Death certification reform in England
BMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k2668 (Published 21 June 2018) Cite this as: BMJ 2018;361:k2668
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I welcome the T.Luce's article and the reform of the death certificate (1). My intervention will be about the process for completing death notification.
The attending Physician will complete the Cause of Death section of the Notification of Death form immediately upon pronouncing a patient deceased and this shall be filed with the Central Statistics Office of the Ministry of Public Health. The Notification of Death form will be completely filled out in an authoritative expression of the physician’s opinion in a clear, legible, concise manner. The demographic information, including place, time and date of death, shall be completed by the attending Registered Nurse, and the particulars of the deceased shall correlate with the demographics in the patient’s medical record. Where language is a barrier, the informant’s particulars shall refer to the person who assisted in taking information from the relative, family, or next of kin of the deceased. The attending Physician shall document in the cause of death section of the form, the disease or condition causing the death, the underlying cause of death in part one and if applicable other significant conditions contributing to death in part two. If etiology of death is unknown, a provisional cause in the best judgment of the Physician shall be stated, listing the sequence of disease condition related to one another etiology or pathophysiology(2).
For health care workers to understand whether people are dying unnecessarily every day in our hospitals, we need a diagnostic journey that shifts from the judiciary model to the learning model. Show accurate diagnosis, communication and planning; this will help you understand the local environment.
1- https://www.gov.uk/government/consultations/death-certification-reforms
2- http://intraappsrv01/POLICIES/search.asp/ AS 9003 Undeniable Death - Revised July 2017
Competing interests: No competing interests
We welcome T.Luce’s article and the introduction of death certification reforms (1). We wish to take this opportunity to highlight the fact that these reforms will improve other aspects of healthcare quality.
It is common that junior doctors have the task of completing death certificates but it is imperative that the certificates are also approved by their senior clinical supervisors such as consultant colleagues. Because of the onerous nature of work this does not always happen. Any delay in the completion of a death certificate will inevitably lead to delay in the release of the body of the deceased patient which would then have a negative impact on expectations of relatives.
The accuracy of death certificates will have a direct impact on the mortality reduction programmes of all healthcare organizations (2). Mortality is the most important healthcare indicator on the performance of healthcare organizations and hence the local programmes of mortality review including establishing whether the death was avoidable or not and what lessons can be learned to reduce mortality and improve healthcare in general is directly reliant on the accuracy of what is documented on death certificates.
Another aspect which is important mention is the documentation of alert organisms as a cause of death within the context of healthcare associated infections. It is important that the documentation reflects exactly the role of these organisms whether they were the direct cause of death or contributed to it or their presence had no bearing at all on mortality. This is not only important for local purposes but also for national reasons in terms of providing a true reflection of mortality due to healthcare associated infections in the interest of healthcare performance and epidemiological profile. The typical two examples are Clostridium difficile and Meticillin-Resistant Staphylococcus aureus (MRSA).There is sometimes a tendency to include these organisms as a cause of death as direct or indirect mortality factors despite that in reality they were either only colonizing patients or causing minor infections with no relevance to mortality (3). We therefore strongly recommend that when faced with uncertainty as regards to the significance of these healthcare-associated infective agents in relation to mortality that the Medical Microbiologist or Infectious Disease Physicians are consulted to assist in ensuring accuracy in the diagnosis and documentation of cause of death.
1. https://www.gov.uk/government/consultations/death-certification-reforms
2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3310441/
3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3471622/
Competing interests: No competing interests
Improving accuracy and safety in death certification is an aim to be admired. But when introducing a requirement for second certification for burials, it is important not to cause undue delay.
In faiths such as Judaism and Islam, burial rather than cremation is the usual practice; and it is considered highly important for burial to take place as soon as possible after death, ideally on the same day. If second certification for burials is introduced, it is imperative to maintain sensitivity to members of these faiths, by ensuring availability of examiners at short notice, at all times.
This issue is highlighted by the recent debacle in North London surrounding the coroner's decision not to prioritise inquests on the basis of religious requirements. The High Court ruled this practice unlawful (https://www.bbc.co.uk/news/uk-england-london-43922000). This episode caused significant distress to numerous families, including many of our patients. The proposed new system must avoid doing the same.
Competing interests: No competing interests
Death certificates for deceased patients in Greek hospitals contain serious mistakes in 64.6% of cases and minor errors in 100% of cases. [1][2]
Thus, investigations on patient deaths or disease specific mortality in Greece may not be trustworthy.
Clinicians, researchers, academics who include statistical data coming from Greece must have this in mind.
Published systematic reviews, meta-analyses, research studies, may be flawed if they include input from Greek hospitals.
Death certification reform is urgent in Greece, as well.
References
[1] http://www.hippokratia.gr/index.php/archives/volume-20-2016/issue-1/1521...
[2] http://www.ekathimerini.com/213507/article/ekathimerini/news/six-in-10-d...
Competing interests: No competing interests
Re: Death certification reform in England
We share Luce and Smith’s disappointment at the recent announcement of another deferral of the introduction of Medical Examiners (ME) in the community. This is risky since over half of all deaths are out of hospital, and Shipman exploited weaknesses in the current system which will remain unchanged. The system is already showing fragility – for example, it can be hard to find GPs to sign the second part (Cremation 5) forms in some areas.
A key part of the system is the Crematorium Medical Referee (CMR) who oversees all the stages to permit a cremation, and we have concerns about clinical governance in this area. It is clearly essential that these doctors must be fully registered with a licence to practise. However, many CMRs are retired from clinical work, often from General Practice or Public Health (the latter probably being a legacy from Medical Officers of Health). Many have been loyally ‘hanging on’ for some years expecting to be replaced by a ME.
Public Health England is the designated body for doctors employed by local authorities and so provides professional appraisal and Responsible Officer functions for many CMRs. Our experience is that finding supporting information for revalidation can be challenging for the group of doctors whose sole role is CMR and who may be long out of clinical practice. Many will now have to make an active decision about when to retire, since they will not be replaced in the foreseeable future.
Local Authorities will need to do some succession planning to ensure the role is maintained. Where they are replaced we would encourage local authorities to appoint people in current clinical practice, with CMR as part of their scope of practice. This will ensure a well-governed system and professional appraisal and revalidation will be straightforward
Competing interests: No competing interests