Intended for healthcare professionals


Death certification reform in England

BMJ 2018; 361 doi: (Published 21 June 2018) Cite this as: BMJ 2018;361:k2668
  1. Tom Luce, chair of 2001-03 fundamental review of death certification and investigation,
  2. Janet Smith, chair of Shipman inquiry (2001-05)
  1. Correspondence to: T Luce Tom.luce{at}

New medical examiners will eventually scrutinise all deaths

The 11 June announcement from England’s Department of Health and Social Care heralds a new phase, though not a final one, in the long slow saga of death certification reform.1 New local “medical examiners”—different from North American forensic pathology services with the same title—will from April 2019 start checking all death certificates issued by treating doctors for accuracy and compliance with coroner notification obligations.

The reform originates in the 2000 conviction of Harold Shipman, an English family doctor, for murdering 15 patients. The judicial Shipman inquiry found that he had probably murdered 250 patients during his career,2 certifying most deaths as natural. It recommended major reform of death regulation,3 as did a government appointed policy review.4

The Coroners and Justice Act 2009 empowers government to create medical examiners as statutory office holders appointed by English local authorities. In 2016, the health department consulted on impressively thorough details of the statutory scheme prepared with professional and service partners.1 A pilot projects report said, “Death certification is usually done very badly.” One third of scrutinised certificates needed major change, 8% showed failure to understand the indications for referral to a coroner, and 12% led to wrong International Classification of Diseases coding.5

But it is not this statutory scheme that is to be introduced from April 2019. Instead, for an interim period of undetermined length, there will be a hybrid scheme, based in NHS trusts. Medical examiners will assume the second certification function now randomly assigned in the cremation system and extend it to burials. Most are likely to be people at senior level in the NHS hospital service with close links to recent hospital safety initiatives. From April 2019 medical examiners will progressively extend their coverage from deaths in hospitals (48% of the total in 2016) to those in homes, care homes, and other settings.

Once fully rolled out the system will prevent burials being authorised on the unchecked certificate of the treating doctor. Relatives will have a bigger role in the certification process and perhaps more confidence in its robustness. NHS involvement should give more consistency and reliability to the cremation review process, which the Shipman inquiry judged an ineffective safeguard. Unlike in the independent statutory scheme envisaged by parliament, however, medical examiners will not have the safeguard of professional independence from employer influence that the 2009 legislation provides.

The second and supposedly final phase of the reform needs fresh parliamentary legislation to allow NHS Trusts rather than English local authorities to appoint examiners. A proper statutory scheme could then replace the informal interim arrangements. But this scheme will herald the end of a vision, for England, of a death regulation system that is structurally and legally independent of healthcare providers and colocating death registration, certification, and coroner investigation in one public authority also responsible for public health.

Difficulty in agreeing a funding scheme in the now highly conflicted financial relations between central and local government probably explains the switch away from the local authority model. Existing cremation certification fees will largely finance the interim scheme.

Delay and dilution

Shipman’s serial murders were among the biggest catastrophes in modern crime history. Government response was initially prompt and radical, with a 2004 proposal closely reflecting a recommendation of the Shipman inquiry for a new independent national agency combining medical and legal skills for certification and investigation.6

Delay and dilution soon set in. A 2006 proposal preserved the new chief coroner post but left the service with local authorities and revealed scepticism over the need for serious reform of death certification.7 A sharp rebuke from the health select committee got death certification back on the agenda.8 Legislation for reform of both death certification and coroner services was eventually enacted in 2009. In 2013 a chief coroner was appointed, after a quango-phobic decision to abolish the office was reversed under parliamentary pressure.

The coroner service was nevertheless shorn of the internal appeal process originally intended for it. Also lost along the way were a statutory committee to keep death certification and coroner services working properly together, and inspection of the coroner service’s interaction with families. A bereaved families’ charter has survived.

Five deferments of certification reform ensued from 2012 despite another fierce health select committee rebuke in 2014 and complaints of delay in the 2013 and 2015 reports on deaths from serious care failings in Mid-Staffordshire and Morecambe Bay.910 Between Shipman’s conviction and 2019 around nine million deaths will have been handled through procedures known to be unreliable.

The pace of action remains slow. Cabinet Office guidance prescribes that the responses to consultations should be reported within 12 weeks,11 but the health department has taken two years to report on its 2016 consultation.1 The justice ministry has yet to report on its 2015 post-implementation consultation on coroner reform or to make any substantive response to thoughtful annual chief coroner reports advocating sensible developments, some with cost-saving potential.1213

Parliamentary, professional, and public vigilance will be essential to stop the important safeguards of death certification and investigation from again suffering the long historical neglect largely responsible for the defects falteringly addressed over the past decade and a half.


  • Competing interests: We have read and understood BMJ policy on declaration of interests and have no interests to declare.

  • Provenance and peer review: Commissioned; not externally peer reviewed.


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