Last reviewed 18 August 2016
The Government has published guidance on the changes it is making to the process of death certification in England and Wales, Martin Hodgson explains.
The changes are being introduced under the Coroners and Justice Act 2009.
An Overview of the Death Certification Reforms, published in May, provides guidance on the proposed introduction of medical examiners and describes the reforms being introduced to the death certification process itself.
Calls for changes were made following the inquiry into the murders committed by Dr Harold Shipman.
Shipman was able to conceal his activities by utilising weaknesses in the death certification process. For instance, for cremations other doctors, whose role was to independently certify the cause of death, trusted Dr Shipman and confirmed his accounts. For burials, he did not need to consult anyone else and used the lack of medical knowledge of registrars for his dishonest causes of death to be accepted.
Reviewing the process, the Government accepted the conclusion of the Shipman inquiry that arrangements were confusing and provide inadequate safeguards. The system was seen to have too many loopholes and bereaved families had too little access to information. There were inconsistencies between areas and overview and governance arrangements were also seen as inadequate, meaning that nobody was in a position to spot when things were going wrong. These views were strongly supported by the Francis inquiry into deaths at Mid Staffordshire NHS Foundation Trust.
In February 2007, the Department of Health (DoH) published a consultation on improving processes and implementing a uniform new system of death certification for both burials and cremations.
The proposals, outlined in Consultation on Improving the Process of Death Certification, enabled by the Coroners and Justice Act 2009, were designed to:
increase transparency for bereaved families
improve the quality and accuracy of medical certificates of cause of death (MCCDs)
introduce the role of “medical examiners” to provide a system of effective medical scrutiny applicable to all deaths that do not require a coroner’s post-mortem or inquest
enable medical examiners to report matters of a clinical governance nature to support local learning and changes to practice and procedures
provide information on public health surveillance.
Under the new “medical examiner” system, a common approach will be introduced whereby all deaths will be scrutinised in “a robust and proportionate way” regardless of whether they are followed by burial or cremation.
All MCCDs will be confirmed by local medical examiners, with an out-of-hours scrutiny service in place where it is needed, for example, for organ donation or to comply with religious practices. This level of scrutiny and overview is designed to ensure that the right deaths are referred to a coroner and that a case like Shipman can never happen again.
As well as these additional safeguards, the new system is designed to be fairer and more transparent for relatives. The certified cause of death will be explained to relatives and they will be given an opportunity to discuss any concerns they might have.
Under the proposed arrangements, the efficiency of the service will be improved to eliminate unnecessary delays. Relevant clinical information will be sent to the medical examiner by secure electronic transmission (usually secure email, or in some cases, direct access to records) to enable quicker, fuller scrutiny. Confirmed MCCDs will be collected from the local hospital or GP or, if required, sent by secure post.
The DoH guidance states that rejections of MCCDs by registrars will be all but eliminated in the new system, and registrars will no longer need to understand complex medical terminology. Unnecessary distress for those who are bereaved, resulting from unanswered questions about the certified cause of death or from unexpected delays when registering a death, will therefore be avoided.
The new system is designed to help eliminate the sort of malpractice that allowed Shipman to hide his crimes. It will also help to identify the unusual patterns of deaths that were a feature of the Francis inquiry into the Mid Staffordshire NHS Foundation Trust.
The guidance states that, under the new system, more complete information on MCCDs will be available, including contributory conditions and factors leading to cause of death. This will improve the quality of cause of death information for local clinical governance and public health surveillance systems to help the NHS learn and save more lives in the future. Poor practice will also be identified by powers for medical examiners to report safety concerns to local clinical governance teams.
The DoH guidance confirms that, under the new system.
Where a death does not need to be investigated by a coroner, the attending doctor will prepare the MCCD and send a copy to the Medical Examiner’s Office.
Doctors who are unsure of the cause of death will be able to call a medical examiner for guidance, increasing the quality and accuracy of MCCDs and reducing unnecessary reports to a coroner.
Medical examiners scrutinise each MCCD and the medical records of the deceased.
The medical examiner may determine that the MCCD appears to be incorrect and discuss this with the attending doctor.
The medical examiner may also determine that a death is reportable and refer it to a coroner, an activity currently undertaken by registrars.
When a death that has been notified to a coroner is found not to require a post-mortem or inquest, the doctor will prepare an MCCD and transmit it to the medical examiner in the same way as for a non-reportable death.
To confirm the cause of death, the medical examiner will discuss the cause of death with a member or representative of the family of the deceased (the informant) and if there are no concerns, the medical examiner will prepare and sign a notification stating the confirmed cause of death — this will be countersigned by the informant.
The notification will be given to the attending doctor and the registrar that the MCCD is confirmed and can be issued to the informant.
The registrar compares the MCCD and the notification, ensures the notification is signed by the informant, and registers the death.
Once the confirmed MCCD has been issued, the funeral director will be able to prepare the body for burial, cremation or other chosen legal action.
Burials are authorised by the registrar through issue of a completed form.
The current role of the medical referee, who authorises cremations at a crematorium, will be abolished when medical examiners are introduced.
The new system has been piloted successfully in a number of areas. It is expected to be introduced from April 2018.
Work is now going ahead to recruit sufficient numbers of new medical examiners.
The DoH guidance states that medical examiners must be a registered medical practitioner with at least 5 years experience and have been practising within the previous 5 years. In collaboration with the Coroners’ Society of England and Wales, the Academy of Medical Royal Colleges has developed a curriculum and training materials for medical examiners. A Medical Examiner Committee has also been established, leading the development of quality and performance standards.
Local authorities in England and local health boards in Wales will have responsibility for appointing medical examiners.
The DoH guidance will be further informed by the results of a new consultation, Introduction of Medical Examiners and Reforms to Death Certification in England and Wales: Policy and Draft Regulations. In addition to seeking views on introducing a statutory duty on registered medical practitioners to report deaths in prescribed circumstances to the coroner for investigation, this latest consultation, which closed in June 2016, also explored changes to cremation regulations.
An Overview of the Death Certification Reforms, is available on the GOV.UK website.