Abstract
Wrongful declaration of death in premature newborns continues in Nepal notwithstanding modern medical advances. We describe four cases of neonates who were wrongly declared dead and later found to be alive. This report aims to analyse the systemic failures that contributed to these outcomes which were identified over 6 years (2019–2025) through ‘grey’ literature. All these premature neonates were found alive hours later, some when enroute to cremation or burial. These cases highlight minimal or absent vital signs assessment before declaration of death was wrongly made and was shockingly negligent and a breach of the duty of care owed to the baby. In one case, death was declared by a nurse rather than a doctor in breach of minimum WHO standards and raises profound ethical and legal issues.
Background
In 1967, Christiaan Barnard conducted the first successful human-to-human heart transplant 1 ; it was a landmark surgical event which also prompted society to ask fundamental questions on medico-legal issues. What defines death? What are the measures to ensure that life has ended before irreversible actions are taken? 1 These questions prompted the need for stringent protocols and legal frameworks to diagnose death. 1 Death is not an event but a process. Even though the person is clinically dead, organs and tissues die/disintegrate at different rates and times. The concept of brain death was also established to differentiate it from a persistent vegetative state or deep coma. 2 All these criteria were set to confirm that death had indeed occurred. However, six decades after Barnard’s landmark surgery, premature death declarations are still being made, which strongly emphasises the need for robust protocols and their careful application in medical practice.
Declaring a person dead is one of the delicate procedures in medical practice. It is associated with significant emotional, ethical and legal implications not only for the grieving families but also for healthcare professionals and institutions. Therefore, strict protocols must be followed to avoid diagnostic errors. Declaring a living person dead without full verification violates the duty of care and is negligent and indicates that the attending physician failed to comply with established protocols when assessing vital signs, such as heart rate, breathing and brain activity. Such misdiagnoses cause unnecessary emotional trauma to the family and may lead to premature withdrawal of life-saving interventions or delay in giving treatment. In Nepal, recent reports revealed that four newborns were found alive after being declared dead.
Case series
A preterm newborn was delivered at 23 weeks in a government hospital in Nepal. 3 The newborn weighed 617 g. The doctor on duty did not observe signs of life and declared the baby dead. 3 The grieving family was travelling home with the newborn when, 4 hours later, the family witnessed signs of life. 3
Following this incident, a Google search was conducted to identify the misdiagnoses of death in Nepal reported in the ‘grey’ literature. Three more cases were reported in the newspapers during the last 6 years (Table 1).3–6
Recent misdiagnosed deaths in Nepal.
Case 2 was an 18-day-old neonate who was taken to a government hospital by her parents for treatment, after her mother found she did not suck milk. 4 The on-duty doctor, after examining the baby declared her dead and asked the parents to take her home. 4 However, after reaching home the grieving parents who were planning for cremation, noted the baby move and cry. The parents then immediately rushed to a private hospital for treatment. 4 The history suggested that she was also a premature baby, weighing 1400 g at birth. 4
Case 3 was a premature female baby born at 23 weeks who weighed 600 g. 5 The baby was delivered by 20-year-old female by normal vaginal delivery assisted by nurses in the delivery room. However, after 2–3 hours of live birth, the child did not show signs of life and the in-charge nurse who had delivered the baby declared her dead. 5 Wrapped in plastic, the baby was then taken to the burial ground for cremation. 5 Once the grave was dug and the child was ready for burial, the cemetery worker opened up the plastic only to find the child alive. 5
In case 4, an unmarried woman delivered a child at a hospital. 6 The provided history suggests that the baby was premature. Having been declared dead the baby was being taken for cremation, while the people in the funeral procession found the baby alive. 6
Discussion
In all four cases, the neonates were extremely premature or critically ill, with low birth weights ranging from 600 to 1400 g. Such neonates often show barely detectable or minimal signs of life (i.e. weak cardiac activity, irregular breathing or transient apnoea), obscuring suspended animation as somatic death. However, these phenomena do not exempt clinicians from their duty of thorough evaluation which must be properly documented before a declaration of death. Medico-legally, death must be confirmed according to accepted clinical criteria and should be adequately monitored over a reasonable period of time.
It has long been recognised that it is necessary to distinguish between suspended animation and death in severely compromised newborns. As early as 1839, in the scientific literature, doctors noted and described methods of reviving apparently dead babies while recognising that faint vital signs in very premature or asphyxiated infants maybe missed. 7 Historical resuscitation methods substantiate rather than excuse the failures in the present cases. Even 19th-century practitioners understood the need for prolonged observation and revival attempts were essential before declaring death. 8 With modern monitoring equipment, pulse oximetry and several standardised assessment tools, the diagnostic errors documented here are even less defensible than they would have been two centuries ago.
These cases in which neonates declared dead later showed signs of life upon reaching the funeral site for last rites have once again raised serious concerns and anger towards doctors. Outraged by media reports, members of the public initiated a ‘trial by media’, which promptly found the doctors negligent. Punitive actions alone, without systemic reform, risk mere scapegoating rather than the prevention of a recurrence. In the first case, the doctor attributed the event to the rare Lazarus phenomenon, a condition in which signs of life reappear or spontaneous return of circulation after unsuccessful resuscitation efforts. 9 However, available reports provide no conclusive evidence that resuscitation efforts were ever attempted or documented, thereby undermining (if not negating) this diagnosis.
In case 3 of the present case series, it was noted that the duty nurse declared death. It is current practice in Nepal for a doctor holding a medical degree to declare death. The World Health Organisation (WHO) also states the doctor should only certify death after they are satisfied that there are no signs of life after thorough physical examination and investigation. 10 However, in the present case, if the nurse had declared the newborn dead then the death certificate was not issued. The newborn declared dead had left the hospital without the death certificate or without police intimation. This is bad practice and has medico-legal implications.
Declaring someone dead goes beyond giving a medical opinion; it has legal consequences and a series of legal and administrative procedures follow: death certification, body transfer and funeral arrangements.
In each of these four cases families were told the babies were dead, following which signs of life were discovered. Concerns about medical malpractice, duty of care violations, especially in emergency and neonatal settings and institutional liability for systemic faults such as insufficient personnel, protocols or equipment are raised by this premature declaration of death. These kinds of scenarios can create a mob frenzy and trigger violence against medical practitioners and endanger other healthcare providers.
Further, these four cases raise grave ethical concerns about neonatal rights and respect for life. Reports of babies discovered alive at burial grounds, sometimes repeatedly, point to broader systemic failures and not just the result of individual acts. 5 According to a burial ground worker this is not that uncommon in Nepal which suggests premature death announcements may be less unusual than realised. 5
Healthcare professionals and systems have a profound ethical obligation to preserve life, especially for vulnerable newborns, by minimising avoidable harms due to ignorance, procedural haste, resource constraints or diagnostic uncertainty. 11 The WHO affirms every newborn’s right to essential care, including resuscitation when needed. 12 The American Medical Association (AMA) code of medical ethics stresses that such decisions should prioritise the neonate’s best interests, with parental involvement and support. 13 In addition, poor counselling and communication were a common occurrence in all cases. Families were not adequately informed about the possibility of delayed or subtle signs of life in compromised neonates, the infant’s critical condition and prognostic uncertainty or the clinical reasoning behind declaring death. 14 From an ethical and medico-legal perspective, poor communication significantly augments liability. 15 Even when medical outcomes prove unavoidable, the failure to provide adequate counselling to families may constitute professional misconduct. 15 Documentation is equally important: insufficient, ambiguous, no or missing records undermine public trust in the healthcare system and weaken any legal or institutional defence.
During the 19th century cholera epidemic, the deceased were hastily buried due to fear of contagion. 16 The doctors had a fear of unintentional live burial, known as taphophobia. 17 This led to the design of safety coffins that were equipped with signalling mechanisms such as the bell cord tied to the deceased’s hand, while the bell was kept outside. 17 Despite this fear, there are no recorded instances of someone being saved by a safety coffin. On the contrary, the advent of advanced medical technology and monitoring tools should make premature death pronouncements nearly impossible.
Common administrative response to such incidents includes public apologies, pledges of systemic reform, suspension of healthcare personnel involved and convening investigative committees. Without deep structural reforms, relying solely on punitive measures is insufficient to prevent recurrence of such incidents and may only target individuals instead of addressing the root cause. In addition to individual accountability, systemic responsibility requires standardised, longer, and more thorough death declaration process for newborns. This approach requires comprehensive training to recognise subtle signs of life in compromised newborns. In addition, it necessitates an official national protocol for the management of extremely premature births, including essential monitoring and clear resuscitation criteria.
Conclusions
Premature death declarations represent a profound violation of ethical, legal and social responsibilities and are not merely a clinical error. The consequences extend beyond medical mistakes that affect patient rights, family trauma and public trust. In neonatal and critical care settings, clinical presentations can be elusive. Extremely premature neonates may present with unique diagnostic challenges with barely detectable vital signs. However, these challenges do not exempt clinicians from their duty of care. To prevent such incidents in future, attending clinician must be vigilant, follow clear protocols, possess effective communication skills and should document findings thoroughly. Declaring death requires a combination of professional competence, ethical awareness and legal caution.
Footnotes
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
