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Improving the death certification process
This is an overview of the proposed introduction of medical examiners and reforms to the process of Death Certification in England and Wales.
The reforms are expected to be introduced from April 2018 and responses to the death certification reforms consultation (closing 15 June 2016) will provide more detail about how the changes will be implemented.
Why the current system needs to change
Existing arrangements for death certification are confusing, provide inadequate safeguards, and there is no mechanism that allows the NHS to see patterns, take action and learn from them.
Dr Harold Shipman was able to conceal his wilful malpractice and kill many patients because he relied on others having no reason to question or suspect malpractice when he certified the causes of death. For cremations other doctors, whose role was to independently certify the cause of death, trusted Dr Shipman as a respected colleague and confirmed his dishonest account. For burials Dr Shipman did not need to consult anyone else and relied on the lack of medical knowledge of registrars for his causes of death to be accepted. The system depends on the integrity of a doctor and there is no independent oversight.
The new system will introduce independent safeguards and checks to highlight patterns, both through a review of relevant medical records and by making sure that the family has the chance to raise any concerns. This independent review will make the identifying malpractice easier, provide opportunities for the NHS to learn and address system failures earlier.
The Department of Health accepted the conclusion of the Shipman inquiry third report, published in June 2003, that existing arrangements for death certification are confusing and provide inadequate safeguards.
The government accepted the recommendations from the Francis Inquiry report, 2013 into the events at Mid Staffordshire NHS Foundation Trust, which included the introduction of medical examiners. Medical examiners are doctors who will scrutinise and confirm the cause of all deaths that do not need to be investigated by a coroner before a medical certificate of cause of death (MCCD) is issued.
In February 2007, the Department of Health published a consultation on improving the process of death certification, outlining a programme of work to design, pilot and implement a rigorous and unified system of death certification for both burials and cremations in England and Wales.
The reforms, now enabled in the Coroners and Justice Act 2009, will:
- increase transparency for bereaved families
- improve the quality and accuracy of medical certificates of cause of death (MCCDs)
- introduce 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 requested by a Director of Public Health
The Department of Health recognises that it needs to achieve these outcomes without imposing undue delays on bereaved families or unacceptable burdens on medical practitioners or others involved in the process. We also need to make sure the new system is transparent, proportionate, consistent and affordable.
How the system will be improved
The new medical examiner system aims to provide:
A common approach
All deaths will be scrutinised in a robust and proportionate way, regardless of whether they are followed by burial or cremation, making the system fairer.
Medical certification and the registration of all deaths not requiring coroner’s post-mortem or inquest will be examined in the same way, including:
- unified arrangements for burial and cremation
- a simpler process for arranging funerals
- removal of any inequalities
All deaths will be scrutinised in a thorough and proportionate way, regardless of whether they are followed by burial or cremation, making the system fairer.
Proportionate, independent and consistent scrutiny
All medical certificates of cause of death (MCCDs) will be confirmed by local medical examiners. There will also be an out of hours scrutiny service where it is needed, for example for organ donation or to comply with religious practices.
This will strengthen safeguards for the public and ensure that the right deaths are referred to a coroner.
A transparent process
The certified cause of death is explained to relatives. Relatives will also be given an opportunity to discuss any concerns they might have about the care provided to the person who has died and report the death to a coroner.
An efficient and convenient service
Secure electronic transmission (usually secure email, or in some cases, direct access to records) of all relevant medical information to the medical examiner enables quicker scrutiny and reduces costs. Confirmed MCCDs can be collected from the local hospital or GP or, if required, sent by secure post.
Rejections of MCCDs by registrars are all but eliminated and registrars no longer need to understand medical terminology.
Any 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 be avoided.
High quality information
More complete information on MCCDs, including contributory conditions and factors leading to cause of death and spotting of unusual trends in deaths for local public health surveillance. This will improve the quality of cause of death information for local clinical governance and public health surveillance to help the NHS learn and save more lives in the future.
Malpractice will be easier to detect. The new system will also confirm to the registrar that the death has been discussed and that no concerns were raised that might require the death to be investigated by a coroner.
A system that learns from errors and poor practise
Medical examiners will have powers to report matters of patient safety to the local clinical governance team for prompt action. This will improve safety in the NHS, allowing easier identification of trends and unusual patterns, and enable local learning and changes to practise and procedures.
Paying for the new system
The Coroners and Justice Act 2009 provides medical examiner services for a fee payable to a local authority in England, or local health board in Wales.
At present, families who choose cremation (the large majority in England and Wales) usually pay about £184 in fees for 3 cremation forms. Burial fees are very varied. The new medical examiner system will replace existing forms, processes and associated fees.
The Department of Health’s preferred option for England is a nationally-set fee. The consultation documents and assumptions suggest this fee will be between £80 and £100.
The consultation asks specific questions about who should be responsible for paying for the medical examiner scrutiny and certification of all deaths that do not require investigation by a coroner, and how quickly the fee will need to be paid. The Welsh Government will consult separately on its own funding method and level of fee.
For most people, the new system will cost less, but it will introduce this new fee for those who choose burial. Families opting for burial deserve the same degree of safeguard and assurance about the circumstances surrounding their loved one’s death. We believe there are significant benefits to the new system and it is fairer that these safeguards, either through scrutiny by a medical examiner or investigation by a coroner, apply to all deaths.
The new process
Doctors who are unsure of the cause of death on the MCCD will be able to call a medical examiner for guidance. This will increase the quality and accuracy of the MCCDs and reduce the number of deaths that are unnecessarily reported to a coroner.
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.
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. If there is no attending doctor or none available, then the MCCD can be prepared and signed by the medical examiner.
During scrutiny, a medical examiner may determine that the death is reportable and will refer the death to a coroner. This activity is currently undertaken by registrars and can be difficult if it requires medical knowledge or if it causes distress for bereaved families.
Confirming cause of death
The medical examiner scrutinises the MCCD and the medical records of the deceased.
A medical examiner may determine that the MCCD appears to be incorrect. This would be discussed with the attending doctor, and agree any changes that may need to be made.
A medical examiner may identify clinical governance issues and will advise colleagues who are responsible for taking appropriate local action.
The medical examiner or a medical examiner’s officer will discuss the cause of death with a member or representative of the family of the deceased – ‘the informant’. This is an opportunity for any questions or concerns about the cause of death to be raised. If there are no concerns to be addressed then the medical examiner will prepare and sign a notification stating the confirmed cause of death.
The notification includes the name of the informant – the person with whom the cause of death has been discussed – their relationship to the deceased and the date and time of the discussion. The notification must be signed by the informant, to confirm that the discussion has taken place, before registration of the death can be completed.
Confirmed MCCD and registration
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. Removal of implants and medical devices will need to be confirmed prior to cremation. The informant is expected to give information about any infection hazards to a funeral director or funeral arranger so that appropriate action is taken to meet health and safety requirements.
A death is usually registered before burial, cremation or other chosen legal action. However, where a funeral needs to take place very quickly after a death, possibly to comply with religious or cultural practices, the registrar may be able to issue authority to proceed prior to registration, provided that the scrutiny is completed, and the MCCD and notification form are confirmed.
Burials are authorised by the registrar – they issue the Green Form to the informant once they are satisfied all the safeguards have been completed. The Green Form must be handed to the funeral director or arranger.
Testing the reforms
Local teams piloted the system successfully in Sheffield, Gloucestershire, Powys, Mid Essex, Leicester, Inner London and Brighton and Hove. These test sites provide feedback and help to improve the process; making sure that the procedures and forms are practical, effective and acceptable, and that the bereaved remain at the centre of the reforms.
Results from the pilots show that:
- the time required by medical examiners to scrutinise and confirm the cause of death has not caused undue delay or difficulty for the bereaved
- coroners are receiving fewer calls from doctors asking for advice
- registrars have welcomed the new process and reported that it makes registration easier to complete
- rejection of MCCDs by registrars have been all but eliminated
- the majority of the bereaved provided positive feedback about the discussion of the cause of death
Professional standards and training
The Academy of Medical Royal Colleges has developed a curriculum and training materials for medical examiners.
The curriculum being developed for medical examiners will help them:
- navigate the system of death certification and develop strong relationships with their partners
- understand the issues when discussing the cause of death with the recently bereaved
- identify and overcome death certification problems
A Medical Examiner Committee has been established, leading the development of quality and performance standards for medical examiners, alongside the training.
The Medical Examiner Curriculum has been developed in partnership with:
- The Coroners’ Society of England and Wales
- The Royal College of Pathologists
- Department of Health
- Royal College of Physicians
- Ministry of Justice
- The Royal College of Surgeons of England
- The Royal College of Obstetricians and Gynaecologists
- The College of Emergency Medicine
- The Royal College of Psychiatrists
- The Royal College of Paediatrics and Child Health
- Royal College of General Practitioners
Medical examiner recruitment
Local authorities will have responsibility for appointing medical examiners. Local Health Boards will be responsible for appointing medical examiners in Wales.
It is expected that around 385 experienced doctors will be recruited to work as medical examiners, mostly on a part-time basis.
Medical examiners must be registered medical practitioners with at least 5 years experience and have been practising within the previous 5 years.
Dr Alan Fletcher, Consultant Emergency Physician, Medical Examiner, Sheffield Teaching Hospitals NHS Foundation Trust said,
It has been one of the most rewarding roles in my medical career. The opportunity to listen to and help bereaved people as well as guide and enlighten attending doctors has been so worthwhile.
Feedback has been overwhelmingly positive and steps towards extended implementation are very much welcomed.
Background: history of death certification
Death certification is almost unchanged since 1935:
- 1840s: Introduction of first books of forms for certifying the cause of death. These became the medical certificates of cause of death (MCCDs).
- 1874: Registered doctors required to provide a written statement of the medical cause of death unless they know that an inquest is to be held.
- 1885: Registrars required to report any sudden deaths or deaths where the cause was unknown to the coroner, as well as deaths that appeared to be due to violence or suspicious circumstances.
- 1903: Regulations formalised the role of the Medical Referee and the use of Cremation Forms.
- 1911: International Classification of Diseases adopted by the UK and made available to doctors to improve the certification of death.
- 1926: Burial or cremation requires a registrar’s certificate or coroner’s order. Attending doctor required to give MCCD to registrar before a certificate for disposal can be issued and must have seen the deceased person in the 14 days prior to death or seen the body after death.
- 1935: Cremation Regulations widened the doctors who can provide secondary certification and moved responsibility for the appointment of Medical Referees to the Home Office.
- 1935 to 2000: Arrangements for death certification, particularly secondary certification for cremations, reviewed. Differences of opinion prevented any changes being made.
- 2009: The Coroners and Justice Act enables a new independent role, the medical examiner, to scrutinise and confirm the cause of death proposed by a doctor.
If you would like further information please contact email@example.com
You can also provide your views on death certification reforms in the consultation.
There is more information available from the Bereavement Advice Centre.