1. Certification of Death (Scotland) Act 2011 Implementation April 2015

2. Content Background & Context The Certification of Death (Scotland) Act 2011 Interpreting the Act – the main changes Implementing the Act – the role of the key organisations The Review Process – the basics Other Related Changes What Does it Mean for You? Sources of Information

3. Background & Context 2005-2008 Sheriff Brodie’s Burial and Cremations Review Group makes recommendations for change. 2009-2010 SG consults on agreed recommendations and subsequently prioritises a ‘first phase’ development and implementation of death certification legislation. 2011 Certification of Death (Scotland) Act receives Royal Assent in April 2011. 2011 - 2015 Death Certification Implementation: planning and development activity 2014 onwards‘Second phase’ work commences eg to develop a Bill in relation to wider burial and cremation matters, as identified by the Review Group.

4. Certification of Death (Scotland) Act 2011 The Certification of Death (Scotland) Act 2011 will: Introduce a new death certification system in Scotland - through a single system of independent effective scrutiny; improve the quality and accuracy of Medical Certificates of Cause of Death (MCCD) – through electronic completion of the MCCD where possible, the new scrutiny (‘review’) process and revision of MCCD content. provide improved public health information – through enhanced data monitoring, analysis and trends identification strengthen clinical governance in relation to deaths – through linkages between the new review system and health boards.

5. Certification of Death (Scotland) Act 2011 Once fully implemented, the Act will bring an end to: cremation forms and associated fees amounting to circa £170 to bereaved families the statutory role of crematoria medical referees burial before registration some, but not all, of the existing Cremation (Scotland) Regulations 1935

6. Interpreting the Act – the main changes Current scrutiny process, which only encompasses cremation and is undertaken via cremation forms checked by crematoria medical referees, will come to an end. Instead, new Medical Reviewers will check a random sample of MCCDs for accuracy and quality, regardless of whether burial or cremation is later involved. New scrutiny is applied more equally, is applied earlier in the funeral arrangement chain of events and involves no direct charges to the bereaved. Role of the Procurator Fiscal remains unchanged.

7. Implementing the Act – roles of the key planning organisations 1 Healthcare Improvement Scotland (HIS)– responsible for developing, implementing, monitoring and continuously improving the detailed procedures around the review processes. They will also be the employing organisation of the new statutory Senior Medical Reviewer and Medical Reviewers, who will conduct reviews and work with certifying doctors. National Records of Scotland (NRS) and local authorities – responsible for introducing revised content of Form 11 and Form 14; also for any changes to registration procedures as a result of the requirements of the new system; and ensuring registrars are aware of and ready for these changes. NHS Boards – responsible for ensuring all relevant staff eg records managers, bereavement officers and all certifying doctors are aware of and ready for any changes to their procedures as a result of the requirements of the new review system.

8. Implementing the Act – roles of the key planning organisations 2 NHS Information Services Division (ISD) – will link with HIS and national Records Scotland to use data/information from the review process to inform NHS and the SG about mortality issues NHS Education Scotland (NES) – is developing new online training modules for all certifying doctors and wider medical staff, to be available prior to implementation, early in 2015. NHS National Services Scotland Information Technology (NSS IT) - leading on the availability of electronic completion of MCCDs within the NHS by 2015. Cremation Authorities (and representative bodies) – responsible for any changes to their procedures including cross border protocols, as well as ensuring all relevant staff are aware of and ready for these changes; also any contractual requirements for their outgoing crematoria medical referees.

9. Implementing the Act – roles of the key planning organisations 3 Funeral Directors (and representative bodies) – responsible for any changes to their procedures including cross border protocols; also for ensuring their staff and members are aware of and ready for these changes. Scottish Government (SG) – responsible for enacting relevant legislation, funding arrangements, apprising Ministers of progress, and for ensuring an appropriate level of public and stakeholder awareness. Death Certification National Advisory Group (DC NAG) - incorporates all of the previously mentioned organisations plus key bereavement and faith organisations. It oversees the implementation planning, development and delivery being undertaken by others.

10. The Review Process – the basics Around 55,000 deaths annually in Scotland, although does fluctuate. Nearly all review cases will be randomly selected before or at the point of registration, through the registrars’ electronic system. Although the level of scrutiny is not fixed by legislation, and can vary, our current expectation is that, when implemented, the system will randomly select circa 10% of all deaths for review (excluding those which have already undergone scrutiny eg through the Procurator Fiscal service). Completion of the registration process will be put ‘on hold’ while the review is underway. Options will be in place for relatives / informants who do not wish to make a second visit to the registrar, and also to ensure a funeral can still take place quickly if necessary e.g. for religious or cultural reasons.

11. The Review Process – the basics Two types of review will be undertaken. These are not set out within the Certification of Death (Scotland) Act 2011. Rather these two approaches were agreed following their development and successful trialling in two test sites during 2012. Level 1 (shorter): medical reviewer scrutinises MCCD and speaks to certifying doctor (or another doctor in the team, if appropriate) before authorising the completion of death registration. Level 2 (comprehensive) – in addition to above: scrutiny of electronic and/or hard copy medical records and speaking to any other relevant persons. These review types will be conducted through the random selection process, will be available on request from ‘interested persons’, or may be self-selected by Medical Reviewers in response to any emerging pattern that requires further checks.

12. The Review Process – the basics Level 1 Reviews should normally be completed within one working day and Level 2 Reviews within three working days. The certifying doctor will be contacted during the review, to discuss the MCCD with the Medical Reviewer. Electronic or hard copy access to relevant medical records may also be required. Initial funeral arrangements, including transfer of the deceased to the funeral directors and any necessary preservation of the deceased, can take place whilst the review is underway, but the funeral itself (with its associated burial or cremation) cannot take place until the review is completed and the Certificate of Registration of Death (Form 14) is produced. Although not directly part of the new system, the MCCD (Form 11) and the Certificate of Registration of Death (Form 14) will be revised with a view to including information on the presence of hazardous implants etc to assist in determining whether it is (e.g.) safe to cremate.

13. Other Related Changes A new paper-based Medical Certificate of Cause of Death / Form 11, with revised content and format, will be introduced as of 6 August 2014 by National Records Scotland. This is a prior exercise to the implementation of the new death certification system in 2015, although some of the revisions to the MCCD form do address the future needs of the new system. Changes to the MCCD form will include font size and page layout; as well as some additional information on the deceased and the certifying doctor. Other changes, which will be carried over to the Form 14 in due course, will include additional information on the presence or otherwise of hazardous implants etc. This is to assist funeral directors and crematoria staff in determining whether it is (e.g.) safe to cremate.

14. What Does it Mean for You? The main groups affected by the changes are those set out below, although there may be subgroups within these groups, particularly in relation to medical staff. General Public People Who Are Bereaved Medical Staff Registrars Funeral Directors Crematoria Staff

15. What Does it Mean For You? – General Public Minimal impact: general awareness only Certain pre-defined ‘interested persons’ (generally, close relatives or professionals with a clear interest or involvement in a particular case) can request a review, provided it is within three years of the death, does not pre- date the new legislation and has not already been reviewed or subject to Procurator Fiscal investigation. Medical Reviewers will help with optional post-mortem arrangements and associated costs, in the event of a death abroad where cause of death is unclear.

16. What Does it Mean For You? – People Who Are Bereaved 1 Those who opt for cremation will no longer be charged circa £170 in cremation fees. There will be no direct charge to anyone who has been bereaved in relation to the new review system. Circa 90% of those who have been bereaved will experience no significant changes, from their perspective.

17. What Does it Mean For You? – People Who Are Bereaved 2 The remaining circa 10% of those who have been bereaved will have their MCCDs selected for review either before or at the point when they visit the registrars’ office (depending on whether the MCCD has already been completed and transmitted electronically). If the review is still underway or to be commenced, then these individuals will not immediately be able to complete the registration process / receive the Form 14. The review process and timescales will be explained, including that once the review is complete the Form 14 can be sent to them and/or sent direct to the funeral director to allow the funeral to go ahead. If the person registering the death has a compelling reason for the funeral to go ahead before a review can be completed, then they can apply for their particular circumstances to be taken into account and the Medical Reviewer will decide if the Form 14 can be released before the review is completed (the ‘expedited procedure’).

18. What Does it Mean For You? – Medical Staff Each NHS Health Board is expected to set up an implementation group, led by a director-level ‘implementation lead’ to ensure a smooth changeover to the new system. New online training modules on new system for full range of medical professionals will be available in early 2015. Electronic completion of the MCCD, wherever possible, by April 2015 (paper MCCDs may still be required in certain areas and circumstances) Procurator Fiscal referral criteria (and processes) are unchanged, but if still uncertain then advice on whether to refer a death to the PF could be sought from a Medical Reviewer. Any doctor who certifies a death (or an informed member of that doctor’s team) which is then subject to review, must make themselves available to discuss the case with the Medical Reviewer, when contacted. Cremation certificates B and C, with their associated payments, will no longer exist under the new system.

19. What Does it Mean For You? – Registrars Some IT changes may be introduced to accommodate the electronic completion and transmission of the MCCD from the NHS to NRS (where this is possible). Registrar training on changes as a result of new system will take place several months in advance of 2015 implementation date. The majority of death registrations (circa 90%) will be largely unaffected by the new system. As the main point of contact with the bereaved, registrars will explain the general process and timescales to those informants (circa 10%) whose cases are to be or are already being reviewed. An information leaflet for the public will also be available, to aid these discussions. Registrars at individual, or at wider office level, will need to ensure that any and all their communications with the Medical Reviewers’ office, and with informants, are carried out efficiently and consistently.

20. What Does it Mean For You? – Funeral Directors No cremation certificates Forms B and C, but following amendments to the MCCD, a revised Form 14 will include information on the presence or otherwise of hazardous implants etc, to assist in decisions on safe cremation and safety in handling the body. Transportation and any necessary processes for the preservation of the deceased can take place whilst a review is underway. As informants will not know if their case is one of the 10% selected for review until they visit the registrar, consider any need to e.g. amend local funeral booking procedures for both burial and cremation. Removal from funeral invoices of the medical fees associated with the completion of cremation certificates.

21. What Does it Mean For You? – Crematoria Staff No cremation certificates (Forms B & C) Statutory role of crematoria medical referees will come to an end when Certification of Death (Scotland) Act 2011 comes into force. Any roles that have to date been undertaken by crematoria medical referees, but that are outwith the legislation that defines their role, will need to be assessed and re-assigned, as and if required. This includes eg making decisions on whether it is safe to cremate. To assist crematoria with this, Form 14 will be revised on a statutory basis to include new information re the presence or otherwise of hazardous implants etc. This will improve on the current non statutory information added to Forms B & C.

22. Sources of Information Scottish Government webpages: http://www.scotland.gov.uk/Topics/Health/Policy/BurialsCremation/Death- Certificate Contact details for the policy team Link to the Certification of Death (Scotland) Act 2011 and information on its development stages Information on the Death Certification National Advisory Group General Background, Contextual information, Stakeholder Updates, General Resources Any updated version of this presentation. Please check you have the latest version before using. SG Version 2