A number of inquiry reports into poor practice and misconduct by health bodies and health professionals have recommended reform of the death certification process in England and Wales (Smith, 2003; Francis, 2013; Gosport Independent Panel, 2018).
The third report of the Shipman Inquiry (Smith, 2003) found that the system of certification of cause of death in England and Wales was open to the concealment of a crime and other wrongdoing by the doctor providing the certificate. It was also open to the risk of a certifying doctor who knows that a death may have been caused by poor practice or misconduct by a professional colleague choosing not to take the matter further.
Such situations could arise because there is no statutory definition of death (Grubb et al, 2010). Generally, the Triad of Bichat (Griffith and Tengnah, 2008) is used to determine whether a person has died: this defines death as ‘the failure of the body as an integrated system associated with the irreversible loss of circulation, respiration and innervation’.
In law, a person is dead when a doctor says so. Such a system requires there to be checks and balances in place to prevent wrongdoing. The administrative system for confirming cause of death to date has relied heavily on the opinion of a single doctor to confirm cause of death. In addition, there has been a duty on the registered medical practitioner attending a patient during their last illness to issue a medical certificate of cause of death (MCCD) (Births and Deaths Registration Act 1953, section 22(1)). If the doctor was unable to issue or fully complete the requirements of this certificate, the matter was referred to the coroner (Griffith and Tengnah, 2008).
Reform of the certification process
There has been little change to the death registration process for over 50 years. Registrars relied on the MCCD issued by a single attending doctor to proceed with certification. Only cases referred to the coroner were subject to independent scrutiny.
Attending practitioners will continue to issue an MCCD, or refer the case to the coroner. To be an attending practitioner under the 2024 regulations the doctor will need to be fully registered and have a licence to practise under the Medical Act 1983. This means that foundation doctors, who have provisional registration, will not be able to issue a MCCD.
From September this year, all deaths in any health setting, not reported to the corner, will have the MCCD independently scrutinised by a medical examiner under the provisions of three new sets of regulations: The Medical Certificate of Cause of Death Regulations 2024, The Medical Examiners (England) Regulations 2024, and The Medical Examiners (Wales) Regulations 2024.
The regulations provide for a statutory system of independent scrutiny of deaths and are the culmination of some 15 years of gradual reform, beginning with the Coroners and Justice Act 2009. The introduction of statutory medical examiners will require a revised MCCD.
Certification and scrutiny of deaths not referred to the coroner
The MCCD Regulations 2024 require the attending practitioner to review:
The attending practitioner must then decide if they can issue a certificate or refer the matter to the coroner. Where an attending practitioner has issued a certificate, they must make it available to the medical examiner, along with the person's health records and any other information they use in their review.
Medical examiners
Medical examiners will be appointed by NHS bodies in England and Wales, and will be drawn from registered medical practitioners with at least 5 years' post-qualifying experience (Coroners and Justice Act 2009, section 19). They are overseen by a National Medical Examiner appointed by the Secretary of State for Health and Social Care (Coroners and Justice Act 2009, section 21).
The MCCD Regulations 2024 require medical examiners to confirm the cause of death by making such enquiries as they consider necessary, including an external examination of the body. Such enquiries can include putting further questions, and recording the responses, to the attending practitioner, who has a duty under regulation 7 of the MCCD regulations to respond to those further enquiries.
Discussion of the cause of death
The medical examiner, or someone acting on their behalf, must also discuss the cause of death with a person qualified to provide the information necessary to complete the certification of death with the registrar under the Births and Deaths Registration Act 1953. This would usually be the bereaved relatives, who will have the opportunity to ask questions and raise concerns with the medical examiner, who is independent and not involved in the care of the person prior to their death.
Completing registration of death
The medical examiner will review the deceased's medical records and work with attending practitioners to complete an MCCD that is accurate, and will highlight any concerns about the care of the deceased person prior to their death that have arisen from their review and discussion with the bereaved.
When the medical examiner is satisfied that the attending practitioner's MCCD is accurate and properly completed, they will endorse the MCCD and the matter can proceed to the registrar for death certification under the 1953 Act (Medical Certificate of Cause of Death Regulations 2024, regulation 11). If the medical examiner is unable to confirm cause of death or the circumstances of death need further scrutiny, they will refer the matter to the coroner.
Conclusion
The implementation of a statutory medical examiner system that will provide independent scrutiny of deaths in any health setting continues the reform of the death certification process and aims to address the concerns raised by the Shipman inquiry (Smith, 2003), the Mid Staffordshire Hospital inquiry (Francis, 2013) and the Gosport War Memorial Hospital Inquiry (Gosport Independent Panel, 2018), which all found that the single doctor MCCD process at risk of misuse and cover-up.
Independent scrutiny by a medical examiner, which includes a requirement to discuss the cause of death with the bereaved, provides a more robust MCCD process.
Nurses will be part of the process and may be called on to provide information as part of the medical examiner's enquiries. Nurses are also well placed to explain the aims of the medical examiner system to the bereaved. This includes informing relatives that they will be given an opportunity to discuss the cause of death and raise concerns with a person independent of the care of the individual leading up to their death. The nurse also has a duty to raise concerns and, where necessary, report the death to the coroner.