Research and analysis

Amending the medical certificate of cause of death (MCCD) process: survey results

Published 9 September 2024

Applies to England and Wales

Executive summary

A medical certificate of cause of death (MCCD) is a permanent legal record of the cause of a person’s death. It enables the representative of the deceased to:

• register the death
• arrange disposal of the body
• settle the deceased’s estate

Data from death certificates is also used to measure the relative contributions of different diseases to mortality and is therefore an important source of information for designing and evaluating public health interventions and recognising priorities for medical research and health services.

Under the Coroners and Justice Act 2009, the medical practitioner (registered medical practitioner according to the General Medical Council’s register) who attended the deceased during their last illness has a legal responsibility to complete a MCCD and arrange for delivery of the certificate to the relevant registrar to enable the registration to take place.

The death is referred to a coroner if the medical practitioner:

• had not seen the patient within the 28 days preceding death (this can include consultation using video technology)
• had not seen the body after death (this must be through physical attendance)
• and/or was not involved in the patient’s care at any time during the illness from which they died

If the coroner does not investigate the death through an autopsy and/or inquest, the death will be legally ‘uncertified’. In 2022, there were 8,054 legally uncertified deaths in England and Wales, accounting for 1.4% of all registered deaths that year. This was an increase on the rate seen in previous years, which averaged 0.4% from 2017 to 2021.

To understand whether the system could go further in addressing this problem, the Department of Health and Social Care (DHSC) issued a survey to professionals involved in the death management system in England and Wales. The survey remained open for 5 weeks over June and July 2023. It asked respondents whether the period within which a medical practitioner attended a patient prior to death should continue to be specified and, if so, whether the current 28-day period should be retained or extended.

Respondents also had the opportunity to explain their answers and highlight practical considerations for implementing change.

935 individuals responded to the survey, of which 70% worked in England and 30% in Wales. In summary:

• respondent views were mixed: around 3 in 5 (61%) said a period should continue to be specified; 1 in 3 (34%) said it is not necessary; and 1 in 20 (5%) were unsure. Respondents were most likely to say a period should continue to be specified if they were a ‘funeral director or manager’ (79% in favour), and least likely if they were a ‘coroner or coroner’s officer’ (58% in favour) or medical practitioner (55% in favour)
• of those who said a period should continue to be specified, roughly 2 in 5 said ‘in the 28 days preceding death’ (42%) and/or ‘in the 3 months preceding death’ (40%) were reasonable options. Support for retaining the existing 28-day period was higher among respondents in Wales (52%) than England (38%), and among funeral directors (51%) compared to other professions, such as ‘coroners and coroners’ officers’ (27%)
• a further 1 in 5 respondents (19%) said attendance ‘at any point during the patient’s last illness’ would be a reasonable period. Support for this option was highest, on average, among ‘coroners and coroners’ officers’ (27%) and lowest among funeral directors (8%)
• those in favour of retaining a shorter period felt this was necessary to maintain accuracy in cause of death certification, making it easier for medical practitioners to remember the patients they have cared for, lowering the risk of missing an acute illness or infection, and providing reassurance to family members that the practitioner issuing the certificate knew the deceased
• those in favour of extending the requirement to ‘any time during the patient’s last illness’ felt it better reflected the realities of the health system today, with a greater volume of people receiving care from a range of professionals (or multi-disciplinary teams) rather than a single named GP. They also felt the need for a ‘rigid’ period was less relevant where a death is expected, electronic medical records are up-to-date, and there were no unusual circumstances surrounding the death
• irrespective of views held on whether a period should be stipulated, and what that period should be, respondents put forward many of the same practical points to consider if any changes are introduced. This included, for example:
  • ensuring the term ‘attended’ is more clearly defined, and reflects the increased use of telephone consultations in general practice
  • expanding the pool of medical practitioners who can certify cause of death
  • ensuring patients’ medical records are accurate, kept up to date, supported where necessary by healthcare professional notes and observations, and accessible across the health system
  • ensuring there is independent scrutiny of deaths (for example, by medical examiners) to maintain accuracy and confidence in the system
  • the need for an intensive communications campaign, alongside training, education and guidance on any changes to all involved in the death management system
  • not forgetting and continuing to learn from what has ‘gone wrong’ in the past, putting the needs of the bereaved at the centre of change, and introducing more effective controls to govern the cremation process and guard against malpractice

Background

Death certification reforms

The death certification system in England and Wales has remained largely unchanged for over 50 years. Introducing a robust system in England and Wales whereby all deaths would be subject to either a medical examiner’s scrutiny or a coroner’s investigation has been an ambition of successive governments and ministers.

The Coronavirus Act 2020 introduced some easements to death certification processes, as part of the government’s emergency response to the COVID-19 pandemic. Prior to this, the attending doctor had to have seen the deceased within 14 (rather than 28) days preceding death. While many provisions in the act expired on 24 March 2022, this change was retained on a permanent basis.

To understand whether the system could go further in reducing the volume of legally uncertified deaths, DHSC issued a survey to professionals involved in the death management system in England and Wales, in 2023.

The purpose of the survey was to gather views on whether the period within which a medical practitioner attended a patient prior to death should continue to be specified and, if so, what the timeframe should be. Respondents also had the opportunity to explain their answers and highlight practical considerations for implementing change.

Survey methodology  

Format of the survey

DHSC worked closely with NHS England, the Ministry of Justice, Home Office, and Office of the Chief Coroner, to disseminate an online survey to professionals working in the death management system in England and Wales.

The survey contained 3 demographic questions (on geographical location and profession) and 5 attitudinal questions (including space to provide detailed comments). It remained open for 5 weeks across June and July 2023.

Data analysis

Free-text responses

Within the survey, respondents were asked to select their profession(s) from a pre-defined list. They could also select ‘other’ and type in another profession and/or post held.

Two analysts reviewed the ‘other’ responses and, where appropriate, combined categories or created new categories of job roles where there were enough respondents.

Table 1 sets out the final labels that were used for our analysis of results by profession, and the roles disclosed by respondents that were captured in each group.

Table 1: grouping of responses by profession

Final label	Roles included (of those disclosed through the survey)
Bereavement services	bereavement officer; bereavement services manager or leader; mortuary and bereavement service manager or leader
Burial and cremation services or authority	burial and cremation professional; cemetery and/or crematoria manager or operator; undertaker
Coroners and coroner’s officers	coroner; coroner’s officer; medically qualified coroner; coroner’s service manager
Funeral director or manager	funeral director; funeral company manager; funeral home owner
Medical examiners and officers	medical examiner; lead medical examiner (LMEO); medical examiner officer (MEO)
Medical practitioners	medical practitioner; consultant; pathologist
Medical referee	medical referee
Registrar or registrar officer	registrar; registration officer of births and deaths
Other	advanced nurse practitioner (ANP); consultant nurse; local authority; medical academic; paramedic; pharmacist; physiotherapist; public health doctor; faith body representative

For the other open-ended questions in the survey, where respondents could explain their views or provide suggestions, 2 analysts undertook inductive content analysis to identify patterns and themes, without preconceived categories or theories.

Calculating percentages

All percentages presented in this report have been calculated out of the total number of respondents answering the question in hand, rather than the total number of people responding to the survey overall.

Data suppression

Within our data tables and charts, the shorthand [c] is used where a data point would disclose confidential information (for example, the answer provided by a single or very small group of respondents). This is in line with government Statistical Disclosure Control (SDC) guidelines.

Limitations of the results

When reading this report, it is important to note the following caveats:

• the results are only representative of those who responded to this survey and cannot be taken to represent the views of all those involved in the death management system
• the suggestions for and against change set out in this report represent the views of those who responded to this survey – we recognise there may be alternative views on specific issues, and the inclusion of these does not mean they are endorsed or accepted by DHSC or government

Survey results

Overall, 935 individuals responded to our survey. The results are summarised under the following sub-headings:

• respondent characteristics
• specifying a period for attending the patient before death
• practical considerations for change

Respondent characteristics

Work location

All respondents were asked a mandatory question: ‘Where in the UK do you work?’ This was to ensure we only gathered views from professionals based in England or Wales.

As shown in table 2, 70% told us they work in England and 30% in Wales.

Table 2: work location in UK

Country	Count	Percentage
England	651	70%
Wales	284	30%
Total	935	100%

Respondents were then asked where in England or Wales they were based. The results are shown in tables 3 and 4 below.

Table 3: work location in England

Region	Count	Percentage
East of England	67	10%
London	90	14%
Midlands	106	16%
North East and Yorkshire	94	14%
North West	48	7%
South East	145	22%
South West	99	15%

Table 4: work location in Wales

Region	Count	Percentage
Mid or West Wales	15	5%
North Wales	60	21%
South Wales East or South Wales Central	157	55%
South Wales West	51	18%

Profession

To ensure we were gathering views from respondents involved in the death management system, we asked them: ‘What is your profession?’

Respondents could select one or more professions from a pre-defined list, and/or select ‘other’ and type in their role.

As shown in table 5, the most common profession held by two-thirds (66%) of respondents was that of ‘medical practitioner’.

Table 5: what is your profession? (multiple choice allowed)

Profession	Count	Percentage
Medical practitioner	620	66%
Medical examiners and officers	125	13%
Medical referee	84	9%
Funeral director or manager	80	9%
Coroner and coroner’s officers	64	7%
Registrar or registrar officer	56	6%
Burial and cremation services or authority	25	3%
Bereavement services	8	1%
Other	18	2%

Specifying a period for attending the patient before death

Whether a period should be specified

We asked respondents whether legislation should continue to specify the period within which a medical practitioner attended a patient prior to death, for the purpose of certifying their cause of death.

Respondent views were mixed: around 3 in 5 respondents (61%) said a period should continue to be specified; 1 in 3 (34%) said it does not need to be specified; and 1 in 20 (5%) were unsure (table 6). 

Table 6: should the period within which a medical practitioner attended a patient prior to death be specified, assuming they can state the cause of death to the best of their knowledge and belief? (overall results)

Response	Count	Percentage
Yes - the time period should be specified	572	61%
No - the time period does not need to be specified	319	34%
Not sure	44	5%

Similar views were held across England and Wales (table 7).

Table 7: should the period within which a medical practitioner attended a patient prior to death be specified, assuming they can state the cause of death to the best of their knowledge and belief? (results by country)

Response	England	Wales
Yes - the time period should be specified	61%	62%
No - the time period does not need to be specified	36%	31%
Not sure	4%	7%

However, views did vary by profession. As shown in Figure 1, 79% of respondents who were funeral directors or managers said a time period should continue to be specified, compared to just 55% of medical practitioners.

Figure 1: proportion of respondents by profession agreeing that the period within which a medical practitioner attended a patient prior to death should be specified

Profession	Percentage
Funeral director or manager	79%
Medical referee	77%
Registrar or registrar officer	75%
Medical examiners and officers	62%
Other profession	61%
Coroner and coroner’s officers	58%
Medical practitioner	55%

Note that the results for ‘Burial and cremation services or authority’ and ‘Bereavement services’ in Figure 1 are suppressed due to small sample sizes.

Rationale for specifying a period (or not)

Respondents were given the opportunity to explain why they thought the period within which a medical practitioner attended a patient prior to death should continue to be specified (or not).

The main point stressed by respondents in favour of retaining a specified period was that some level of ‘recent’ attendance is necessary to ensure continuity of ‘care’ and accuracy in completing the medical certificate of cause of death.

However, many of the same respondents caveated their response by suggesting that:

• the period does not necessarily need to remain at 28 days - many surgeries now have part-time GPs, and so extending the period could help prevent delays caused by the relevant GP working fewer days per month
• ‘attendance’ prior to death should include a broader range of virtual consultations - with some general practices using an e-consult or telephone appointment first model, and video consultations requiring much more organisation and in some instances being done ‘just in case’ the patient passes away
• a wider range of health professionals should be able to certify cause of death

Interestingly, respondents who said that it was no longer necessary to stipulate a period for attending the patient prior to death cited many of these ‘caveats’ as ‘justifications’ for removing the requirement. For example, they said that:

• the system does not reflect the fact that, nowadays, GPs often delegate ‘seeing or attending’ patients to others in their practice (such as district nurses) and are less likely to have physically seen their patients recently, especially with the uptake of telephone consultations
• the out-of-hours service is usually undertaken by locums who may not reside in the associated area and are sometimes disinclined to provide a MCCD (even though they satisfy the criteria of having ‘attended’), leaving it to the ‘usual’ GP to issue which may not be possible
• the electronic patient record held by the general practice can give considerable insight to complete a MCCD on ‘best knowledge and belief’, with some questioning whether face-to-face contact with the patient 28 days prior to death would add any new insight
• when a death is expected (for example, in the case of patients with chronic or terminal conditions), medical records are up-to-date, and there were no unusual circumstances surrounding the death, the requirement for them to have been seen 28 days prior to death appears arbitrary and disproportionate
• the current system does not reflect the growing use of multi-disciplinary teams and the fact that there are often health professionals who have more frequent contact with patients prior to death than their medical practitioner, particularly those involved in palliative and end-of-life care

What the period should be

If a respondent told us that the period for attending a patient prior to death should continue to be specified, they had the opportunity to tell us what they thought a reasonable period would be.

Of those who answered the question, roughly 2 in 5 said ‘in the 28 days preceding death’ (42%) and/or ‘in the 3 months preceding death’ (40%). A further 1 in 5 respondents (19%) suggested attendance be ‘at any point during the patient’s last illness’. See table 8.

Table 8: time period for attending patient prior to death, of those who agreed a period should still be stipulated (multiple choice allowed)         

Response	Count	Percentage
Attended in the 28 days preceding death	239	42%
Attended in the 3 months preceding death	229	40%
Attended in the 6 months preceding death	77	14%
Attended in the 9 months preceding death	7	1%
Attended at any time during the last illness	106	19%
Other time period not listed	17	3%

Respondents based in Wales were more likely than those based in England to say that ‘attending in the 28 days preceding death’ is a reasonable amount of time (52% compared to 38% respectively). See table 9.

Table 9: time period for attending patient prior to death, of those who agreed a period should still be stipulated (multiple choice allowed) - by country

Note: c means results have been suppressed due to small sample size.

Response	England	Wales
Attended in the 28 days preceding death	38%	52%
Attended in the 3 months preceding death	43%	34%
Attended in the 6 months preceding death	16%	8%
Attended in the 9 months preceding death	2%	c
Attended at any time during the last illness	17%	22%
Other time period not listed	3%	c

Respondents’ views also varied by profession, as shown in table 10.

For example, across professions (where there were enough responses):

• ‘Attended in the 28 days preceding death’ was the most popular option selected by respondents who worked in ‘funeral director or manager’, ‘medical referee’ and ‘registrar or registrar officer’ roles (51%, 45% and 45% respectively)
• ‘Attended in the 3 months preceding death’ was the most popular option selected by respondents who worked in ‘medical examiner and officer’, ‘medical practitioner’ and ‘coroner and coroner’s officer’ roles (44%, 41% and 38% respectively)

Table 10: time period for attending patient prior to death, of those who agreed a period should still be stipulated (multiple choice allowed) by profession

Note: c means results have been suppressed due to small sample size.

Profession (multiple choice allowed)	Attended in the 28 days preceding death	Attended in the 3 months preceding death	Attended in the 6 months preceding death	Attended in the 9 months preceding death	Attended any time during last illness
Bereavement services	c	c	c	c	c
Burial and cremation services or authority	c	c	c	c	c
Coroner and coroner’s officers	27%	38%	c	c	27%
Funeral director or manager	51%	41%	c	c	8%
Medical examiners and officers	32%	44%	c	c	22%
Medical practitioner	39%	41%	16%	c	21%
Medical referee	45%	34%	c	c	20%
Registrar or registrar officer	45%	43%	c	c	14%
Other profession	c	55%	c	c	c

Rationale for different time periods

Respondents had the option of explaining the length of time they felt was reasonable for a medical practitioner to have attended the patient prior to death.  

Most comments focused on the ‘extremities’ of retaining a ‘shorter’ period of 28 days or 3 months or easing the requirement to ‘any time during the last illness’.

Retaining a ‘shorter’ period

The main points raised by those in favour of retaining the current 28-day period or extending slightly to a 3-month period were:

• the limit has already been doubled, from 14 to 28 days, with measures introduced during the pandemic being retained - there is no need for further change
• the shorter the period, the lower the risk of missing an acute illness or infection, and of introducing inaccuracies and conjecture into the specified cause of death
• given the volumes of patients’ medical practitioners deal with, it is easier to remember individuals and certify their cause of death if you saw them and/or were involved in their care ‘recently’
• it provides reassurance to family members that the practitioner issuing the death certificate knew the deceased and can be confident in stating the cause
• a longer period may place a greater burden on the medical examiner system, to ensure deaths are sufficiently scrutinised and the recorded cause of death credible

Extending the requirement to ‘any time during last illness’

The main points raised by those in favour of extending the requirement to ‘any time during the patient’s last illness’ were:

• if the cause of death is certain, or can be accurately deduced from medical records and speaking to those professionals involved in the patient’s care, then the need for a rigid time period becomes irrelevant
• there are groups of patients - such as those with terminal health conditions under regular review with a palliative care team - who may not need a GP to see them directly within 28 days prior to death, and so getting rid of an arbitrary requirement may reduce the number of coroner referrals and delays for families in making funeral arrangements
• it better reflects the way the health care system operates in ‘today’s world’, with fewer people seeing GPs as regularly since the COVID-19 pandemic, and a greater volume of people being cared for by a range of healthcare professionals rather than a single, named doctor

Points raised beyond the time period specified

Many respondents raised points that went beyond justifying what a reasonable period may be for attending the patient prior to death.

These included, for example:

• the term ‘attended’ has never been adequately defined in the regulations, is too vague and open to misinterpretation
• the death certification system does not reflect the post-COVID-19 landscape of GP surgeries holding an increasing number of consultations over the phone, where the patient is therefore not physically seen by a doctor (in person or via video call)
• the pool of practitioners who can certify a death should be expanded: fewer patients have a ‘family GP’ now, doctors are dealing with a much higher volume of patients, and there is an increase in the use of multi-disciplinary teams in caring for patients, all of which reduce the likelihood of a single, named doctor caring for a patient during their lifetime and/or illness
• there is a need for patient records to be improved - accessing current and historic medical records is not always straightforward, and quality can vary, with use of abbreviations and lack of a clear narrative of the patient’s journey to the illness or condition which resulted in their death

Practical considerations for change

We asked respondents if there are any practical points they think should be considered if the time period is removed or extended beyond the current 28 days.

The main suggestions put forward were:

• if there is to be increased reliance on patients’ medical records, there is a greater need to ensure those records are accurate, thorough, kept up-to-date, and supported where necessary, by other healthcare professional notes
• new forms of patient ‘attendance’ and/or interaction should be included in the certification process, going beyond ‘face-to-face’ contact
• the pool of healthcare professionals who can certify a death should be expanded - or at the very least, they should play a greater role in the certification process, such as being consulted where cause of death is not clear from medical records
• there is a need for a ‘second pair of eyes’ and/or  independent scrutiny of deaths to maintain accuracy and confidence in the system - which some felt would be addressed through the Medical Examiner System
• an intensive communications campaign, alongside training, education and guidance to all involved in the death management system, is crucial to implementing any changes successfully

Finally, some respondents emphasised the importance of not forgetting and continuing to learn from what has ‘gone wrong’ in the past (building on, for example, the Shipman Inquiry). The main points raised were:

• the desire to respond to system pressures should not supersede the need for medical probity
• bereaved families need to be at the centre of any change - they deserve a robust system of death certification to provide peace of mind, as well as access to a funeral within an acceptable timeframe
• there needs to be more effective controls in place to govern the cremation process and guard against malpractice - especially with the removal of the requirement to complete a confirmatory medical certificate (form Cremation 5)