Dr Man-Hong Tseung and Dr Paul Baughan discuss some common pitfalls of death certification and summarise updated and proposed UK legislation
Read this article to learn more about:
- planning certification of an expected death
- issues that arise from incorrect completion of death certificates
- recent and proposed changes to death certification in the UK.
A voidable problems encountered in the death certification process of an expected death can add to the distress of grieving relatives during this difficult time. A carer's experience highlights this in Box 1 (below).
Box 1: A carer's experience of problematic death certification
'A dear friend of mine died of metastatic breast cancer in her early 50s. It had been a long and gruelling illness with her final 3 months spent virtually bed-bound with spinal cord compression and brain metastases. She was nursed by her family and friends with the support of the palliative care team from the local independent hospice, private carers, and a very supportive GP. Her death had been expected for several weeks before she died and she had planned her funeral with her relatives, who had come over from South Africa.
'Just over a week before her death, her usual GP went on holiday.
'[My friend] died peacefully, with her family around her and her death was verified by a nurse from the hospice. A GP from the same practice who had not seen her before her death signed the death certificate.
'When the certificate was taken to the registrar it was rejected as [the GP] had declared she was not the usual GP but had not rung the coroner to explain the situation. In the end the issue was not resolved until the return of [my friend's] usual GP from holiday.
'This had been a particularly difficult terminal illness, managed very well, but as a result of not planning for death certification, the family suffered a lot of unnecessary distress and all the good care that the GP had given was eclipsed by the avoidable distress of not being able to move forward.
'The learning points were ensuring that a GP hands over care before a planned holiday if a death is expected, and also ensuring a colleague has seen the patient before they die. Failing this, it is important that the GP signing the death certificate rings and speaks to the coroner first to get agreement for the issuing of the certificate, explaining that the death was expected and the patient had a terminal illness. This would have avoided the delay and uncertainty that caused so much distress to the family.'
Jane, carer from London
Doctors worldwide have been assumed to know how to complete death certificates (Medical Certificate of Cause of Death [MCCD]), but there is little evidence of any formal training for doctors on how to do this.1,2 It is also important for other healthcare professionals (nurses, out-of-hours services, nursing and residential care homes) to understand the basics of this procedure because they may be the professionals who are involved with relatives and carers at the time of death, and the people to whom they will turn for initial advice.
Issues arising from incorrect completion of death certificates
A variety of issues arise from incorrect completion of death certificates, which can result in unnecessary delays that add to the distress already experienced by grieving families and carers. These issues are discussed in this article and include:
- clarification between death confirmation (or verification) and death certification
- timely completion of the MCCD
- completing the MCCD using correct terminology
- the importance of checking whether a Deprivation of Liberty Safeguards (DoLS) is in place and valid at the time of death (only applicable to England and Wales)
- timescales in which a doctor has to have seen the patient alive before death, in order to issue the MCCD
- local coroner variations, of which doctors may be unaware (such as reporting of deaths of patients who have recently had systemic anti-cancer treatment, prior to agreement for the issue of an MCCD).
Clarification between death confirmation (or verification) and death certification
Death confirmation has been misunderstood as death certification in some instances, especially if confirmation has been done out of hours. Death confirmation/verification is confirmation of the fact of death, whereas death certification is confirmation of the cause of death. In situations where death confirmation has been confused with death certification, relatives are kept waiting for the MCCD until the error has been realised. Furthermore, death confirmation need not be performed by a doctor; it can be done by any suitably trained healthcare professional (e.g. district nurse), whereas death certification can only be carried out by a medically trained doctor.3
Timely completion of the medical certificate of cause of death
In the authors' experience, in instances when there has been delay in issuing the MCCD, relatives have experienced distress and confusion, especially when the reasons for delay are not explained. There will be times when delay is unavoidable, such as when the coroner (or procurator fiscal in Scotland) has to be involved, so it is important to explain this legal requirement to the relatives and to give an estimate of when the MCCD will be issued. However, delays can also arise from confusion as to whether a doctor can issue the MCCD or not, because the doctors themselves may be unsure—such as when the usually attending doctor is away on leave, or if the patient has not been seen within the stipulated time scale (within the last 14 days of life for England and Wales;4 there is no minimum time scale for Scotland although guidance about the meaning of 'attending doctor' in Scotland is available5–7). It is important to have systems in place to deal with these eventualities, such as appropriate handover when a patient is near the end of life and the usual doctor may be away when they die.8,9
Completing the MCCD using correct terminology
From the authors' own experiences in the UK, if the cause of death is incorrectly documented on the MCCD then it will be returned to the doctor, which can cause unnecessary delays. Common errors consist of documenting a mode of death (such as asphyxia, heart failure, renal failure, respiratory arrest) instead of the disease, injury, or complication that caused the death. 'Old age' can be accepted as a cause of death if the patient is aged over 80 years, but only if the doctor completing the MCCD:4
- has personally cared for the deceased over a long period (years, or many months)
- has observed a gradual decline in the patient's general health and functioning
- is not aware of any identifiable disease or injury that contributed to the death
- is certain that there is no reason that the death should be reported to the coroner.
A doctor does not need to be 'certain' of the exact cause of death to complete an MCCD. They should use their medical skills and the known history of the deceased to indicate the most likely cause of death. It is acceptable to write 'probable myocardial infarction' if there is not a definitive diagnosis but the history suggests this as a likely cause of death. The sequencing of the cause of death should tell a story with the underlying cause at the bottom of the sequence, for example:
- 1a) pulmonary embolism
- 1b) deep venous thrombosis left leg
- 1c) endometrial adenocarcinoma.
The causal timescale must be entered as a number of days, months, or years and cannot be omitted or simply ticked. Simple and easily avoidable mistakes can also be made, such as forgetting to include the doctor's General Medical Council number, using abbreviations, and even forgetting to sign the MCCD.
Importance of checking if a Deprivation of Liberty Safeguards is in place and valid at the time of death (only applicable to England and Wales)
If a patient has a valid Deprivation of Liberty Safeguards (DoLS) order in place, then the coroner will need to be notified after the patient has died. It is important that family and carers are aware of this, as there will be some delay in issuing the MCCD in this situation. Once notified, the coroner will first check that the DoLS order is valid and not out of date, send the doctor a brief questionnaire to complete, and then inform the relatives, before arranging an inquest after which the coroner issues the MCCD. Because nursing homes, residential care homes, and even hospitals apply for the DoLS order,10 GP practices may be caught out if they are not informed that the order exists, and if it does, whether it is still valid.
Timescales in which a doctor has to have seen the patient alive before death, in order to issue the MCCD
There are differences in death certification procedures among the different nations of the UK. For example, for a doctor to be eligible to issue an MCCD in England and Wales, they must have seen the patient within the last 14 days of life,8 in Northern Ireland they must have seen the patient within 28 days of death,9 and in Scotland they do not have to have seen the patient alive at all, in order to issue the MCCD.7,11
Local coroner variations that doctors may be unaware of, such as reporting the deaths of patients who have recently had systemic anticancer treatment prior to agreement for the issue of an MCCD
It is important to be aware of any local variations in procedures that a local coroner may insist on, otherwise further delays can occur in issuing the MCCD. For example, in Merseyside and Cheshire (and certain areas of Northern Ireland) the local coroner insists on being notified of the death of any patient who has received any systemic anti-cancer treatment in the 30 days preceding the patient's death. This encompasses any sort of anticancer treatment, including surgery, chemotherapy, radiotherapy, and hormonal therapy.8,9 The coroner will then send the doctor a questionnaire about the treatment, and if satisfied that the treatment did not cause the death, instruct the doctor to issue an MCCD with an agreed cause of death. If the coroner has concerns, an inquest will be convened. This local requirement does not seem to be needed in other areas of the UK.
Recent changes to the death certification process in Scotland5,6
In May 2015, a medical review system was introduced in Scotland to provide independent checks on the quality and accuracy of MCCDs.6 The aim was to:
- improve the quality and accuracy of MCCDs
- provide better public health information about causes of death, and
- ensure that the processes around death certification were robust and had appropriate safeguards.
The medical reviewers undertake two different levels of review on a random selection of MCCDs. Level 1 reviews (10% of all deaths) involve the medical reviewer phoning the certifying doctor and discussing what is written on the MCCD. A small number of level 2 reviews (up to 4% of all deaths) will involve the medical reviewer speaking to the doctor and examining relevant medical records.7
There is no longer a distinction in the process for certifying a death for burial and a death for cremation in Scotland. This ends the need to find a second doctor to sign a cremation form. General practitioners are also able to complete an electronic MCCD, which speeds up the review process.7
During the first year of reviewing MCCDs in Scotland, 46% of MCCDs were found to be 'not in order'.11 The most common errors picked up by the medical reviewers were as follows:11
- cause of death too vague
- causal timescales omitted (or ticked, rather than a number entered)
- cause of death incorrect
- registrar error
- sequence of cause of death incorrect (1a, 1b, 1c, and 2)
- conditions omitted
- abbreviations used.
There is clear evidence that the accuracy of MCCDs is improving in Scotland since the medical reviewer service began. Many doctors in Scotland now use the medical reviewers as a sounding board to talk through how best to sequence the medical causes of death before issuing the MCCD.
Future proposed changes to the death certification process in England and Wales
Between March and June 2016, the Department of Health (England and Wales) published a consultation document12 on changes proposed to the way deaths will be certified. This was in part fuelled by the results from the Shipman Inquiry.13 The consultation results are currently being analysed at the time of writing (December 2016). The consultation document has proposed some significant changes, which include:
- the appointment of a medical examiner system to oversee the death certification process:12
- on the death of a patient, once verified, the attending doctor must prepare an MCCD and send this along with 'statutory information' to their medical examiner, who then scrutinises the information. If the medical examiner approves, then the doctor can proceed to issue the MCCD but can also delegate the actual issuing to a member of staff (e.g. ward or practice staff, or bereavement services in hospitals and hospices). If it is not approved, then discussions are held with the family and the local coroner, which may result in further investigation (such as a post mortem)
- if the doctor has concerns about the cause of death, they can discuss this with the medical examiner, who will also discuss with the family
- families no longer need to pay cremation form fees and doctors no longer need to complete cremation forms. Instead, families will be liable to pay one medical examiner's fee for either cremation or burial
- in England and Wales, currently a doctor can only issue an MCCD if they have seen the patient within 14 days before their death—the new proposals are extending this time limit to 28 days.
Other proposed changes will be announced by the Department of Health when the final consultation has been analysed.
In summary, correct adherence to the death certification procedures will help to ensure a smooth process following an expected death, and so reduce the amount of distress and confusion that can be experienced by already grieving relatives. The death of a relative can be a very emotionally distressing and traumatic time for carers and relatives. Grieving carers and relatives are at a vulnerable stage in their lives, and legal and administrative processes surrounding death can be confusing at such a distressing time. Prompt, timely, and correct completion of the MCCD, along with printed guidance on who relatives need to contact after death can help to alleviate some of this distress. The problems discussed above can be easily avoided, if practitioners are aware of the processes and are pragmatic in their approach. This will go towards helping grieving patients during their bereavement process.
- Doctors and other health and care professionals need to have knowledge of death certification procedures
- Incorrect completion of death certificates causes unnecessary delays, adding to the distress of grieving families and carers
- Know the difference between death confirmation and death certification:
- death confirmation is confirmation of the fact of death and can be carried out by any suitably trained healthcare professional
- death certification is confirmation of the cause of death and can only be carried out by a medically trained doctor
- If the MCCD is delayed, the reason for this should be explained to relatives
- When a patient is nearing the end of life and the usual doctor may be away when they die, arrange an appropriate handover
- The cause of death should be correctly documented on the MCCD or this may be returned, causing delays
- Check whether a valid DoLS order is in place
- Be aware of:
- any timescale within which the doctor has to have seen the patient alive to certify the death (currently within the last 14 days of life in England and Wales)
- any local variations in procedures set by coroners
- Scotland's medical review system, introduced in 2015
- proposed changes to the death certification process in England and Wales, and the proposed appointment of medical examiners.
MCCD=Medical Certificate of Cause of Death; DoLS=Deprivation of Liberty Safeguards
GP commissioning messages
written by Dr David Jenner, GP, Cullompton, Devon
- There are often inaccuracies or delays in the death certification process, which can cause distress to bereaved relatives
- NHS England and CCGs should consider providing training for local GPs:
- local coroners should be involved in the process as there can be significant variation between local coroners' requirements
- With new legislation and a potential new process pending, it will be vital for proper training to be provided for GPs, nurses, and local care homes if the proposed changes to death certification come into force
- National guidance and an algorithm should be developed to act as a 'checklist' for GPs to refer to when completing a death certificate, both now and with any future changes.
- Comstock G, Marjush R. Further comments on problems in death certification. Am J Epidemiol 1986: 124 (2): 180–181.
- Switzer D. Death certificate process and issues. Ohio: Medical Economics, 25 March 2011. medicaleconomics.modernmedicine.com/medical-economics/news/modernmedicine/modern-medicine-feature-articles/death-certificate-process-and (accessed 9 December 2016).
- British Medical Association website. Confirmation and certification of death. October 2011, updated September 2016. www.bma.org.uk/advice/employment/gp-practices/service-provision/confirmation-and-certification-of-death (accessed 9 December 2016).
- Office of National Statistics and Home Office Identity and Passport Service. Guidance for doctors completing medical certificates of cause of death in England and Wales. Southport: General Register Office, 2010. Available at: www.gro.gov.uk/images/medcert_july_2010.pdf
- Certification of Death (Scotland) Act 2011. Available at: www.legislation.gov.uk/asp/2011/11/pdfs/asp_20110011_en.pdf (accessed 9 December 2016).
- Scotland Death Certification Review Service. Death certification in Scotland. Healthcare Improvement Scotland, 2015. Available at: www.healthcareimprovementscotland.org/our_work/governance_and_assurance/death_certification.aspx (accessed 9 December 2016).
- Chief Medical Officer and Public Health Directorate. Guidance for doctors completing medical certificates of the cause of death (MCCD) and its quality assurance. The Scottish Government; National Records of Scotland. 16 October 2014. Available at: www.sehd.scot.nhs.uk/cmo/CMO(2014)27.pdf
- Macmillan End of Life Care GP Advisers Team. 10 top tips on death certification/procedures of an expected death (England only). Macmillan Cancer Support, 2016. Available at: www.macmillan.org.uk/_images/ten-tips-death-certification-england_tcm9-300178.pdf
- Millar G, Andrew G. 10 top tips on death certification/procedures of an expected death (Northern Ireland). Macmillan Cancer Support, 2016. Available at: www.macmillan.org.uk/_images/ten-tips-death-certification-northern-ireland_tcm9-300179.pdf
- Alzheimer's Society. Deprivation of liberty safeguards (DoLS). Alzheimer's Society, 2016. Available at: www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=1327 (accessed 9 December 2016).
- Healthcare Improvement Scotland. Death Certification Review Service annual report 2015–2016. HIS, 2016. Available at: www.healthcareimprovementscotland.org/our_work/governance_and_assurance/death_certification/dcrs_annual_report_2015-2016.aspx (accessed 9 December 2016).
- Department of Health. Introduction of medical examiners and reforms to death certification in England and Wales: policy and draft regulations. Consultation. London: DoH, 2016. Available at: www.gov.uk/government/uploads/system/uploads/attachment_data/file/517184/DCR_Consultion_Document.pdf (accessed 11 January 2017).
- Shipman Inquiry. Third Report. Death certification and the investigation of deaths by coroners. The Shipman Inquiry, 2003. Cm 5854. Norwich: The Stationery Office, 2003). Available at: www.gov.uk/government/uploads/system/uploads/attachment_data/file/273227/5854.pdf (accessed 19 December 2016). G