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New death certification system ‘postponed due to legal delays’, GPs told

New death certification system ‘postponed due to legal delays’, GPs told

Exclusive A new system requiring GPs to agree death certificates with a medical examiner may have been postponed due to legal delays, Pulse has learned. 

The system was meant to commence from April this year, with the intention of medical examiners (MEs) providing independent scrutiny of all deaths in the community which are not taken to the coroner. 

However, some GPs have flagged that the legislation necessary to mandate this system is currently missing, with one LMC leader calling the implementation process a ‘car crash’. 

And Pulse has heard from multiple GP leaders across the country that the commencement of the system has been postponed with no new start date confirmed. 

The Department of Health and Social Care (DHSC) did not deny this claim, and said that an announcement would be made in the next few weeks. 

Last week Pulse revealed the BMA is planning to ask DHSC to remove workload from GP practices that could be done elsewhere in order to relieve pressures. And a potential list of ‘bureaucratic items which could be done by others’ sent to DHSC included the medical examiner system.

The statutory system was formally introduced by the Health and Care Act last year and NHS England wrote to GP practices in England in July asking them to implement processes to facilitate the work of medical examiners by 31 March 2023. 

It means GPs would have to give access to a deceased patient’s records in order for the medical examiner to reach agreement on the accuracy of the medical certificate of cause of death (MCCD), where before this extra scrutiny was not required. 

Implementation has so far been determined locally and some GP practices have been using the system for many months already as a pilot scheme. 

Last month, the temporary permission granted by the Confidentiality Advisory Committee (CAG) to medical examiners for them to access deceased people’s records was extended until March 2024. 

The extension suggests that ‘the national team doesn’t have confidence [the ME system] is going to be sorted any time soon’, according to Leicestershire, Leicester and Rutland LMC chair Dr Grant Ingrams.

Dr Ingrams said in his area they have worked through a process with the local ME, and together they agreed to ‘slimline’ the national process because it was ‘far too bureaucratic’. 

However, he said: ‘Now we don’t know what to do next because we don’t know what the legislation is going to say. Until we’ve seen the legislation, we can’t do anything more.

‘We’re waiting, waiting, waiting, without any idea what’s happening. It’s a bit like watching a car crash in slow motion, because you know it’s going to go wrong.’

Dr Michael Mullineux, a GP in Maidenhead who is concerned by the rollout, said that while he agrees with the new system in principle, the law has not been adequately changed to mandate it.

He said: ‘It concerns me that as usual a partial statute has been launched without any legal framework, inferring it’s our duty to follow this.

‘It would appear absolutely zero consideration has been given to the impact on general practice.’ 

The Health and Care Act 2022 amended the Coroners and Justice Act 2009 to allow NHS bodies to appoint medical examiners, instead of local authorities, in order to improve the quality and accuracy of MCCDs. 

However, GP leaders highlighted that the necessary changes have not been made to the Births and Deaths Registration Act 1953. 

According to Dr Ingrams, this means the legislation requires that there is a process in place, but does not actually require that doctors use the system, so MCCDs do not legally need ME scrutiny. 

Cambridgeshire LMC, in its recent March newsletter, also highlighted this gap in legislation, saying the 1953 Act ‘does not provide for any other doctor to intersperse themselves into the attending doctor’s decision making about MCCD’.

It added: ‘Therefore, until there is both a legal and practical framework in place, Cambs LMC advice is there is no requirement that GPs change current working practices around MCCD.’

On 23 February, the Confidentiality Advisory Group extended its permission, under section 251 of the NHS Act 2006, for MEs to ‘access the records of deceased individuals held outside Host Trust by different healthcare providers’. 

The permission has been extended twice since initial approval in 2021, and will now last until 31 March 2024. 

The DHSC did not confirm whether the system has been postponed and did not comment on what legislation is needed to mandate the system, but said it will set out next steps in due course. 

Dr Ingrams said the lack of clarity from the Government was ‘appalling because there are so many people putting so much work into this, working to a timescale, not knowing whether it’s going to go to waste or not’.

‘No one can finalise their plans without knowing the final wording of the legislation and the final guidance. Services don’t know whether or not in two weeks’ time they need to implement this or not – what do they do?’

Last year, then-primary care minister Maria Caulfield said the medical examiner system would enhance detection of ‘poor practice’ among GPs.

And a House of Commons document from 2021 said: ‘The introduction of a system of medical examiners follows a long period of policy development, including pilot schemes, which originated, at least in part, as a response to Harold Shipman’s murder of his patients.

‘In 2003, the Shipman Inquiry, chaired by Dame Janet Smith, proposed that there should be an effective cross-check of the account of events given by the doctor who treated the deceased and who claimed to be able to identify the cause of death, regardless of whether the death was followed by burial or cremation.’

How the statutory medical examiner system will work

Under the new system, all deaths not taken for investigation by a coroner will have independent scrutiny by a medical examiner, who is based in either an acute trust in England or local health board in Wales. Medical examiners are senior medical doctors who are trained in the legal and clinical elements of death certification processes. 

The purpose of the new system is to:

  • provide greater safeguards for the public by ensuring independent scrutiny;
  • provide a better service for the bereaved and the opportunity for conversation with a doctor who is not involved in the care of the deceased; 
  • improve the quality of mortality data.

Once it becomes a statutory system, GPs who complete MCCDs will have to share this with the medical examiner in order to agree the proposed cause of death. This means GP practices must have arrangements to share the records of deceased patients with their local ME office. 



Please note, only GPs are permitted to add comments to articles

Anthony Everington 17 March, 2023 5:28 pm

I presume the medical examiners will be available 24 hours a day, 7 days a week? Very important to our muslim and Jewish patients that they can be buried within 24 hours.

Bonglim Bong 17 March, 2023 5:31 pm

don’t be silly Anthony – that kind of planning has never been a strength of NHS England. And they just assume GPs only work Monday-Thursday 10-3.30

Douglas Callow 17 March, 2023 6:07 pm

not necessary in my opinion to go down this road
hope its rethought

Sam Tapsell 17 March, 2023 9:27 pm

We volunteered to take part as pilot at start of the year and in strange blip have have had no deaths to test the system since.
I have noticed that previously we felt it was helpful to keep contact with patients in the last few weeks of their life, partly to help complete the certification.
But now this is someone else’s problem…
Unintended consequence, fewer visits for palliative care?

Jonathan Gregson 18 March, 2023 2:59 am

LOL this is insane.
We all have patients were the MCCD is educated guess to avoid futile postmortem.
To avoid someone scrutinising my opinion I think I may refer more deaths to the coroner.

Othimalaigounder Velusami 18 March, 2023 6:42 am

Adding another bureaucracy to the existing system creating more stress and grief for the bereaved families

Neil Bhatia 18 March, 2023 9:53 am

That CAG have extended authority reinforces the fact that this remains voluntary for GPs, even those in a pilot area. CAG authority (s251 approval to access the records of deceased patients) is permissive, so practices do not have to allow it, and would/will not be needed if/when this is a legal obligation.

Faen Faen 19 March, 2023 9:53 pm

Of course it’ll be the GP having to absorb complaints from the relatives who will have to wait weeks for a decision and given a number that goes straight to answerphone.

David Ruben 20 March, 2023 11:09 am

System is clunky at best. #1 report needs generating giving patients last 3months of clinical notes, all discharge letters in last year and description of patients last illness and then the MCCD that we propose. #2 await for Medical Examiner to call to discuss or email back their agreement. #3 Now we can complete a MCCD with Medical Examiner Care Number recorded on this. #4 The MCCD then needs to be submitted back to the Medical Examiner for their verification that this been completed correctly . #5 Wait for the Medical Examiner to email back that they are satisfied with the MCCD and then we can email this to local Registrar.
This all supposes we are constantly monitoring our email, or that doctors perhaps only work a half day and are then out of the officer, or worse might be that the GP only works part time and wont be back at our surgery until the following week. I did enquire why at step 4 if the ME was satisfied with our completed MCCD they could not send direct to the Registrar rather than yet a further email cycle and was told they could not send this themselves and anyway why were we not having our administrator doing this (as if an administrator could fix a MCCD is any changes were required, we have administrators free throughout the day, or that anyone should able to access individual GP confidential email accounts… I gave up)
Even marking the urgency option (i.e. have religious reason for fast processing for ideally same-day burial) the quickest I have been able to complete this from a 9:30am notification of an expected death was by 4pm same day, and on a day we were particularly overwhelmed took 3 working days.

Truth Finder 20 March, 2023 11:38 am

If it ain’t broke……doctors don’t enter medicine to kill people. The risk must be almost zero. What a waste of time and money.

Centreground Centreground 20 March, 2023 1:49 pm

I have absolutely no confidence in the Medical Examiners appointed in our area who are simply GPs looking for an easy number and money for nothing – this system adds nothing except to the bank accounts of these layabouts!

David Turner 20 March, 2023 4:21 pm

Totally unnecessary ,pointless and valueless bureaucracy, when we are already drowning in plenty of that
What amazes me is there seem to be GPs out there who support this!!
Do they have too much spare time on their hands or something?

This is nothing more than yet another way to try to undermine our professional status and engage in a bit more ‘GP bashing’.

Shame on any GP who takes this work on, this is yet more of the government’s dirty work you are doing for them.

James Weems 20 March, 2023 4:48 pm

What problem is this trying to fix exactly?

paul cundy 21 March, 2023 8:53 am

Dear Dr Ruben,
Your description is horrendous. May I copy it?
Paul C

Robert Bruce-Chwatt 21 March, 2023 9:09 am

Dear Dr Ruben, Thank you for an excellent summation.

David Jarvis 23 March, 2023 10:56 am

Interestingly looking at that well organised and thought through system Dr Ruben describes it would appear quicker and less work as a GP to just refer em all the the coroner.

Gary Heron 23 March, 2023 1:45 pm

I’m a GP and an ME and I work exceptionally hard

Patrick Pearson 28 April, 2023 1:20 pm

As this bureaucratic nonsense has been implemeted in our area I can confirm it takes a considerable amount of time to complete. Does the information given in the article mean we can refuse to continue having to do it locally?