1. Improving the Process of Death Certification in England and Wales Presentation at HSUG workshop 29 th March 2011 Paul Ader – Programme Team Lead for Process Design & Piloting

2. Improving the Process of Death Certification 2 Agenda Overview & Key Dates Current process Summary of changes New process Pilots and lessons learned

3. Improving the Process of Death Certification 3 Overview & Key Dates 1935 Last substantive change to certification and registration of death 2003 Shipman Inquiry’s Third Report concluded that current arrangements are confusing and provide inadequate safeguards 2007 Consultation on Improving the Process of Death Certification 2008 Proposed process designed to simplify and strengthen the system. 2009 Changes enabled by provisions in Coroners and Justice Act 2009 2012 Regulations made after public consultation in 2011 2013 Introduction of new process from April 2013

4. Improving the Process of Death Certification 4 Current System: People, Process & Technology

5. Improving the Process of Death Certification 5 Decision: is death reportable? Prepare MCCD Coroner’s Post Mortem Inquest Issue MCCD Form 99 or 120 & 121 Form 100B Registration of death Burial or Cremation Reportable Deaths & Enquires Current Process Talk with Relatives? Form100A Activities carried out by the Coronial Service Activities carried out by the Medical Examiners Service Activities carried out by Attending Doctor certifying death Key: Abbreviations: MEO = Medical Examiner’s Officer. Note: ME-1 is the proposed name of the form used to document information required for scrutiny. Advise NFA or 100A Form 6 or Burial Order Discussion with doctor v008b (24-Mar-09) Decision to carry out a PM or open Inquest Cremation Form 4 Cremation Form 5 Cremation Form 10 Verification of Fact of Death Activities carried out by other people / services Verifier. Police. Delay. Information. Additional scrutiny only on cremations. Mostly procedural. Differences in causes not reflected on MCCD. Limited access to notes. No trends / patterns. ‘Advice’ on causes from Bereavement & Coroners Service Many coroners have different arrangements for 100As and discussions with relatives Up to 30% of causes may be inaccurate or not sufficiently precise Form 100A / “Part A” Informant delivers MCCD Too many MCCDs need to be rejected

6. Improving the Process of Death Certification 6 Summary of Changes 1.Statutory duty: Doctors will have a statutory duty to report deaths that might need to be investigated by a coroner and will not prepare a MCCD for any death that is investigated. 2.Medical examiners: Consultant-grade doctors will be appointed in each area, mostly on a part-time / sessional basis, to provide an independent and proportionate scrutiny of the cause of all deaths not investigated by a coroner irrespective of the type of disposal.  Medical examiners will need to complete eLearning and conventional training prior to appointment.  The scrutiny provided by medical examiners will unify the current process, remove cremation forms 4, 5 and 10 and replace the associated activities of the secondary certifier and medical referees.  The public fee currently charged for completion of cremation forms is expected to be applied to all deaths and used to fund local medical examiner’s services.

7. Improving the Process of Death Certification 7 Summary of Changes 3.Advice: Doctors will be able to request pre-certification advice from a medical examiner on a cause of death. This may be provided before or after scrutiny of records. Coroners will also be able to ask for general medical advice. 4.Preparation of a MCCD: An attending doctor will not be able prepare a MCCD until the deceased has been externally examined by a doctor and will need to provide a copy of it to a medical examiner for scrutiny with the records and other required information. 5.Scrutiny: Medical examiners will need to carry out scrutiny in a way that complies with quality and performance standards issued by a National Medical Examiner. Scrutiny will include the following activities and lead either to the death being investigated by a coroner or to confirmation of the cause. In some cases, it might require an attending doctor to reissue a MCCD.  Review of records and other required information and, if necessary, a discussion with the certifying doctor.  Consideration (where proportionate) of any trends or unusual patterns identified by public health surveillance and any issues raised by local clinical governance.  Discussion with an informant or other appropriate person to ensure the cause of death is understood and to provide an opportunity to raise any matters that might require the death to be investigated by a coroner

8. Improving the Process of Death Certification 8 Summary of Changes 6.HMC-1: Coroners will send an HMC-1 form to a medical examiner (rather than a Form A to a registrar) for deaths that are reported but do not need to be investigated. Where an apparently natural death is reported because there was no attending doctor or none are available in a prescribed period, a coroner can refer it to a medical examiner for certification (after scrutiny). 7.Confirmation and issue of a MCCD: If a medical examiner is able to confirm the cause of a death s/he will issue a statutory ME-2 ‘Medical Examiner’s Confirmation and Notification of a Certified Cause of Death’ to the doctor and, separately, to the registrar.  Once an ME-2 been received by the doctor (or ward / GP staff or bereavement service) the MCCD can be issued and the deceased can be ‘released’ and prepared for burial, cremation or other form of disposal. 8.Registration: Registrars must wait for a ME-2 from a medical examiner before registering a death / issuing a Green Form.  Causes on the MCCD delivered by an informant must agree with ME-2 and the informant will usually need to sign Part B of the ME-2 to confirm that s/he knows that the cause of death has been discussed.  Registrars can request a fresh certificate from / via a medical examiner or, where required, report a death to a coroner – however this is likely to happen infrequently.

9. Improving the Process of Death Certification 9 Advise NFA or 100A Decision to carry out a PM or open Inquest Decision: is death reportable? Prepare MCCD Coroner’s Post Mortem Inquest Issue MCCD Form 99 or 120 & 121 Form 100B Burial or Cremation Reportable Deaths & Enquires New Process Talk with Relatives? Discussion with doctor v008b (24-Mar-09) Verification of Fact of Death Advice to Doctors & Coroner Referral Copy of MCCD, records & required info. Scrutiny by Medical Examiner ME-2 Decision to investigate death Initial AssessmentInvestigation Informant delivers MCCD Activities carried out by the Coronial Service Activities carried out by the Medical Examiners Service Activities carried out by Attending Doctor certifying death Key: Abbreviations: MEO = Medical Examiner’s Officer. Note: ME-1 is the proposed name of the form used to document information required for scrutiny. Activities carried out by other people / services Registration of death RME & NFA HMC-1 ME-2 Coroner’s Disposal Order Green Form MEO: Prep. for Scrutiny Information from public health surveillance and local clinical governance

10. Improving the Process of Death Certification 10 Pilot communities in England and Wales Brighton & Hove Leicester Short term pilot focusing on urgent / out-of-hours scrutiny Inner North London Short term pilot focusing on urgent / out-of-hours scrutiny

11. Improving the Process of Death Certification 11 Pilot communities in England and Wales

12. Improving the Process of Death Certification 12 Key lessons from the pilots (to-date) 1.Ward staff, bereavement services and GP practice staff have been able to retain MCCDs until they have been scrutinised and confirmed by a medical examiner. 2.Medical examiners can usually scrutinise a deceased person’s records in 15 – 45 minutes. 3.Workload and availability of doctors to talk with the medical examiner (where required) means that the elapsed time for the scrutiny process is often 6 – 12 working hours. 4.Where there is a need for urgent release / disposal, the scrutiny process can be completed more quickly. 5.The bereaved have accepted a slightly later bereavement appointment without problem – the key is to set expectations correctly at the outset

13. Improving the Process of Death Certification 13 Key lessons from the pilots (to-date) 6.Doctors are providing positive feedback about the value of the advice & scrutiny 7.Number of coroner’s post-mortems are not decreasing – however type of post-mortem may be changing. 8.Medical examiner well positioned to ask bereaved people whether they would like a consent post-mortem where there may be a need to learn more about the known cause of a natural death.

14. Improving the Process of Death Certification 14 Contact Details & Further Information DH Programme Manager: Simon Bennett Head of NHS Clinical Governance – Clinical Quality & Strategy DH Programme Team: Meena Paterson Regulations Ruth Benjamin Stakeholder Communications & Programme Office Paul Ader Process Design & Piloting Website:www.dh.gov.uk/deathcertification Email: DeathCertification@dh.gsi.gov.uk Phone: 0113 254 5813

15. Improving the Process of Death Certification 15 Thank you.