal Death V9
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User Verification

Upon submission it may take a few seconds for Medical practitioner details to be confirmed and the remainder of the form to open for completion. Your details must exactly match the details that AHPRA holds for you. If you are unable to log in, check that: you have used your first name and last name only; do not include any middle names MED is in capital letters and there are no spaces between numbers or after MED you have checked how your details are registered with AHPRA by visiting Registers of Practitioners you do not have any extra spaces after any of your details.
If you still cannot log in, try adding : single spaces to the names (eg Smith_) double-spaces (eg Mary__Jane) space around hyphens (eg Anna_-_Maria).
Please check your details on the AHPRA website or contact AHPRA on 1300 419 495
The form is currently in test mode, no doctor details are required.

Eligibility

Medical Certificate of cause of Perinatal Death V9
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Eligibility

Is this death a reviewable or reportable death in accordance with sections 10 or 13 of the Coroners Act 2008?
Do not complete this form. You must report this death to a coroner or an officer in charge of a police station immediately.
Did you examine the deceased child's body after death or still-birth?
Were you responsible for providing medical care to the deceased child immediately before death?
Were you responsible for providing medical care to the mother at the birth?
Do not complete this form. You must satisfy the obligations of the Coroners Act 2008 and the Births, Deaths and Marriages Registration Act 1996. Report this death to a coroner or an officer in charge of a police station immediately.
Please advise how you can accurately state the cause of this death.
(Select as many as appropriate)
of 100 characters

Deceased Child's Details

Medical Certificate of cause of Perinatal Death V9
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Deceased Child's Details

Sex of deceased
Upon submission of the notice a copy will be emailed to the nominated Hospital. If no email address is provided the Medical Practitioner may forward a copy.
Was the child one of multiple births?
What was the birth order of this child? (e.g. first of twins or second of triplets)
What was the birth order of this child? (e.g. first of twins or second of triplets)
of

Mother's Details

Medical Certificate of cause of Perinatal Death V9
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Mother's Details

Is the mother of Australian Aboriginal or Torres Strait Islander origin?
Please specify:
Is the deceased's father of Australian Aboriginal or Torres Strait Islander origin?
Please specify:

Cause of Death

Medical Certificate of cause of Perinatal Death V9
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Cause of Death

Disease or condition directly leading to death Note: Please specify the disease, injury or condition which led directly to the death not only the mode of dying such as heart or respiratory failure.
of 250 characters
Duration between onset and death
Duration between onset and death

Antecedent causes

Note: If the direct cause of death as described in "Cause of Death" was due to, or arose as a consequence of another disease, injury or condition, this should be reported in "Antecedent causes". Similarly, if the condition in "Antecedent causes" was due to another condition, use the add button.
Antecedent Cause
of 250 characters
Duration between onset and death
Duration between onset and death

Maternal conditions

Note: Please specify any maternal condition giving rise to the underlying cause of death of the child or fetus.
of 250 characters
Duration between onset and death
Duration between onset and death

Other significant conditions

Note: Provide details of any other significant condition(s) contributing to the death but not related to the disease, injury or condition causing it.
of 250 characters
Duration between onset and death
Duration between onset and death

Supporting Information

Medical Certificate of cause of Perinatal Death V9
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Supporting Information

Was the child still-born?
If the child was born alive please specify
If the child was born alive please specify
Upon submission of the notice a copy will be emailed to the nominated Hospital. If no email address is provided the Medical Practitioner may forward a copy.
Did the child breathe after birth?
When did the child's heartbeat cease? Please select one of the following:
Was a post mortem examination held?
Who is organising the disposal of the deceased's remains?

Siblings

Does the deceased have any siblings?
Sibling
Mother
Father

Medical Practitioner's Details

Medical Certificate of cause of Perinatal Death V9
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Medical Practitioner's Details

Did you acquire or anticipate acquiring any property, pecuniary or other benefit(s) by reason of this death?

Declaration

Medical Certificate of cause of Perinatal Death V9
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Declaration

I, hereby certify that:
1.I am a currently registered medical practitioner and my details as provided in Medical Practitioner's Details are correct;
2.This individual is deceased and I believe the death is neither reportable nor reviewable;
3.I examined the deceased child's body after death; and/or I was responsible for providing medical care to the deceased child immediately before death; and/or I was responsible for providing medical care to the mother at the birth;
4.The particulars and cause(s) of death recorded in this certificate are true to the best of my knowledge and belief; and
5.I understand that it is an offence to knowingly provide false or misleading information and that penalties may apply.

Statutory Requirements

Medical Certificate of cause of Perinatal Death V9
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Statutory Requirements

ResetNumberingToFour 1.One 2.Two 3.Three
Births, Deaths and Marriages Registration Act 1996 Section 12. Notification of births 4.When notice of a still-birth is given, the responsible person must also give the Registrar a doctor's certificate, in a form approved by the Registrar, certifying the cause of foetal death. 5.The doctor's certificate referred to in sub-section (4) must be completed by a.the doctor responsible for the professional care of the mother at the birth; or b.a doctor who examined the body of the still-born child after the birth. 6.In this section - 'responsible person' means - a.in the case of a child born in a hospital or brought to a hospital within 24 hours after birth, the chief executive officer of the hospital; or b.in any other case - i.the doctor or midwife responsible for the professional care of the mother at the birth or a doctor who examined the body of the still-born child after the birth; or ii.if no doctor or midwife was in attendance at the birth, any other person in attendance at the birth
Section 37. Notification of deaths by doctors
1.A doctor who was responsible for a person's medical care immediately before death, or who examines the body of a deceased person after death, must, within 48 hours after the death, notify the Registrar of the death and of the cause of death in a form and manner approved by the Registrar and specifying any prescribed particulars.
Penalty: 12 penalty units.
2.When a notice is given under sub-section (1), the doctor must also give a notice in the form and manner approved by the Registrar and specifying any prescribed particulars that the death has occurred to the funeral director or other person who will be arranging for the disposal of the human remains.
Penalty: 12 penalty units.
3.However, a doctor is not required to give a notice under sub-section (1) or (2) if another doctor has given the required notices. 4.A doctor must not give a notice under sub-section (1) or (2) if a coroner or police officer is required to be notified of the death under the Coroners Act 2008.
Penalty: 12 penalty units.

A 'still-born' means: A child born of at least 20 weeks gestation, or if it cannot be reliably established whether the period of gestation is more or less than 20 weeks, with a body mass of at least 400 grams at birth, that exhibits no sign of respiration or heartbeat, or other sign of life, after birth. A still-birth means the birth of a still-born child. Coroners Act 2008 Section 10. Obligation of registered medical practitioner to report death 1.Subject to subsection (2), a registered medical practitioner who is present at or after the death of a person must report the death without delay to a coroner if the death is a reportable death.
Penalty: 20 penalty units.
2.If more than one registered medical practitioner is present at or after a death and one of them reports it to a coroner, the other practitioners need not report the death.
Section 13. Obligation to report reviewable death
1.Subject to subsection (2), a registered medical practitioner who is present at or after the death of a child must report the death without delay to the State Coroner if the death is a reviewable death.
Penalty: 20 penalty units.
2.If more than one registered medical practitioner is present at or after a reviewable death and one of them reports it to the State Coroner, the other practitioners need not report the death. 3.A person who has reasonable grounds to believe that a reviewable death has not been reported to the State Coroner as a reviewable death must report the death without delay to the State Coroner.
Penalty: 20 penalty units.
Reportable death 1.In this Act, a death of a person is a reportable death if a.the body is in Victoria; or b.the death occurred in Victoria; or c.the cause of the death occurred in Victoria; or d.the person ordinarily resided in Victoria at the time of death and the death was a death specified in subsection (2). 2.For the purposes of subsection (1), the deaths are a.a death that appears to have been unexpected, unnatural or violent or to have resulted, directly or indirectly, from an accident or injury; or b.a death that occurs i.during a medical procedure; or ii.following a medical procedure where the death is or may be causally related to the medical procedure and a registered medical practitioner would not, immediately before the procedure was undertaken, have reasonably expected the death; orc.the death of a person who immediately before death was a person placed in custody or care; or d.the death of a person who immediately before death was a patient within the meaning of the Mental Health Act 1986; or e.the death of a person under the control, care or custody of the Secretary to the Department of Justice or a member of the police force; or f.the death of a person who is subject to a non-custodial supervision order under section 26 of the Crimes (Mental Impairment and Unfitness to be Tried) Act 1997; or g.the death of a person whose identity is unknown; or h.a death that occurs in Victoria if a notice under section 37(1) of the Births, Deaths and Marriages Registration Act 1996 has not been signed and is not likely to be signed; or i.a death that occurs at a place outside Victoria if the cause of death is not certified by a person who, under the law in force in that place, is authorised to certify that death and the cause of death is not likely to be certified by a person who is authorised to certify in that place; or j.a death i.of a prescribed class of person; ii.that occurs in prescribed circumstances.

Reviewable death 1.In this Act, the death of a child (the deceased child) is a reviewable death if the deceased child is the second or subsequent child of the deceased child's parent to have died and one of the following applies a.the body is in Victoria; or b.the death occurred in Victoria; or c.the cause of the death occurred in Victoria; or d.the child ordinarily resided in Victoria at the time of death. 2.Despite subsection (1), a death of a deceased child is not a reviewable death if a.the death occurs in a hospital; and b.the child was born at a hospital and had always been an in-patient of a hospital; and c.the death is not a reportable death. 3.In this section a.hospital means a public hospital, a public health service, a denominational hospital or a private hospital within the meaning of the Health Services Act 1988; b.in-patient of a hospital includes a child whose only period spent outside a hospital was during a transfer from one hospital to another, by whatever means.
Victorian Registry of Births, Deaths and Marriages