UK: Changes To Death Certification: A Brief Overview

The Department of Health is currently in the process of transforming the death certification procedure following recommendations made by the Shipman Inquiry. The proposed changes will require the certified cause(s) of all deaths that are not investigated by a coroner to be independently scrutinised and confirmed by a locally appointed medical examiner. The changes will also offer an important opportunity to provide improved information on cause of death to strengthen public health surveillance.

Background

There can be few people who are unaware of Harold Shipman, a respected GP from Manchester, who, over a great number of years, was responsible for the murder of around 250 of his patients. After Shipman’s conviction, an inquiry was set up to investigate the extent of his unlawful activities. Part of the inquiry examined the processes for death certification and the coronial system, and considered whether more clues could have been found by better scrutiny either of individual deaths or of the pattern of deaths among Shipman’s patients.

Under the current system, the doctor responsible for a patient’s care during their final illness completes a ‘medical certificate of the cause of death’ (MCCD). This is the basis of the registration of the death. Doctors refer the case to the coroner if they have any suspicions over the cause of death or in other specified circumstances. The registrar of births and deaths checks the MCCD to ensure that it is correctly completed and reports any cases to the coroner where the MCCD or information from the family of the deceased suggests that further investigation is needed1 .

Where the bereaved family chooses a burial, there are no further checks on the MCCD. A number of further steps are required where the family chooses a cremation. Currently therefore, setting aside coroners’ cases, only deaths followed by cremation are subject to formal checks for any untoward signs.

The Shipman Inquiry concluded that the system provided inadequate safeguards, particularly against the very unlikely albeit not unthinkable possibility that the doctor completing the MCCD was responsible for the patient’s death. It proposed a radical overhaul both of the coronial system and of the arrangements for death certification, in which principally, a single system for the oversight of death certificates would be established.

Aims of reform

The new system will seek to address the above discrepancies and is intended to:

  • Increase safeguards for the public by providing robust and independent scrutiny of the medical circumstances and cause of death and ensuring that the right deaths are notified or referred to a coroner

  • Improve the quality of certification by providing expert advice to doctors based on a review of relevant health records

  • Avoid unnecessary distress for the bereaved resulting from unanswered questions about the certified cause of apparently natural deaths or from unexpected delays when registering a death

The aims of the reforms will be achieved through the appointment of medical examiners, the creation of local medical examiner’s services and the introduction of a unified process of certification. The new system will provide safeguards for all deaths, which do not need to go to a coroner.

Medical examiners

The new medical examiner service will be run by local authorities. It is anticipated that each area/service will have a lead medical examiner and that one lead examiner in each region will represent colleagues in discussions at a national level. The location of medical examiner’s offices will likely be a matter for each (lead) local authority/local health board.

The Coroners and Justice Act 2009 sets the minimum requirement that, at the time of their appointment, all medical examiners must have been a registered medical practitioner for at least five years and either be in practice or have practised during the last five years. Medical examiners can come from any medical speciality or from general practice.

General consensus is that medical examiners should be (or have been) consultant grade doctors in hospitals or their equivalent in general practice, to ensure that they have the seniority, experience and credibility to provide advice to senior medical colleagues and to coroners on a peer-to-peer basis.

Timeframe

The Department of Health is continuing to prepare for implementation of the reforms. The Coroners and Justice Act 2009 sets out the legal basis for the new system and The Health and Social Care Act 2012 includes provision for responsibility for the new medical examiner service to sit with local authorities.

National implementation of the new local medical examiner service will likely take place in April 2014. The Department of Health is due to launch a second public consultation on the death certification process imminently, which will centre on the draft regulations. In the meantime, The Department of Health is currently producing two monthly newsletters on its website designed to keep all parties up to date with the reforms as they progress.

As with all reforms, and particularly those dependent on the reallocation of a finite pool of public money, it remains to be seen whether or not they will be adopted entirely. Nevertheless, Trusts should be encouraged to monitor progress, which in due course will require steps to ensure that the new system of reporting is familiar to staff and is properly and consistently implemented.

Footnotes

1 Incidentally, registrars are not medically qualified, do not have access to medical records, and are not necessarily in a position to make informed judgments about the validity of the stated cause of death.

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.

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