Why the delays in counting the dead?BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g4305 (Published 09 July 2014) Cite this as: BMJ 2014;349:g4305
- Nigel Hawkes, freelance journalist, London
Death may be final, but in England and Wales it isn’t the last word: you aren’t officially dead until somebody else says so. That depends on establishing a cause of death—and if that should require an inquest, the fact of death goes unrecorded, sometimes for years.
Just how long depends on local coroners, who enjoy considerable autonomy. A group of charities recently wrote a letter to the prime minister calling for urgent changes to the law, saying that it can take from six months to two and a half years to register a death. Such delays have a significant effect on research and public health, not to mention the burden on grieving families who cannot close the book on the life of a loved one.
I wish the charities well, because their cause is just, but few institutions have proved as difficult to change as the coronial system. Set up in the wake of the Norman conquest and older than Magna Carta, the office of coroner is an institution that has survived the Reformation, the Glorious Revolution, the growth of democracy, Victorian busybodying, and everything that more recent reformers have thrown at it. As an admirer of ancient monuments, I instinctively applaud its improbable survival and wish it another 800 years, but for that to happen it needs some overdue tweaks. “If we want things to stay as they are, things will have to change,” as Giuseppe di Lampedusa unimprovably put it in The Leopard.
The statistics on the delays in recording deaths are striking. Around 10 000 deaths a year in England and Wales are not registered for six months, and a fifth of all deaths that occur between the ages of 5 and 44 years suffer the same delay. The average delay in recording suicides in England and Wales is 255 days; while in Scotland, where a death can be registered before its cause is established, the average delay is just seven days. For some deaths, such as those caused by suicide or the misuse of drugs, only half that were registered in 2011 actually occurred in 2011—the other half occurred in previous years.
For many causes of death these delays limit the usefulness of the system in important ways. The charities involved in the appeal to David Cameron and from whom these figures come—Samaritans, SANE, Transform Drug Policy Foundation, the Scottish Cot Death Trust, the Howard League for Penal Reform, the Royal Statistical Society, and Sense about Science—point out that any research involving calendar trends in deaths is compromised. If there is a change in public policy, such as the introduction of seat belts in cars, the reduction in deaths resulting from it is obscured, even though it may be obvious to police forces on the ground.
The campaign to improve death registration in England owes its inspiration to Sheila Bird of the Medical Research Council’s Biostatistics Unit at Cambridge, whose research interests have included studies of the deaths of prisoners recently released from jail. Many prisoners who may have been treated for drug addiction while inside relapse swiftly once released and are in considerable danger of dying as a result. But tracing such deaths and matching them with prison release dates is almost impossible in England until several years have passed. Bird said, “A whole range of studies in the public interest and that help to protect public health rely fundamentally on knowing who has died and when. It simply beggars belief that in the 21st century the registration system in England and Wales fails so basic a test.”1
The irony is that the coronial service has not gone unreformed throughout all those years since its establishment in 1194. The most recent reform was the Coroners and Justice Act 2009, which introduced the role of chief coroner but made no changes in death certification. Warning that the proposals that eventually became that act were inadequate, the Constitutional Affairs Committee of the House of Commons said in 2006 that the government was in danger of “wasting a golden opportunity for substantial reform of the systems of death certification and investigation in England and Wales.”
The proposals had even drawn back from those outlined in a Home Office paper published in March 2004 that had proposed verifying the fact of death as a separate step from its certification. Had such a step been incorporated into the Coroners and Justice Act, then death verifications would have provided timely data on who had died and where, as a similar arrangement already does in Scotland. Subsequent certification of death would then follow in much the same way as at present, subject to additional checks designed to make it harder for future Dr Shipmans to murder their patients and then “certify their way out of trouble.” Just why the then government retreated from the position taken in the Home Office paper is not clear, but the suspicion is that it would have cost more to implement.
The actual changes that resulted did not tackle the issue of delay in any way adequately. New rules introduced in July last year said that inquests were expected to be completed within six months of the date at which the coroner was made aware of a death. When an inquest has not been held within a year, coroners must notify the chief coroner and explain why. But gingering up coroners, even in this polite and gentlemanly way, is not a solution. The truth is that the proper investigation of a suspicious death cannot and should not be hurried, which is why it is important to separate the fact of death from its cause.
Why has this eluded the coronial service in England and Wales, when Scotland and 23 other European countries can properly and promptly count their dead, the charities asked Mr Cameron? He is yet to reply.
Cite this as: BMJ 2014;349:g4305
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.
thebmj.com/archive Personal View: What are coroners and pathologists for? (BMJ 2009;338:b1355); Editorial: Reform of the coroner system and death certification (BMJ 2007;335:680)