The LMC receives many queries on the subject of death certification, and Coronial regulations.

It is incumbent on those working with the bereaved to recognise that these processes can cause significant distress to them.

The BMA promotes the following core principles in these matters:

• This subject matter is of significant distress to the bereaved. All participants in the system must be conscious of this and conduct themselves in a manner that does not add to the emotional suffering of families.
• All those involved respect the dignity, religious and cultural needs of the deceased and family members.
• The timely and efficient verification of death is highly important and those responsible should act accordingly. We encourage workers in the wider health and care system to work collaboratively with doctors to achieve this.
• The procedures for certification can provide a valuable safeguard against wrongdoing and everyone involved in this process should raise any concerns they have as a matter of urgency.

There are three separate processes to go through when a patient dies:

• Firstly, the death must be verified by a suitable qualified person pronouncing that life is extinct.
• Secondly, a decision must be made as to whether the death is referred to the coroner.
• Thirdly, the MCCD must be signed by a doctor and countersigned by a medical examiner from 9/9/2024

The law requires a doctor to notify to the Registrar of Births and Deaths the cause of death for any patient whom he or she has attended (documented consultation in person or via video) during that patient’s lifetime, and who knows the cause of death to the best of their knowledge and belief. The doctor is required to notify the cause of death as a certificate, on a form prescribed.

It should be noted that the strict interpretation of the law is that the doctor shall notify the cause of death, not the fact. Thus, a doctor does not certify that death has occurred, only what in his or her opinion was the cause, assuming that death has taken place. Arising out of this interpretation there is no obligation on the doctor even to see, let alone examine the body before issuing the certificate. The Broderick report recommended that a doctor should be required to inspect the body of a deceased person before issuing the certificate, but this recommendation has never been implemented. Thus, there is no requirement in English law for a General Practitioner or any other registered medical practitioner to see or examine the body of a person who is said to be dead.

GPs, as a body would not and as individuals should not, seek to use this quirk of English law to avoid attending upon an apparently deceased patient for whom the GP is responsible.

However, the fact that there is no legal obligation upon a GP to attend the deceased should be remembered and, if necessary, quoted when organisations such as the emergency services ask GPs, either in or out of hours, to attend the deceased as a matter of urgency. If a patient is declared to be dead by a relative, a member of staff in a nursing home, ambulance personnel or the police, GPs would be acting correctly by prioritising the needs of their living patients.

On a parallel basis, case law exists to confirm that an NHS GP does not have a contractual obligation to attend upon the body of a patient declared to be dead. Once again, the fact that a contractual obligation does not exist should never be used by GPs to avoid the ethical and moral responsibility to make the experience of bereavement as gentle and easy as possible for relatives and friends.

Verification of Death

There is often confusion around this issue. It has never been necessary for a doctor to verify death – this task has always been something that can be done by a nurse or other competent person, a phrase which can be interpreted to include other professionals who have been trained to do this.

We want to be able to allow staff to work efficiently to the top of their licence. We must support them to do so. We also want to avoid unnecessary visits to verify death, in order to protect clinician capacity in the face of significant workload and workforce pressures

Verification of the fact of death:

Verification of the fact of death documents this formally in line with national guidance and is associated with responsibilities of identification of deceased, notification of infectious illnesses, and implantable devices. This is recognised as the official time of death. Verification of death follows a set of steps and therefore requires some training.

Certification of death:

Certification of death is the process of completing the ‘Medical Certificate of the Cause of Death’ (MCCD) by a medical practitioner in accordance with The Births and Deaths Registration Act 1953, underpinning the legal requirements for recording a person’s death.

Expected death:

An expected death is the result of an acute or gradual deterioration in a patient’s health status, usually due to advanced progressive incurable disease. The death is anticipated, expected and predicted. It is anticipated in these circumstances that advance care planning and the consideration of DNACPR will have taken place.

You may wish to work with your local care homes to ensure that they have staff members adequately trained to verify expected deaths. Ideally the Care homes, as the employers, have to agree to a policy, training and form of documentation and the RCGP suggests that all nursing homes should have a nurse trained in verification.

Death Registration

Deaths will not be registered until the registrar receives notification of the cause of death from the medical examiner or the coroner. This notification will also start the 5-day statutory time frame to register a death. This is a positive amendment and takes pressure off the GP and family in terms the previous requirement to register the death within 5 days of its occurrence.

Cremation and Burial

Once the statutory medical examiner system is implemented, the medical examiner’s scrutiny will make the form Cremation 4 confirmation obsolete and the regulatory requirement for the medical referee to scrutinise it will therefore be removed. There will no longer be a requirement for GPs to complete cremation forms.

Information about medical devices and implants in the body of the deceased (which is currently recorded on form Cremation 4) will be included on the MCCD and transferred to the certificate for burial or cremation (green form) completed by the registrar in order to inform relevant authorities of the presence of any devices or implants.

Death Certification reform and Statutory Medical Examiner system

Key Points:

1. From 9^th September 2024, all deaths in England and Wales will be independently reviewed, either by a coroner where they have a duty to investigate, or by a medical examiner.

2. Medical examiners address 3 key questions:

• what did the person die from?
• does the death need to be reported to a coroner?
• are there any clinical governance concerns?

3. A core objective of the medical examiner system is to support bereaved people and the ME will contact the bereaved directly to give them an opportunity to ask questions and raise concerns.

4. Coroner notification is required in the circumstances set out in the Notification of Deaths Regulations 2019. This will usually be done by the attending practitioner either after consultation with the medical examiner or directly if requirement for notification is clear.

5. If you are unsure of whether coronial referral is required, the Medical Examiner will guide you.

6. It is a statutory requirement for an attending practitioner (DOCTOR) to complete the Attending Practitioner (AP) Medical Certificate of Cause of Death MCCD. The GMC sets out this obligation, confirming this is part of medical practitioners’ professional responsibility to their patients.

7. The requirement to have seen the patient in the 28 days before death, during their last illness, or to see the body after death has been withdrawn. The only requirement is that the medical practitioner (DOCTOR) must have attended the deceased in their lifetime and be able to give a cause of death. (‘Attendance’ is defined as a documented consultation either in person or via video).

8.The Coroners and Justice Act 2009 allows for completion of a ME MCCD in exceptional circumstances where:

• the referring medical practitioner has exhausted all efforts to identify an attending practitioner, and has not been able to identify one or an attending practitioner is not available within a reasonable time
• the senior coroner decides not to investigate and
• the senior coroner refers the case to a medical examiner to certify the death by completing a ME MCCD.

9. A new MCCD will replace the current certificate and will :

• Include details of the scrutinising ME and be signed by them.
• Record ethnicity from the patient’s medical record.**
• Have 2 new questions relating to the pregnancy status of the deceased.
• Have a new line, 1d, for the cause of death (To facilitate longer sequences of causes that have led to death, bringing the MCCD in line with international standards)
• Document medical devices and implants.
• The new MCCD will be accessible in both paper and digital(online) formats. The exact launch date for the digital version is yet to be confirmed

** Note: If the patient medical record does not include information on ethnicity, then the attending practitioner can complete it as ‘unknown’ on the MCCD and should not in any circumstance ask for this information from the representative of the deceased

10. GPs will usually initially communicate with their local Medical Examiner office in writing either via an online portal or GP IT system task where this is available.

11. When the cause of death is agreed with the Medical Examiner’s Office the GP sends the completed AP MCCD to the ME office electronically where it is reviewed and signed by the ME.

12. The medical examiner office sends the completed AP MCCD to the registrar.

13. Informants are now required to register deaths within 5 days of the register office receiving the completed AP MCCD or ME MCCD from the medical examiner office. (not 5 days from the date of death)

14. There will no longer be a requirement to complete cremation forms

 

The Statutory Medical Examiner system.

Following regulations laid in Parliament in April 2024, the Death Certification Reforms come into force on 9 September 2024. From this date, all deaths in England and Wales will be independently reviewed, either by a coroner where they have a duty to investigate, or by a medical examiner.

Medical examiners are senior doctors who, in the period before a death is registered, provide independent scrutiny of deaths in England and Wales not investigated by a coroner.

A person may be appointed as a medical examiner if, at the time of the appointment, he or she:

1. a) is a registered medical practitioner and has been throughout the previous 5 years, and
   b) practises as such or has done within the previous 5 years.

The National Medical Examiner recommends that medical examiners should be consultant grade doctors or other senior doctors from a range of specialties (including GPs) with an equivalent level of experience.

Medical examiners address 3 key questions:

• what did the person die from? Ensuring accuracy of the Medical Certificate of Cause of Death
• does the death need to be reported to a coroner? Ensuring timely and accurate notification in line with statutory requirements and guidance
• are there any clinical governance concerns? Ensuring the relevant referral is made where appropriate

Their independent scrutiny has 3 elements:

First, medical examiners or their officers give bereaved people the opportunity to ask questions and raise concerns.

Second, they interact with the attending medical practitioner completing the Medical Certificate of Cause of Death (MCCD), review the cause of death proposed by them and consider whether the coroner needs to be notified.

Finally, medical examiners carry out a proportionate review of medical records. If they detect issues or concerns, medical examiners refer cases for further review, but do not investigate themselves as their scrutiny must be completed rapidly.

What if the causes of death cannot be agreed?

The AP MCCD requires a declaration from both an attending practitioner and a medical examiner that the causes of death are correct to the best of their knowledge and belief. Where initial views differ, a pragmatic, constructive discussion usually facilitates agreement on cause of death and, where appropriate, the causes of death will be revised in the final completed MCCD.

In the rare case where a difference of opinion is irreconcilable, local escalation to the consultant in charge of the case for deaths in hospital or discussion with another medical examiner who is a GP (for deaths in the community) and the lead medical examiner is recommended. If the issue still cannot be resolved, the coroner should be notified that the cause of death cannot be established.

What if concerns are identified by the Medical Examiner?

A core objective of the medical examiner system is to support bereaved people

Bereaved people will at times raise concerns that require action such as referral to the clinical team responsible for care and/or to healthcare providers’ complaints services. Such referrals should be made in accordance with good practice and local complaints policies.

In most cases where medical examiners refer concerns to another person or organisation, it will be courteous and appropriate to inform the treating medical practitioner of the referral. In a few cases (for example, suspected criminal activity by the medical practitioner or clinician) it is not appropriate to inform them.

In a minority of cases there will be concerns about care. Medical examiners must still facilitate registration of the death in a timely manner and will not investigate concerns in depth. Rather, when they detect concerns about care, their role is to refer these to the appropriate quality lead at the relevant organisation, ensuring this person is of sufficient seniority to ensure appropriate action is taken. Medical examiners should follow local and national requirements, and the following general principles should be followed for appropriate referral of concerns.

• For primary care, appropriate contacts are likely to be the GP practice manager or nominated GP clinical governance lead. In some cases, local and national guidance will also require notification of the commissioning body’s senior clinical governance or quality lead (or equivalent) at the ICB in England, and in Wales the health board medical director and/or relevant assistant medical director. In England, NHS England is responsible for administering the NHS performers list regulations, and deficient clinical care or inappropriate professional conduct should be notified to the regional Professional Standards team at NHS England.

Supporting timely registration of deaths

Informants are required to register deaths within 5 days of the registry office receiving the completed AP MCCD or ME MCCD from the medical examiner office. (This is a change from the current requirement for informants (eg next of kin) to register the death within 5 days of the date of death)

Scrutiny of straightforward cases should normally be completed within 24 hours of the medical examiner office being notified of the death. Medical examiners must prioritise case scrutiny appropriately and respect the needs and wishes of bereaved people, including where urgent release of a body is required.

Access to patient records

From 9 September 2024, the Access to Health Records Act 1990 gives medical examiners a specific statutory right of access to records of deceased patients that they consider relevant when carrying out their duties.

Healthcare providers should consider whether their data sharing arrangements support medical examiner requirements appropriately, and ensure electronic patient records are shared rapidly with medical examiners to avoid unnecessary distress and delay to bereaved people.

What is the lawful basis for sharing personal data with medical examiners?

The UK General Data Protection Regulation (UK GDPR) and Data Protection Act 2018 (DPA) only apply to information relating to living individuals.

Information relating to deceased patients does not constitute personal data and therefore is not subject to data protection law.

Information relating to living next of kin and healthcare professionals is personal data and is subject to data protection law.

The main lawful basis for sharing such personal data is “public task” (Article 6.1(e) UK GDPR). This says you may process personal data where this is necessary for the performance of a task carried out in the public interest or in the exercise of official authority. This includes the exercise of a function conferred on a person by an enactment or rule of law. In this case, the processing of personal data is necessary for both the attending practitioner and medical examiner to undertake their statutory duties

For personal data held within health records, the lawful basis is also “legal obligation” (Article 6.1(c) UK GDPR). This says you may process personal data where this is necessary for compliance with a legal obligation to which you are subject. In this case the relevant legal obligation is to provide access under the AHRA.

There will now be two possible types of MCCD.

An Attending Practitioner MCCD

A Medical Examiner MCCD

Attending Practitioner Medical Certificate of Cause of Death (AP MCCD)

It is a statutory requirement for an attending practitioner to complete the AP MCCD. The GMC sets out this obligation, confirming this is part of medical practitioners’ professional responsibility to their patients.

“Your professional responsibility does not come to an end when a patient dies. For the patient’s family and others close to them, their memories of the death, and of the person who has died, may be affected by the way in which you behave at this very difficult time… You must be professional and compassionate when confirming and pronouncing death and must follow the law, and statutory codes of practice, governing completion of death and cremation certificates. If it is your responsibility to sign a death or cremation certificate, you should do so without unnecessary delay.” (GMC, Treatment and care towards the end of life guidance, paragraphs 83-85)

The attending practitioner should develop their own preliminary view of the cause of death before discussing the case with the medical examiner or medical examiner officer. (The term ‘discussion’ can be taken as in writing or verbally). It is not the role of medical examiners to tell the attending practitioner what causes of death to record. The attending practitioner remains personally accountable and responsible for completing their statutory statement confirming the causes of death.

There is official guidance for completing a MCCD

The 2024 death certification reforms widen the pool of medical practitioners who can complete AP MCCDs, as the requirement to have seen the patient in the 28 days before death or to see the body after death has been withdrawn. The only requirement is that the medical practitioner must have attended the deceased in their lifetime and can give a cause of death. This will enable more AP MCCDs to be completed in the normal way and scrutinised by a medical examiner. Such deaths can then be registered without unnecessary referral to a coroner.

Medical examiner MCCDs (ME MCCDs)

There will be a small minority of cases where the cause of death is known and natural but no medical practitioner who attended the deceased can be identified within a reasonable period. Historically, there were limited arrangements for such circumstances, and even where the cause of death was a known, the death had to be notified to the coroner and registered as uncertified.

The Coroners and Justice Act 2009 allows for completion of a ME MCCD in exceptional circumstances where:

• the referring medical practitioner has exhausted all efforts to identify an attending practitioner, and has not been able to identify one or an attending practitioner is not available within a reasonable time
• the senior coroner decides not to investigate and
• the senior coroner refers the case to a medical examiner to certify the death by completing a ME MCCD

 

In circumstances where the medical examiner concludes that they are unable to establish the cause of death, the case can be referred back to the senior coroner.

The referring medical practitioner (who has taken responsibility to ensure death certification is completed but does not fulfil the criteria to be the attending practitioner) and the referring coroner are required to be named on the ME MCCD.

Death certification process

Requirements for completing the AP MCCD and ME MCCD are set out in the Medical Certificate of Cause of Death Regulations 2024 and government guidance

Standard process in straightforward cases

The attending practitioner must review the deceased person’s health records to formulate the proposed cause of death. They then complete the AP MCCD and make it available to the medical examiner along with the deceased person’s relevant health records and any other relevant information (eg next of kin).

Medical examiners must then make whatever enquiries they consider necessary. This involves a proportionate review of relevant patient records and consideration of any information provided to them or which they consider relevant.

The medical examiner (or the medical examiner officer acting on their behalf) then interacts with the attending practitioner, which allows discussion of and refinement of the causes of death if appropriate. This interaction may be verbal or by correspondence.

The medical examiner or the medical examiner officer acting on their behalf then offers an appropriate person the opportunity to ask questions about causes of death or raise concerns about care before death or the circumstances of death. Normally this will be a bereaved person, such as the deceased person’s next of kin. This interaction must be verbal (by telephone or face to face/video conference if desired and practical) unless there are exceptional reasons for using other means of communication.

The medical examiner office sends the completed AP MCCD to the registrar and the death must then be registered within 5 days.

If the registrar considers the cause of death may need revision, they consult the medical examiner

What if there is no attending GP in the practice or the attending GP is not available to complete the MCCD in a reasonable time period but the death appears natural with an obvious cause?

It may be that a hospital doctor or other doctor (eg out of hours GP) may be able to issue the MCCD in which case the Medical Examiner can be contacted to explore this. If it is clear that no other doctor is available to complete the MCCD then the GP reporting the death should refer to the coroner. The coroner may then ask the ME to issue an ME MCCD as detailed above.