Update January 2024: Introduction of Medical Examiners and Reforms to Death Certification
Links to Other Wessex LMCs Pages:
The LMC receives many queries on the subject of death certification, cremation and Coronial regulations. The Covid-19 pandemic and associated emergency legislation have added a further level of confusion.
We have summarised updated guidance relating to Death Certification and Cremation following expiry of the Coronavirus Act temporary provisions on 25th March 2022 Here; Wessex LMCs: Death certification (MCCD) process from 25th March 2022 following expiry of the Coronavirus Act temporary provisions
It is incumbent on those working with the bereaved to recognise that these processes can cause significant distress to them. All participants in the system must be ever conscious of this and conduct themselves in a manner that does not add to the emotional suffering of families.
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 in the current crisis 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 four 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.
- Finally, for those patients who will be cremated, the cremation form must be signed.
The law requires a doctor to notify the cause of death for any patient whom he or she has attended during that patient’s last illness, to the Registrar of Births and Deaths. Stating, to the best of his or her 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.
In these challenging times, 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.
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. The death can be verified even if the doctor has not seen the patient in the previous twenty-eight days.
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.
National guidance regarding notification of deaths to coroners is available here ( https://www.gov.uk/government/publications/notification-of-deaths-regulations-2019-guidance.)
We advise that providing basic medical information for a Coroner’s Report is your duty. However, a more detailed report may be asked for. There is nothing in the Coroners Act that clearly stipulates a fee for reports where payment is not being offered. The BMA advises doctors to complete the report otherwise they may face being summonsed.
Working within an established legal framework it is the principal statutory duty of Coroners to investigate deaths which are reported to them and which appear to be
a. due to violence, or
b. are unnatural, or
c. are sudden and of unknown cause, or
d. which occur in legal custody.
They are entitled to request medical information that is relevant and necessary to their enquiries.
The GMC sets out clearly in Good Medical Practice that ‘You must assist the coroner or procurator fiscal in an inquest or inquiry into a patient’s death by responding to their enquiries and by offering all relevant information. You are entitled to remain silent only when your evidence may lead to criminal proceedings being taken against you.’
Viewing the Body
There have been instances of undertakers taking deceased patients into GP car parks to avoid inconveniencing the GP providing cremation certification. We would strongly advise against this on the grounds of the distress it would cause to the family and your other patients if they discover this practice happening.
We realise this may be a particular difficulty in some more rural areas but believe that the Undertakers could arrange to move the body to a more local undertaker to care for whilst waiting to be viewed.
Free from Infection Certificate / Information
If a patient passes away and the family would like to repatriate them to their country of birth, a ‘Free from Infection Certificate’ will be required from the Undertakers. The following provides information on what is required by the GPs in this instance:
- If the patient has had a postmortem the information needs to be provided by a Pathologist from the hospital where this took place.
- If the GP has issued the death certificate this will then need to be provided by the GP.
- There is, as such, no formal certificate. However a letter will need to be provided. This will need to include information regarding the infection status of the following:
- Hep B
- Hep C
- This is not core GMS work therefore you are able to charge for this.
The Respective Roles of Coroners and Doctors in Certification of Death
The Coroner’s office is tasked with establishing who has died, as well as how, when, and where they died. However, they are not medical, and they need specialist medical input to advise them what the cause of death is. If it is not clear or unnatural then the Coroner will seek further specialist medical input i.e. post-mortem or other expert opinion to advise them in making the decision.
The medical specialist who is most often in the position to be able to advise on the cause of death is the patient’s GP who manages the vast majority of a patient’s care. The statutory duty to fill out the death certificate rests with the doctor who has cared for the patient. Therefore, the Coroner will contact the patient’s GP.
In many cases a GP has sufficient knowledge of the patient’s disease or recent health and therefore can offer a cause of death. This applies even if the GP has not seen the patient within the last 28 days. For example, a patient may be known to in a terminal phase of cancer and being cared for at home. In this case, after referral to the Coroner, if the Coroner accepts the cause of death, the coroner’s office will issue paperwork to the Registrar to prove the cause of death has been authorised and the GP circles numbers 3 and 4 on the back of the MCCD.
The death certificate can only be issued by a doctor. The Coroner is not a medical professional and cannot issue death certificates.
The Coroner needs the input of the relevant doctor – either GP or hospital – as to whether they are able to determine a cause of death to put on the MCCD. Until a GP (or hospital doctor) has made this decision, the Coroner’s office is unable to progress with any investigations that might be needed if they cannot issue.
Conversations can be held between Coroner’s Officers and GPs in relation to the cause of death and whether they can issue a certificate, however this is only advice and neither Officers nor the Coroner can tell a GP or Doctor what to write. The GP will use their knowledge and that contained within the patient record to decide whether they can determine a cause of death.
If the GP feels happy to issue an MCCD – then do so.
If the GP feels unable to determine a cause of death to write on the MCCD and/ or is not in a position to issue the certificate in line with the current regulations around attending the deceased– refer to the Coroner for advice.
If the GP suspects the death is unnatural then refer to the Coroner.
Introduction of Medical Examiners and Reforms to Death Certification
The death certification system in England and Wales has remained largely unchanged for over 50 years. The importance of death certification reform and the introduction of medical examiners has been underlined in numerous reports and inquiries. Death certification reforms are planned from April 2024. The draft regulations may be amended before coming into force.
All of these regulations will be laid in Parliament prior to the statutory system coming into force from April 2024.
NHS England and NHS Wales started implementing the medical examiner system on a non-statutory basis in 2019. Medical examiners are now scrutinising almost all deaths in acute trusts and a growing proportion of deaths in all other healthcare settings (including the community).
Medical examiner scrutiny is not mandated in the non-statutory system. However, once the new death certification reforms come into force, there will be an independent review of all deaths in England and Wales, without exception. This will either be provided by independent scrutiny by a medical examiner or by investigation by a coroner.
As part of the reforms planned from April 2024, a medical practitioner will be eligible to be an attending practitioner and complete an MCCD, if they have attended the deceased in their lifetime. The attending practitioner will propose a cause of death, if they can do so, to the best of their knowledge and belief. The introduction of medical examiners will see routine independent scrutiny of the cause of death proposed by an attending practitioner.
This represents a simplification of the current rules that enable medical practitioners to be an attending practitioner, to complete an MCCD, if they had attended the patient during their last illness but required referral of the case to a coroner for review if they had not done so within the 28 days prior to death or had not seen in person the patient after death.
Sadly, calls for other trained medical professionals to be able to complete the MCCD have so far fallen on deaf ears.
Medical Examiner Role
A medical examiner is a senior medical practitioner who is contracted for a number of sessions a week to provide independent scrutiny of causes of death, outside of their usual clinical duties.
Independent scrutiny by a medical examiner will become a statutory requirement prior to the registration of all non-coronial deaths in England and Wales.
Once the relevant attending practitioner and the medical examiner have completed their declarations of certification and scrutiny, and the cause of death is confirmed, the MCCD will be sent to the registrar. The representative of the deceased will be notified at the same time that they can now contact the registrar to arrange the registration of the death.
Contact details for your local Medical Examiner are:
- Royal United Hospitals Bath NHS Foundation Trust: BA1 3NG
Contact numbers : 01225 824015 or 01225 824315
- Somerset NHS Foundation Trust: TA1 5DA
Contact number: 01823 343753
- Great Western Hospitals NHS Foundation Trust: SN3 6BB
Contact number: 01793 607770
- Salisbury NHS Foundation Trust: SP2 8BJ
Contact number: 01722 336262 ext 5429
- North Bristol NHS Trust: BS10 5NB
- Southmead: 0117 414 3447/8
- Bristol Royal Infirmary: 0117 342 7507/9977
- Weston General: 01934 636363 ext 7569
- Dorset County Hospital NHS Foundation Trust: DT1 2JY
Contact number: 01305 255251
- University Hospitals Dorset NHS Foundation Trust: BH7 7DW
Contact number: 0300 019 5758
Community – firstname.lastname@example.org
Bournemouth Office – email@example.com
Poole Office – firstname.lastname@example.org
- Frimley Health NHS Foundation Trust: Frimley Park GU16 7UJ
Contact number: 0300 615 0450
- Hampshire Hospitals NHS Foundation Trust: Basingstoke and North Hampshire Hospital RG24 9NA
- Winchester – 01962 824139 or 01962 824139
- Basingstoke – 01256 313236
- Portsmouth Hospitals NHS Trust: Queen Alexandra PO6 3LY
Contact number: (023) 9228 6185
- University Hospital Southampton NHS Foundation Trust: Southampton General SO16 6YD
Contact number: 023 8120 3564
- Isle of Wight NHS Trust: St Mary’s PO30 5TG
Contact number: 01983 53 4740
Medical Certificate of Cause of Death
From April 2024, a new MCCD will replace the existing certificate to reflect the introduction of medical examiners, who will scrutinise the proposed cause of death.
The new MCCD will include the following new information:
- details of the medical examiner who scrutinised the cause of death
- ethnicity, as self-declared by the patient on the medical record. This builds on learning from the COVID-19 pandemic. If the patient medical record does not include this information, 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
- maternal deaths and a new line, 1d, for the cause of death – bringing the MCCD in line with international standards
- medical devices and implants will be recorded on the MCCD by the attending practitioner, and this will be transferred to the certificate for burial or cremation (contained in the green form) completed by the registrar in order to inform relevant authorities of the presence of any devices or implants.
An online version of the new MCCD will be available later in 2024. ( Which seems a bit late given the changes are proposed from April 2024. Initially it looks like we will be using new paper MCCDs!).
Medical Examiner Certification
This will occur in exceptional circumstances where either:
- there is no attending practitioner.
- an attending practitioner is not available within a reasonable time.
In either of these circumstances, the death is referred to the senior coroner by a referring medical practitioner (not a medical examiner) and the senior coroner decides not to investigate.
In these circumstances only, the senior coroner should refer the case to a medical examiner to certify the death by completing a medical examiner MCCD.
The medical examiner MCCD will only be used in exceptional circumstances where actions to identify an attending practitioner have been exhausted by the referring practitioner.
The Notification of Deaths Regulations 2019 will remain in force (subject to minor amendments flowing from the changes). Attending practitioners should continue to notify deaths that meet the criteria in those regulations to the coroner, who will determine what further action is appropriate.
The attending practitioner or the medical examiner will determine which deaths need to be referred to the coroner.
As at present, the attending practitioner can report a death directly to the coroner where they believe they are under a statutory duty to do so. In this scenario, there will be no regulatory requirement for the attending practitioner to inform the medical examiner that they have done this. Similarly, if the coroner declines jurisdiction, they will advise the attending practitioner. The attending practitioner will be expected to complete the MCCD and scrutiny will be undertaken by the medical examiner.
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 take pressure off the GP and family in terms the current 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.
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.