Creeping privatisation is confusing for patients
Medicolegal adviser Paul Colbrook outlines the position post-Shipman
The cremation certificate system has been under the spotlight recently. The system of certifying deaths has come in for criticism by the Shipman Inquiry. And the six GPs involved in signing cremation forms for Shipman were found not guilty of serious professional misconduct by the GMC.
A number of recommendations have been made for overhauling the death certification system. Most recently the Home Office issued a paper on reforming the death certification and coroners system in England and Wales1.
This proposed that the separate forms for cremation certificates be dropped and that the same system of certification would apply to all deaths. All deaths would be referred to an independent 'medical examiner' assisted by a team who would be well-trained and closely scrutinised. They would confirm the cause of death. Where necessary either the medical examiner or coroner would authorise a cremation.
The MDU is regularly asked for advice about the completion of cremation forms, and many members have had particular concerns as a result of the Shipman Inquiry. While reforms of the system seem likely in the not too distant future, for the time being doctors issuing cremation forms should continue to do so in the usual way, bearing in mind guidance and clarification issued by the Home Office in December 20032.
This guidance helps clarify current practice on how to complete the forms (B and C) appropriately.
Normally form B should be filled out by the doctor who attended the deceased patient. However, in general practice, should the attending partner be unavailable, then a GP partner may be acceptable where he has previously seen the deceased, even if it is outside of the normally acceptable period (14 days).
It is advisable to make a clear record of the circumstances, for example the details of the care that the partner provided, and why the attending GP was not available.
The Home Office says the doctor completing form C should have five years of continuous registration at the relevant time. Where a doctor has not held full registration for a continuous period of five years, the local medical referee should be approached to consider whether a period of temporary or provisional registration can be taken into account in a particular case.
The importance of the independence of the doctors completing the two forms is stressed, and medical referees have been reminded that they should satisfy themselves there is sufficient independence between the two signatories in all cases.
The two signing doctors must be independent of each other so the medical circumstances may be corroborated. The medical practitioners signing forms B and C need not see each other in person, but in such circumstances the Home Office advises that form C should be completed in such a way as to show the inquiries have been 'adequate'. Doctors should be sure that they possess enough information to fill in the form. Where they have discussed this over the telephone an appropriate record on the form should be made.
GPs should complete forms personally and provide a handwritten signature. All questions in the forms must be answered in full. The most frequent errors when completing forms are:
·failure to complete all the questions
·incorrect completion of the forms
·discrepancies between forms as to the date and time of death.
Medical referees who oversee the certifying process will expect that the evidence offered on the certificates demonstrates sound clinical grounds for the cause of death. They have the power to reject forms or to prevent a cremation taking place unless the relevant forms have been properly completed.
There is general onus on doctors to be honest and truthful, and doctors are advised to read and answer each question carefully. GPs should also bear in mind the GMC's advice: 'You must be honest and trustworthy when writing reports, completing or signing forms....you must take reasonable steps to verify any statement before you sign a document. You must not write or sign documents which are false or misleading because they omit relevant information.'
Negative answers to certain questions may not automatically stop a cremation going ahead, but should alert the doctor providing the confirmatory certificate or medical referee that further inquiries may be necessary, or even strongly recommended.
GPs should assist medical referees by completing the cremation certificates fully and accurately, and by responding to any further inquiries as helpfully as possible. If you have even the slightest doubt about the process, contact your medical defence organisation.
1 Reforming the Coroner and Death Certification Service: a Position Paper, Home Office, March 2004
2 Home Office advice to medical practitioners completing cremation forms B & C, December 2003
Paul Colbrook is a medicolegal adviser with the MDU