Certifying and Investigating Deaths in England, Wales
and Northern Ireland
Dr. Maureen Baker FRCGP
Honorary Secretary of Council
Sophy Osborn
The Review of Coroner Services
100 Pall Mall
St. James’s
London
SW1Y 5HP
22 November 2002
1. Thank you
for inviting the Royal College of General Practitioners to respond
to your consultation. We would wish to make some general comments
first and then respond to some of the specific sections within the
document.
General comments
2. We welcome
this document and many of the proposals made. It will clearly
be important that the final recommendations are consistent with
those of the Shipman Inquiry and the other reviews that are
outlined in paragraph 17. We note that the document shares
this view and would hope that it will be possible for a single set
of recommendation to be produced for this (and other) areas.
We commend the coherence of the recommendations laid out in your
consultation document, especially when compared with some other
current consultations.
3. The RCGP
particularly welcomes the very comprehensive terms of reference
given to the working party responsible for the production of this
document and the way in which the review has been conducted.
However, we would like to register our disappointment that there
was no clinician on the working party.
4. We regret that
the bulk of the recommendations of the Brodrick Committee were not
implemented and that the report on the coroner system (Wright 1936)
was largely shelved.
5. It is our
belief that coroners should be selected from a wider choice of
relevant professionals, with both lawyers and clinicians working
together.
6. We are
surprised that the document does not emphasise the need for
training requirements and also a methodology for appointing
assistant coroners.
7. We are
concerned to ensure that a disproportionate emphasis is not given
to the practice of Harold Shipman when considering a change to the
current procedures. However, one practical suggestion we
would like to put forward is that whenever a death occurs when the
only person present was the GP, it should automatically be referred
to the Coroner.
8. We would
emphasise the need for a greater emphasis on death certification in
the medical undergraduate curriculum and GP registrar training
programme.
9. We would
stress to the Working Party that it is important to ensure that
those parts of the system that currently function well are not
discarded along with those parts that operate less
effectively.
10. We would wish to stress that the
accuracy of death certification is affected if clinicians are
inadequately supported by pathologists, because there are not
enough of them, and if post-mortems are not available. We
would also wish to emphasise the importance of clinicians being
able to learn from post-mortems and other pathological evidence
after the deaths of their patients and for this learning to be
enabled rather than obstructed as is often the current
situation.
Specific issues
Fitness for purpose
11. Paragraph 16. We particularly welcome
the conclusions reached in this paragraph and the desire to
moderate systems and provide more support for those working in
them.
12. Paragraph 18. We support the
intention that the registered cause of an individual death should
become private information available to families and approved
users. We recognise that this issue can be a particular cause
for concern of families, for instance when the death is a
suicide.
13. Paragraph 19. We would echo the
importance of Human Rights Law in that it affects the State’s
obligation to investigate deaths in suspicious circumstances.
Critical Systems Defects
14. In general, we agree with the
assessment of the critical defects in the death certification and
investigation process.
15. Paragraph 20.1. The analysis of
fragmentation of certification and investigation is well
made. The certification process should not be separate from
the coronial process. It is important that the certification
process is being correctly carried out, and that those deaths that
should be investigated further are appropriately referred.
16. Paragraph 20.2 We would
agree with the analysis of the current lack of participation for
the bereaved and consequent absence of reliable information and
support about the post-mortem process. This should be given
priority. Putting aside the death itself, the mere mention of
a post-mortem or inquest can be most distressing for many
people. A great deal of understanding and support is
needed.
17. Paragraph 20.4. We feel that
this paragraph needs some clarification. The proposition that
there is a lack of medical skills in support of death certification
and audit is not explained in the rest of the text. This may
be referring to poor performance and/or a lack of education or even
to a systematic absence of people in the right place. We
would assume that you are referring to the last. It should be
made clearer what is actually meant by “lack of medical
skills”.
18. Paragraph 21. Commenting on the
fourth bullet point, we would agree with the factors identified as
important. We would also like to point out that changes in
GP’s working arrangements are partly due to increased pressure from
external demands and workforce shortages. This will also have
an impact on the factors you identify.
19. Paragraphs 21 and 22. We support the
concern that lessons are learnt from premature medical deaths and
that this should be done as far as possible on a systematic
basis. This could be achieved largely without changes to the
current system. We would cite as an example, the use of
Public Health Laboratories.
20. The factors identified do not
recognise the difficulties in the medical management (often through
a team approach) and subsequent death certification, of an ageing
population that has polypathology.
.
Public health issues
21. Paragraph 24. We would
emphasise the importance of informed debate of the issues
surrounding reported errors in certification and the need for
balance between accuracy and intrusive investigation before and
after death. It would be preferable to accept inaccuracy
where there is no suspicion of unnatural causes of death.
This could be written into the arrangements by permitting
descriptions that are more general.
22. There are often occasions when there
is no question of foul play but, nonetheless, the precise cause of
death remains unclear. There needs to be some debate about
the importance of precision; it is not a question of error.
The given cause of death has implications for the family and for
national epidemiological data. There may be a need for a
number of broad categories to be formulated. These could be
used in the difficult, but common circumstances where the only way
of establishing a precise cause would be to conduct a post-mortem
examination and where this is either not wanted by the family or
there is not the capacity to provide one.
23. However, It would be worthwhile to
explore the implications of the high error rate in death
certificate causes of death, as this should highlight whether and
why such errors occurred in the first place and what lessons may be
learnt.
.
Consultative Proposal for a new Medical Auditor
Service
24. Paragraph 26/27. We welcome the
proposal to establish a Medical Audit Service if its functions are
broadly limited to the more effective conduct of current
functions. However, we feel that the suggested title of the
service does not make its function clear to the public.
25. We would wish to highlight these
important additions:
·
Education and training,
·
Monitoring the patterns of certification, providing the first line
of advice in cases of uncertainty about certification,
·
Overseeing second certification.
26. We feel that this could offer a
rational approach to existing tasks as well as providing the
overview of the service that is currently missing.
27. However, there would not seem to be a
need to duplicate a part of the role of Public Health, nor to
mounting a separate function on a routine basis.
28. The suggestion that this function
should decide the nature and scope of further medical investigation
would seem to infringe on the powers of the coroner. We
acknowledge that there may be a role for this service to manage
access to post-mortem examination where there is nothing to suggest
foul play.
29. If a Medical Audit Service is set up,
this has to be adequately supported and needs to give and receive
regular feedback in the true spirit of constructive audit.
30. Paragraph 29. We would pose the
question of how important is the accuracy of certification in
comparison to the importance of establishing death by natural
causes? To adhere to strict accuracy may cause added and
unnecessary distress to families through the imposition of a
greater number of post-mortems.
31. GPs currently have the same access to
information as the proposed Medical Audit Service. It may be
necessary to stress the importance of certification to GPs, some of
whom may be able to add greater accuracy by spending more time on
the certification process, but this is likely to be in the context
of an enhanced primary care workforce.
32. Paragraph 29.3 We support the
proposal that the current system of ‘Part 2’ signatures on
cremations be discontinued and replaced with deaths certified by
two doctors. This is a much more sensible arrangement.
Cremation Certification
33. Paragraph 30.1/2 We would
endorse the identified shortcomings of the current three-tier
cremation certification process as described in these two
sub-paragraphs.
One
or Two Tiers of Certification
34.
Paragraph 33. We support the proposal for the second certificant to
be independent of the first certificant or funeral director. It is
our view that a second tier will reduce the burden carried by the
first certificant, who will often have been the lead professional
in the care of the patient and may understandably be regarded in an
ambivalent way by relatives. In these circumstances, there may well
be an increased demand for post-mortem examination as a defensive
measure, which would be inappropriate. Whilst post-mortem viewing
of the body may often yield little clinical information, the
deceased will usually be well known to the first certificant and
this does provide some safeguard against criminal behaviour. We
would suggest that the first certificant should see the body, but
that the second should do so at his/her discretion.
Status of Medical Audit Service
35. Paragraph 37. With the need for a 365-day
service, we would question where the doctors would be found to
support this function. As you will be aware, there is there is a
great workforce shortage in all areas of the health profession,
including clinical, public health and pathology.
Verifying the Fact of Death
36. Whilst we would see this remaining
primarily with the doctor, we welcome the exploration of using
other specified personnel. We do not see any reason why
trained paramedical staff should not be used to confirm death, but
not certify the death.
37. It will be imperative that adequate
training is provided and that strict protocols are adhered
to.
38. Paragraph 46.2/7 In summary, we
would support:
· the
establishment of a Medical Audit Service with core general
functions as outlined in paragraph 27 and the suggested casework
functions suggested in paragraph 29.
· a
two-tier system for all certification including cremation, but this
could be extended in part 1 to other professionals including nurses
and para-medics with suitable training and standardised procedures
in these new professional verifications of the fact of death.
·
that processes for verifying deaths should be standardised.
Post-Mortems
39. Paragraphs 50 – 58 We support
the suggestions on quality control and audit set out in these
paragraphs.
40. Paragraph 56. The awareness of
cultural sensitivity regarding post-mortems is particularly welcome
and is an important issue. The initiative in Manchester to
fund a scheme for conducting post-mortems using MRI scans is
innovative and should be evaluated to see if this is a useful way
forward in developing non-intrusive examinations.
41. Paragraph 59.1/2 It is our view
that families should be kept informed of post-mortems and also that
they should have the choice of pathologists. We would also
consider it reasonable that families and GPs should have the right
to have a copy of the post-mortem report.
42. Paragraph 59.3/4 Consideration
should be given to exploring the possibility of limiting
post-mortems to those clinical or histo-pathological areas to
confirm the suspected cause of death (e.g. myocardial infarction or
pulmonary embolism) and that a more comprehensive autopsy should be
reserved for unknown causes of death or those in which foul play is
suspected. The person responsible for the post-mortem report
should decide toxicological and histological investigation.
43. Paragraph 60.2 We would endorse
the view that post-mortems should not be “routinely” ordered,
especially as this can cause distress to the family of the
deceased.
44. We would suggest that the following
audit mechanisms could be applied in developing a more focussed
approach:
·
Data collection on expected versus identified cause of death
·
Evidence of discussion with relatives
·
Evidence that the GP was able to
–
provide information for the post-mortem
–
receive a report regarding the outcome of the post-mortem
45. Paragraph 60.3 We would prefer
that the presumption that families should ‘see’ the post-mortem
report goes further. We can see no reason why the family
should not have a copy of the report to keep. Relatives may
wish to ask their doctor or the doctor of the deceased to explain
parts of the report, but the copy should be their own.
46. Paragraph 75 We would like to
make the following comments on the broad proposals outlined:
75.1
We would agree that Coroners’ courts should each work to consistent
procedures
75.2
We agree that there should be an avenue of appeal to a specified
higher court as proposed
75.3
In dealing with especially contentious or complex cases we would
suggest that senior specialist coroners with additional training,
or panels of three coroners might be adequate to deal with such
cases
75.4
We believe it is essential that coroners should be assessed as to
their suitability to work with bereaved families and
individuals.
75.5
We agree with the proposal that the Lord Chancellor should be
responsible for appointments at all judicial levels and for
standards of coronial conduct and discipline
75.6
We support initial and ongoing training of coroners. This
should be mandatory.
75.7
We have no particular view on the regional disposition of full-time
coroners or how part-time appointments are deployed
75.8
We would support coroners in England, Wales or Northern Ireland
coming under a national jurisdiction.
75.9
We would support the Senior Salaries Review Body considering the
pay and terms under the proposed new arrangements.
.
The
Public Inquest
47. Paragraph 107. Our response to
the issues raised are as follows:
107.1
The reference group may also wish to consider the development of a
coding system for causes of death. It may also be of worth
considering the appropriateness of coroners appointing their own
deputies.
107.2
The suggestion of dealing with some cases administratively and in
private would appear to be a significant improvement on the current
practice. We would, however, consider that deaths occurring
abroad should merit an inquest either at the coroner’s discretion
or at the family’s request.
107.3
On the issue of different types of inquest outcomes, it is our view
that the new measures proposed would be more ‘public friendly’ than
those currently reached and would have greater meaning for the
population at large. We do not see any justification for
differences in approach in Northern Ireland. It is our view
that the same rules should be applied throughout the UK.
107.4
We welcome the proposals for putting the support of bereaved people
at the centre of a new inquest process, but would like to emphasise
that this should be done without increasing the burdens upon
them. The promptness of inquests, in particular, would be of
great advantage to the bereaved. We would urge that the
recommendations for support should be adopted as suggested.
However, we do not accept the implication that
all bereaved people either want or need counselling. This
amounts to the medicalisation or professionalism of grief, which
should be viewed as a normal part of life. Bereavement
counselling should obviously be available to those who want it but
it should not re regard as in any way an essential part of the
grieving process. We would support the monitoring of the delivery
of the proposed administrative standards, but feel that the
creation of an inspectorate for this purpose is not
necessary.
107.5
The implied effects of changes to the Legal Services Commission
last autumn, liberalising the availability of legal aid for
families should certainly be subject to study and analysis of the
subsequent recommendations and conclusions. The
recommendation that publicly funded legal aid should be made
available only when representation is from panels of suitably
experienced practitioners, should be given serious
consideration.
107.6
In the interests of public safety, we feel that there should be
more monitoring of follow up by the public services at which they
are directed, particularly through their respective inspectorate
reports.
Issues of Structure and Reporting
48. Paragraph 117. We would support
the need for a fuller understanding amongst the public of issues
about death. Schools and colleges could play a role in
teaching the realities of what happens to the body after
death. The media could also be a conduit for public education
covering death, dying, organ donation etc.
The media could also be a conduit for public
education covering death, dying, organ donation etc.
Conclusion
49. The RCGP would welcome the
opportunity to comment on more fully developed proposals on the
issues of structure and reporting. We also applaud the
intention to support the professional independence of doctors and
others in the certification process.
50. In reforming the system, a high
priority needs to be given to respecting the rights, interests and
feelings of the bereaved. As many people have a fear of
death, and all associated events, it would be prudent to seek to
allay those fears. The provision of clear, concise and ‘user
friendly’ literature on all aspects of death could be issued to the
bereaved by the relevant party at the appropriate
time.
Acknowledgements
We would like to acknowledge the contributions
of the following in compiling this response:
Dr Graham Archard, Ms Mitzi Blennerhassett, Ms
Elizabeth Brain, Dr Terry Davies, Professor Martyn Evans, Dr Philip
Evans, Dr Iona Heath, Dr Ann Orme-Smith, Ms Caroline Page, Ms Janet
Radcliffe-Richards, Dr Jim Rodger, Dr Robert Sibbald, Dr Ben
Sweeney, Dr John Toby, Dr Colin Waine, Ms Alexandra Williams
Yours sincerely
Dr Maureen Baker
Honorary Secretary of Council