Coroner criticises GP ‘reluctance’ to attribute old age as cause of death
A coroner has criticised GPs in one area for their ‘reluctance’ to provide causes of death, claiming it has caused ‘distress to bereaved families’.
Senior coroner for Cheshire Jacqueline Devonish told GP leads in the county that she would not accept GP referrals where they are unable to provide a cause of death, if she was ‘not satisfied’ they had engaged with the medical examiner.
It comes as GPs have reported coming under greater pressure to complete death certificates when unsure of a patient’s cause of death since the medical examiner scheme was introduced in 2024.
In a letter sent to GPs in December, Ms Devonish said: ‘It has been reported that there appears to be an increasing reluctance amongst GPs to provide a cause of death for patients with significant relevant comorbidities who have passed away in the community.
‘Most of these deaths relate to patients aged 80 years and older which permits the coroner to find “old age” as the cause of death. This reluctance is causing delay in the process for release for funeral arrangements, and consequential distress to bereaved families.’
Consequently, responses from GPs where they are unable to provide a cause of death ‘will not be accepted’ by her office, she said.
‘If the coroner’s officer is not satisfied that the Medical Examiner Scheme has been complied with as set out above, jurisdiction will be declined by the coroner and a form CN1A will be issued to the GP practice for an MCCD to be provided, or for formal Medical Examiner scrutiny to be obtained by the doctor.’
The scheme was introduced in 2024, requiring medical examiners to scrutinise the medical certificate of cause of death (MCCD) provided by the GP.
However, GPs have a duty to refer to a coroner if they cannot establish a cause of death.
While most of the patients Ms Devonish referred to were over 80 years old and therefore GPs are permitted to find ‘old age’ as a cause of death, guidance for GPs advises them to avoid attributing ‘old age’ alone as a cause of death.
To list old age as the cause of death, the guidance says the GP must also ‘have observed a gradual decline in (the) patient’s general health and functioning’ and must not be ‘aware of any identifiable disease or injury that contributed to the death’.
The guidance also advises that GPs must ‘be aware that the representative of the deceased may not regard old age as an adequate explanation for the death and may request further investigation’.
Mid Mersey LMC, which covers some of the coroner area, did not provide a comment but told Pulse it is due to meet with the coroner on 14 April to outline its concerns.
Dr Brian McGregor, YORLMC medical secretary, told Pulse: ‘Coroners have their own pressures, and I know they are under pressure to do fewer post mortems. It is an area of friction [between coroners and GPs], but it’s not an area of conflict.
‘The issue is that many legally qualified coroners don’t truly understand that GPs are not always able to offer an adequate cause of death, and old age, particularly in patients that are well, is not always seen as acceptable to general practice. We are looking for a definitive cause of death, which is more helpful from a long-term disease management point of view, and from the perspective of the research that’s required, deciding where we need to invest our energies to help prevent future deaths.’
Last year, a Pulse survey revealed that, following the introduction of the regulations, GPs were coming under greater pressure to complete death certificates even when unsure of a patient’s cause of death.
GPs told Pulse of incidents where medical examiners have put pressure on them to state a specific cause of death they know or suspect is inaccurate. In other cases, medical examiners questioned GPs’ hesitancy to propose a cause of death or sent forms back to practices with erroneous changes.
And a London coroner has previously criticised GPs who had made death referrals to the coroner’s office, accusing them of ‘not understanding’ the medical examiner process.
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READERS' COMMENTS [13]
Please note, only GPs are permitted to add comments to articles
There will always be the issue that you can’t prove a negative, therefore we can never say a patients death did not have a specific cause at their old age.
As I have said before on this hot topic, I’d love to be able to issue MCCD where I do not know the cause, if only I were allowed to say on it:
“Age related natural causes suspected, the family don’t want a postmortem and nor do I believe a postmortem will benefit anything other than satisfying the law that says everyone must have a cause of death stated.”
Everyone will die, and almost all will be natural, though it remains the case that “natural causes” is not a permissible 1a, and regardless of this single coroner’s opinions, GPs as per the article above are actively discouraged in Gov.UK guidance from offering old age alone as a cause of death.
If the aim is to ensure reasons for death are accurately recorded for sake of national records, it makes a mockery of the whole process if such a system demands that – for the expediency of others – one person (GP) put their name to something either specific but entirely unevidenced, or non-specific (old age) and which they themselves can not know, nor have basis for believing to be more likely than any of a half dozen causes.
Coroners will keep needing to do PMs unless system is reformed to allow:
1) Coroner to provide MCCD without a postmortem (just as GPs are apparently expected by this coroner to do on the self same lack of proof!)
2) GP can state ‘Natural causes suspected, nobody wants a postmortem’ without reference to a specific 1a
3) GP can state several reasonably possible causes for 1a where they have no way of knowing which is more likely to have been the cause
Unless/until any of these things happen, I will continue to decline the invitation to supply a 1a cause when I simply do not it to be the single probable cause and therefore cannot in good conscious state I ‘believe’ it to be so.
And I invariably find when cases go to postmortem, the cause found is NOT the one coroners office euphemistically repeatedly told me the coroner and family would ‘support’ me to offer. Again, a licensed professional being pressured by a coroner to sign a false statement of belief (fraud?), where you do not believe and cannot be confident makes a mockery of the whole process of recording a “Medical Certificate of CAUSE of Death”. The clue is in the name- Its not called a “Guess at one of many things that kill people and which I have no grounds to be confident of here”.
PS The registrar wouldn’t allow me to get married without giving one and only one occupation of my male parent for the register. Guesswork not allowed for this meaningless and sexist requirement.
Meanwhile CAUSE of death is guesswork, dressed up as factual data.
Over the years as a GP we had a great working relationship with the coroners officers. It was an excellent system.
Im almost retired and so glad I don’t have to run the gauntlet of the present system. Highlighted by the adversarial approach from a number of the coroners.
I did some 2 years try and phone for guidance on a patient who died and I could have helped. Impossible to contact the coroner.
Remember it’s a very adversarial world. Just get a single complaint from a relative and it will ruin one’s life.
And I’m sorry but everyone in GP land is part time, rarely the sole provider of clinical care.
But more over, it is not good when a coroner labels a patient as old at the age of 80. Indeed it’s even offensive to some?
But then the coroners have no medical training or experience of looking after patients.
There were many hundreds of recommendations from at least 3 enquiry reports after Harold Shipman’s murders. I haven’t read them in full, but I’m still willing to bet that none of the recommendations incluce that GPs should be encouraged or indeed hounded to put old age on a death certificate in order to keep the coroner’s workload under control.
If the workload of the coronial system is too high – then supply needs to increase rather than encouraging doctors to make risky decisions.
The coroner is entiled to their own opinion, but that doesn’t extend to telling a GP what the GP’s opinion should be.
Ignore and walk on.
don’t let coroners bully you. Push back to them if you are not able to sign the death certificate. It is your registration on the line not their’s if something goes wrong.
The reported comments certainly make it appear as if the Coroner in question is not aware of the rules, regulations, or guidance to Doctors from the Registrar-General, GMC, and Legislation relevant to the issue. In cases where there is no obvious direct cause, we are REQUIRED to report the death for further investigation.
While government guidance is national, Coroner’s Offices operate with a level of regional autonomy. This can create a “postcode lottery” where a death certificate accepted in one area is rejected in the next. As well as creating extra work for the certifying doctor, it also leads to a delay for a grieving family who can’t proceed with the funeral arrangements or any other tasks that need a death certificate.
DOI: Former Chair the Death Certification Advisory Group.
Well, people have been dying of old age since Adam and Eve, they still do in the East, but the Corona should know that in the west we like to have a cause, hence we work so hard on the wars, unfortunately it’s just the primitive or people we don’t like die of known causes, and we are safe in that respect, perhaps one day….
It would save many hours of faffing around if the coroner bought a Systmone licence.
Coercion to sign certificates will achieve a worsening of the very risks that medical examiners were supposedly designed to reduce imo. This is proving another in a long line of ineffective, unneccessary, costly and dangerous bureaucratic enforced changes emanating from detached leadership /government groups.
In Scotland we are advised to write what is the most common cause of death so for many sudden deaths with any cardiac history, myocardial infarction will be written. We can write frailty or old age and I have done this especially on an elderly patient who I know is frail. IN the end of the day even with a post mortem it is not always possible to state the actual cause of death. There needs to be an understanding that a death certificate is an opinion, not necessarily fact
As the system stands 1a Old age is ok but only if it is backed up under 2 with a list of underlying actual possible causes like IHD or COPD etc.
I have always wondered at what point does the coroner allow for homicide. I wonder how many old age deaths have been poisoned. Obviously very few but the system makes no effort to consider murder. Perhaps you should always check for a knife in the back when doing a pacemaker check…
I am pretty sure the majority of death certificates are wrong and all of them without a PM are fiction.