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Mine Health and Safety Act, 1996 (Act No. 29 of 1996)

Notices

Guidance Note on Medico-Legal Investigations of Mine Deaths

Part A : The Guidance Note

9. Roles and Responsibilities of Stakeholders

 

When a death occurs on the mine premises, the roles and responsibilities of stakeholders are as follows:

 

9.1 Employer

 

(a) The employer should notify the Principal Inspector of Mines, health and safety representatives and the SAPS.
(b) The employer should initiate a section 11(5) investigation.
(c) The employer must take part in the investigation conducted in terms of section 11(6) and 60(1) of the MHSA if so directed by the PloM.
(d) The employer should ensure that the following steps be taken:
(i) barricading of the accident scene;
(ii) taking of names of witnesses and/or survivors;
(iii) noting in writing the observations of the accident scene;
(iv) taking photographs of undisturbed scene; and
(v) making note of environmental conditions.
(e) The employer should bring the death to the attention of the OMP or any medical practitioner, as soon as possible, who must certify the death.

 

9.1.1 Medical Practitioner

 

(a) A medical practitioner (this may also be the OMP) must examine the body and indicate if the likely cause of death was due to natural or unnatural causes.
(b) The medical practitioner should declare death to be natural only if:
(i) they are familiar with or has access to the deceased's medical records;
(ii) the deceased was known to have a medical condition that was likely to be the cause of death; and
(iii) after they have been made fully conversant with the circumstances surrounding the death, including the environmental conditions.
(c) If a death of any person admitted to a hospital from a mine has occurred following admission for a disease, and the death is deemed to be due to natural causes, the medical practitioner completes the death certificate and no further investigation is required.
(d) If the cause of death is natural, the medical practitioner should complete a death notification certificate (BI 1663) or Department of Home Affairs (DHA) 1663. A copy of this form should be handed to the next-of-kin or funeral undertakers. If a medical practitioner is uncertain or is of the opinion that the death was due to causes other than natural, he/she shall not issue the above-mentioned form and shall inform a police officer and Forensic Pathology Services. (See Annexure 2 on certification of death and unnatural  deaths).
(e) In uncertain and unnatural cases, a medical practitioner must submit with the body or as soon as possible, all information pertaining to the deceased that may be relevant for medico-legal examinations.
(f) All anaesthetic associated deaths when handed over to FPS should be accompanied by form 028 and GW7/24 (anaesthetic forms) which explains the anaesthetic management and follow up during the procedure before death.
(g) All forms of intubation, venous lines, drips, catheters and surgical packs should be left in situ as they will be assessed during autopsy.
(h) No medical practitioner may perform a post mortem examination on the body of a deceased person, unless it is specifically done in terms of the Inquests Act (i.e. within the formal framework of medico-legal investigation of death and with the full involvement and consent of the SAPS).
(i) The only exception is when a certificate (form BI 1663), confirming exclusively natural causes of death, was issued before a post mortem examination was performed. In this event, a  post  mortem  examination may be carried out in terms of the Chapter 8 of the National Health Act, 2003 (Act 61 of 2003) and can only be done with the expression of prior consent of the next of kin or where the deceased has consented to such an examination prior to his/her death.
(j) Arrange for removal of cardiorespiratory organs in line with ODMWA . Ensure that consent was given by employee or relatives to remove lungs and heart.

 

9.1.2 Occupational Medical Practitioner

 

The OMP should:

(a) Assist the medical practitioner who completes the death certificate with relevant information (e.g. medical surveillance data, environment where the body was found, etc.) where required.
(b) Submit, with the body or as soon as possible, all information pertaining to the deceased that may be relevant to the medico-legal examinations, as per Mine Accident Scene Form (Annexure 4) .
(c) Participate in the investigation (section 11(5) of the MHSA).
(d) Assist the Medical Inspectorate with any information that may be required.

 

9.2 Department of Mineral Resources

 

9.2.1 The Chief Inspector of Mines refer to MHSA.

 

9.2.2 The Principal Inspector of Mines

 

(a) The PloM must ensure that an inspection in loco is carried out as part of Section 60 of the MHSA investigation. It is advisable to take sworn statements from witnesses wherever possible. If from the investigation there is suspicion of an irregularity falling outside the ambit of the MHSA, the PloM must report the matter to the police. The provisions of the MHSA dealing with death in mines should be explained to the police when necessary.
(b) The PloM must ensure the following:
(i) The requirements for reporting of any deaths at mines are complied with as per the MHSA.
(ii) All inspectors clearly understand what is expected of them when accidents are reported.
(iii) The Medical Inspectorate participates in the investigation, when necessary.
(iv) The recommendations and remedial action from Section 64 and 72 reports are vigorously followed up to prevent/minimise recurrence .
(v) There is continuous symbiotic communication between the SAPS stations and DMR regional offices concerning all mine deaths. The purpose of this is to ensure that no death happens without being investigated due to claims that it is not mining related.
(vi) If the findings of the post mortem examination link the death to activities and conditions at a mine, then the MHSI should  consider these activities and conditions during the statutory investigation and inquiry under the MHSA.
(vii) If there is uncertainty about whether the accident is mine related or not, the matter is referred to the CloM for a ruling.

 

9.2.3 The Inspector of Mines and Medical Inspector

 

(a) The Inspectorate must offer assistance as may be required by the National Prosecuting Authority, SAPS and magistrates in the inquest that may follow.
(b) Before an inspection in loco is conducted, the Inspector needs to co-ordinate arrangements with the relevant persons, e.g. mine managers, union representatives and necessary mining experts. This should be done to prevent unnecessary delays and possible re-inspections later.
(c) The Medical Inspectorate can communicate with the OMP to gather medical information that may be considered important to the investigation .
(d) The Medical Inspectorate can request a post mortem report from the SAPS Investigating Officer and can communicate with the authorised person at the Forensic Pathology Service who performed the post mortem to obtain any relevant information regarding the post mortem examination.

 

9.3 South African Police Services

 

(a) The SAPS must investigate all deaths due to unnatural and/or uncertain causes, and open an inquest docket (section 2 of the Inquest Act , Act No 58 of 1959, as amended).
(b) The SAPS to notify the Forensic Pathology Services , complete a SAP 180 form and arrange for a medico-legal post mortem examination to be conducted.

 

9.3.1 Forensic Pathology Service

 

(a) The relevant Member of the Executive Council of a province must, within national policy and in terms of these regulations, ensure that a Forensic Pathology Service is established and managed within the department.
(b) The Service contemplated includes , but is not limited to:
(i) where appropriate, commencing with a scene of death investigation in consultation with the Investigating Officer and or appropriate South African Police Service member who is on the scene, which includes but is not limited to, taking notes, questioning family and other witnesses, examining the death scene and photographing the deceased or any exhibit or specimens;
(ii) obtaining any information that is relevant to the medico-legal investigation of a death, including medical and social history, records, as well as taking witness statements;
(iii) taking responsibility for the collection of a body and removal from the scene;
(iv) taking responsibility for the custody of a body from the scene of death until released for burial or cremation, and the processes attached thereto;
(v) taking into custody, thoroughly documenting and maintaining evidence and specimens relating to a body and any associated items or articles at all times;
(vi) assisting, as far as is possible, with the process of identification of the deceased;
(vii) conducting a post mortem investigation, including external and internal examination of a body and retaining of material, tissue or fluids for evidentiary or diagnostic purposes;
(viii) requesting and conducting appropriate special investigations;
(ix) providing medico-legal reports, chain of custody statements, expert testimony and opinions;
(x) archiving documents, specimens and related materials;
(xi) collecting, reviewing and analysing related data; and
(xii) providing information and advice to health or other government authorities or departments

 

9.3.1.1 Referral of unnatural cases

 

All cases of unnatural death as defined in these regulations must be referred to the Forensic Pathology Service.

 

9.3.1.2 Death scene

 

The Service is responsible for attending and participating in the death scene investigation, which may include, but is not limited to:

(a) Managing a request for forensic pathology service response.
(b) Assessing the scene of death in a given situation, this may include any private, public or business premises, vessel, train, motor vehicle , aircraft where death has occurred for the purposes of conducting a comprehensive death scene investigation.
(c) Performing forensic pathology activities associated with the scene of death in terms of relevant scope of practice including:
(i) Declaring death in the following obviously dead cases - decapitation, gross mutilation, putrefaction, and charring.
(ii) Examining the body on scene and recording of the incident for the purposes of forensic investigation which includes but may not be limited to photography, sketching, and documentation.
(iii) Interviewing any relevant party including the next of kin and recording medical history and relevant information.
(iv) Obtaining medical records of the deceased from any party or source where relevant.
(v) Assess, handle, collect, preserve and record evidence in line with forensic pathology service procedural requirements.

 

9.4 Procedure

 

The summary of steps to be followed in the event of a death in the mining industry is in Annexure 1.

 

9.4.1 Death of an employee

 

Reporting to the MHSI about the death

 

As stipulated in Section 60(1), any accident or occurrence at a mine that results in the death of a person must be investigated.

 

In the event of a death, the employer, is required to get a OMP/medical practitioner to certify the death.

 

The OMP/medical practitioner should take into account the circumstances surrounding the death, as provided by the employer, as well as the occupational and medical history of the deceased in determining whether the death is due to natural, unnatural or uncertain causes. Should the OMP/medical practitioner decide that death is due to natural causes, a death notification certificate (BI1663) should be completed.

 

In cases where the medical practitioner/OMP determines the death as unnatural or uncertain, the medical practitioner/OMP must notify the SAPS who will open a docket and notify the Forensic Pathology Services . Should the SAPS refuse to open a docket or fail to refer the case to the FPS, the medical practitioner should refer the matter to the FPS, the regional medicine inspector and copy the Chief Specialist Forensic Pathologist. A record of this referral must be kept for future reference. The FPS must be requested to respond in writing to such referrals.

 

An authorised  person will conduct the post mo1iem and provide a report (FPS to the SAPS Investigating Officer who will complete the investigation . The SAPS Investigating Officer must give a copy of the post mortem report to the Medical Inspectorate of the DMR for the purposes of completing the Section 60(1) investigation.

(i) Declaring death in the following obviously dead cases - decapitation, gross mutilation, putrefaction, and charring.
(ii) Examining the body on scene and recording of the incident for the purposes of forensic investigation which includes but may not be limited to photography, sketching , and documentation.
(iii) Interviewing any relevant party including the next of kin and recording medical history and relevant information.
(iv) Obtaining medical records of the deceased from any party or source where relevant.
(v) Assess, handle, collect, preserve and record evidence in line with forensic pathology service procedural requirements.

 

9.4.2 Death in a hospital

 

Once a death occurs, a medical practitioner must determine if the death is natural, unnatural or uncertain. The medical and occupational history of the deceased should be taken into account in reaching this decision. If the death is due to natural causes, the medical practitioner must complete a notification of death certificate (BI 1663).

 

If a death has occurred in a hospital and is deemed to be due to unnatural causes - i.e. as result of or due to complications that developed following a mine accident or as contemplated in Health Professions Amendment Act 29 of 2007, section 48 (anaesthetic death) - the medical doctor shall not complete the death notification form (BI 1663) and should follow the procedure for unnatural causes of death.

 

If the death is unnatural/uncertain, then the process for unnatural/uncertain deaths, described above, should be followed .

 

 


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