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GP faces form C dilemma thanks to Harold Shipman

Three GPs share their approach to a practice dilemma

Case history

A close friend of your family has died 100 miles away. His relatives want him cremated quickly.

You agreed months ago to do form C because other GPs in his town were refusing to do them.

His own GP did form B but had to go

away urgently and it will be a few days

before you can contact him.

The GP is about to retire and you suspect he no longer worries about correct procedure.

The death was expected, due to old age and advanced Parkinson's, but you want to follow the regulations.

Everyone concerned is becoming irritated and putting pressure on you because you won't just sign the form.

How do you handle this?

Dr Nigel de Kare Silver

'You must stand firm, however much the family plead or get angry with you'

Emotions at a time of family bereavement can be very difficult to deal with. There is a lot of tension and it might be impossible to convince the family the promises made several months earlier cannot be fulfilled immediately.

Strong arguments will be used claiming that your personal knowledge of the person who died and your knowledge of the integrity of his relatives should allow you to circumvent regulations, produce the required certification, and allow the cremation to proceed. But you must stand firm however much they plead with you or get angry with you.

Make contact with the coroner's office as soon as you can. Explain exactly what the situation is and your own role and knowledge of the deceased's illness and medical care.

Ask the officers' advice on how to proceed. The coroner and his team can be quite reasonable and, though they are clear about their own responsibilities, are normally very sensitive to the agonies of death and have no intention of unduly extending grief by delaying funeral arrangements.

If your doubts remain, contact your defence organisation for advice.

Make sure you record absolutely everything and file all notes and records of conversations in more detail than you would for an ordinary patient encounter. Make sure you record the time of any telephone conversations and whom you were speaking to. Under the circumstances of increased scrutiny of all certification around death, ask the coroner's office to send you

e-mails or faxes before releasing any paperwork to the family that allows the cremation to proceed.

Reassure them you are doing all you can to be helpful but make it clear that in the current climate you cannot simply send off the form. Not only are you obliged to comply with all the regulations and procedures but it is your duty to both the deceased and society in general to ensure these are not circumvented.

Nigel de Kare Silver is a GP in north-west London ­ he is a course organiser and trainer and the practice is scoring high on quality points (>1,000]

Dr Alison Rackham

'The trial of the GPs who signed forms for Harold Shipman brings this issue to the fore'

This scenario highlights the uncertainty GPs have now with signing form C. The responsibility we have is to be sure that 'there is no reasonable cause to suspect that the deceased died either a violent or an unnatural death or a sudden death'. We can only make that decision based on what we are told by the doctor who completed form B or from other relatives or carers. It necessitates trust in our colleagues.

The concern here lies in the fact that other GPs in his town are refusing to do form Cs. Do they suspect any wrongdoing by the GP? Or do they not feel adequately protected by the legal system if things go wrong in the future? The recent trial of the GPs who signed cremation forms for Harold Shipman brings this issue to the fore.

The fact you agreed months ago to do form C implies this death had been expected for some time. As a family friend you would presumably know the circumstances of his home situation and who cared for him. I would want to question those who nursed him and find out if there were any significant events over the last few days or weeks of life.

Had his GP seen him and correctly filled in form B? What had been entered on his death certificate. There does not appear to be any controversy about the cause of death although no details are given. If he had been suffering unduly there may be an issue of possible 'mercy killing'. I would not wish to collude with this even if I felt sympathetic towards the motive. If I did suspect this I would inform the police.

In signing a legal document, which makes certain stipulations, we are bound by the law.

When completing form C the doctor must:

·Have seen the body of the deceased

·Have carefully examined the body externally

·Have seen and questioned the medical practitioner who signed form B.

In this case I would not sign form C if I could not contact the deceased's GP. I would tell his relatives that by law I categorically was not able to do it, neither would any other GP until the patient's GP could be contacted. I would contact any carers of the deceased to establish that there was no unnatural nature to his death and agree to sign the form once his GP had returned.

Alison Rackham, who qualified in 1987, is a full-time principal in Uxbridge and a GP trainer

Dr Richard Stokell

'I won't risk my career by falsifying an official document'

Keeping all parties happy and still maintaining professional integrity looks difficult and the shadow of Shipman may influence my decision as well as that of the local GPs.

My first option is simply to sign the form, claiming to have discussed the case and seen the body. With luck no one will notice and the family will be happy and reward me in the usual (liquid) way. Unfortunately, falsifying an official document may be construed as professional misconduct and I am not prepared to risk my career.

My second option is to stick to my guns and refuse to sign until I am able to travel, see the body and see the patient's GP to discuss the case. While this will anger the relatives, will any serious harm really be done?

A third option is to sign the form honestly but try to satisfy the medical referee of the crematorium by supplying enough other information. To do this I would have to travel and examine the body, which is a nuisance. On the other hand he is described as a close friend. I would also try to talk to a partner of the GP involved, a relative of the deceased and another person involved in nursing the deceased in order to be able to provide evidence in questions 5-8 even though I have not been able to see and question the doctor who issued the certificate.

I would then check with the medical referee to the crematorium that this was satisfactory. If the certificate was bounced, I would expect the relatives to be grateful for the trouble taken despite the inconvenience to them.

Richard Stokell completed the VTS in 1988 and practises in Birkenhead, Merseyside ­ he is also a GP trainer and course organiser

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