GPs criticised by coroner for ‘not understanding’ medical examiner process
A London coroner has criticised GPs for ‘not understanding’ the medical examiner process and for making unnecessary death referrals.
At a pre-inquest hearing for the death of a 94-year-old woman, senior coroner for east London Graeme Irvine said that the frequency with which doctors offer a cause of death ‘has declined considerably’ and that communications from GP practices have signalled that they ‘simply do not understand the medical examiner process’.
He called two GPs to the court hearing for failing to provide a cause of death, after Joyce Johnson died at her home in Romford in March.
Police and London ambulance services attended the scene but neither could provide a cause of death.
After preliminary enquiries, police determined the death was ‘non-suspicious’ and referred it to the East London Coroner’s Court on 19 March.
The referrals team contacted Mrs Johnson’s GP surgery, Lynwood Medical Centre, to get her medical history and see if they could offer a cause of death. The surgery was unable to provide a cause of death and it was referred to the coroner.
Mr Irvine called Drs Gurmeet Singh and Louisa Pavli to a pre-inquest hearing on 10 April and criticised their inability to determine a cause of death, despite the ‘very low evidential threshold’ doctors must meet when suggesting a cause of death.
He said: ‘Dr Pavli and Dr Singh may be asking themselves why, as part of their busy duties as GPs in east London, they are being asked to attend a coroner’s hearing.
‘The answer is this: I have looked very, very closely at the circumstances surrounding this death – it is overwhelmingly likely that it was a natural cause of death.
‘I am being asked to consider authorising a post-mortem for this poor woman which will undermine her dignity and cause distress to her next of kin and delay her funeral.
‘This referral was provided to the coroner on the same day that Mrs Johnson died. It is inexcusable that a coronial decision has not been made at this stage.’
Dr Singh said that the death had come as a shock to Mrs Johnson’s family, and this ‘raised concerns’ that if it was reported as a natural death, ‘the family would have objections’.
He also added: ‘The entry that she died after abdominal pain and vomiting blood indicates that there was the rupturing of a blood vessel in the GI tract that led to catastrophic bleeding.
‘We are happy to state that this is the likely cause of death, but the only concern would be if someone says: “How do you know if this is the cause without a post-mortem?”’
The senior coroner responded by saying that the deceased’s family’s shock at her death was ‘not sufficient justification for you to not do your job’.
Regarding Dr Singh’s uncertainty over cause he added: ‘If in every single case, the attending physician asked themselves that same question, we would have a post-mortem in every single death. And then where would we be?’
Mr Irvine added that Drs Singh and Pavli were not anomalies in making unnecessary death referrals, noting that doctors seemed to be using the coroner’s court instead of the medical examiner service, creating pressure on his team.
He pointed out that the system of how doctors provide the cause of death is ‘constantly shifting’ and has been subject to various changes in legislation over the past five years.
In 2019 national rules came into force that required all GPs to report deaths to the coroner in writing, rather than over the phone, in a move that many warned would cause delays to funerals.
Mr Irvine said: ‘Since then, there has been a significant problem and the quality of death referrals has become incredibly poor. The frequency which doctors offer a cause of death has declined considerably.
‘A significant concern to me is that the communications I receive from GP practices signal to me that the doctors who are being asked for this information simply do not understand the medical examiner process.
‘National training has been rolled out, but the responses I received from doctors indicate that they have not got the first clue what they are supposed to be doing when they are invited to offer a cause of death.’
Mr Irvine outlined GPs’ existing duties in assisting coroners, emphasising that they do not have to be 100% certain when providing a cause of death.
He said: ‘It has to be what is the most likely cause of death to the best of their knowledge and understanding.
‘And frankly, dealing with a 94-year-old with comorbidities and multiple polypharmacy at the time of her death, it is bewildering that someone at the surgery was unable to offer a cause of death.’
Dr Pavli apologised for the surgery’s inability to provide a cause of death and promised to sort a death certificate for Mrs Johnson that day.
The most recent change to the death certification system was implemented last September, requiring GPs to agree death certificates with a medical examiner.
Last year NHS England said that the new system had already ‘improved accuracy’ of recorded causes of death, ahead of its statutory implementation.
Ahead of the launch of the new system, the BMA had warned that it would be ‘administratively burdensome’ for GP practices, and that some MEs may not have capacity to provide scrutiny for community deaths within ‘reasonable timescales’.
Dr Grant Ingrams, chief executive of LLR LMC, said: ‘Coroners should be working with local GPs if they have concerns, forging relationships and putting together local guidance with how they think the systems should work – within reason.
‘Providing a cause of death must be done to the best of a doctor’s knowledge and belief. You haven’t got to be beyond a reasonable level of doubt, or the balance of probabilities. You need to be able to go off of something and in this case, unless the patient had a history of vomiting blood from a known cause, you cannot know what caused the death.
‘Locally our view is that the quality of death referrals to coroners have improved and the number has gone down because of the improved flexibilities within the system.
‘These systems forget that an individual GP does not make a lot of referrals to the coroner. An individual GP will not very often have to be part of the process and going to the coroner is an anxiety-provoking experience. Doctors would much rather do the APMCCD than go to the coroner.
‘GPs are doing their best. Sweeping statements like this are unhelpful and unacceptable.’
Chair of the BMA professional fees committee Dr Rob Barnett said: ‘GPs must be able to use their discretion when making referrals to the coroner based on their own judgement and clinical expertise.
‘While the reformed medical examiner system is working well in some parts of the country, there are still inconsistencies that need to be addressed, with some colleagues reporting an increase in workload and bureaucracy.
‘It is vitally important therefore that practices across the country are adequately resourced to ensure that the system can be effectively implemented and delivers reassurance to patients and loved ones.’
Pulse has reached out to Drs Singh and Pavli for comment.
Visit Pulse Reference for details on 140 symptoms, including easily searchable symptoms and categories, offering you a free platform to check symptoms and receive potential diagnoses during consultations.
Related Articles
READERS' COMMENTS [26]
Please note, only GPs are permitted to add comments to articles
Whilst I actually agree with the Coroner’s general points, it’s worth highlighting that the roll out of the (actually pretty decent) ME system was a farcical mess.
Deadline Dates moved, temporary systems in place for months, new forms needed that nobody could access, total confusion about when and how to refer to a Coroner, cremation forms not needed……then needed….then not needed, withdrawal of cremation fees…….it was a bureaucratic disaster, most us didn’t know if we were coming or going, and many remain understandably confused.
Maybe Pulse can do an Idiots Guide for us!!
Sounds like the coroner is a bit of a tw*t
someone is found to have died suddenly at home and there is evidence of vomiting blood. does that mean one does not need a post mortem and the gp can issue a death certificate with a cause of death? does it matter if the person is 94 or 34? what is the cause of death in this case?
A pretty hopeless system. The police surgeon used to go out to cases like this/ assess the situation/ liase with the police and family and then invariably issue a certificate..In Scotland this is no longer available . Not sure if this is the case in England.
If the gp had issued a certificate in this case they could have been open to criticism . Hindsight a wonderful thing but the coroner has access to all the circumstances and information so should just do his/ her job and wind their neck in.
In the distant past we had a Coroner who had actually practiced Medicine, understood how things worked, whom we could actually talk to on the rare occasions necessary, and we thought could generally be trusted to do the Right Thing, without fear or favour.
Sadly he was replaced by a Lawyer who appeared hostile and remote, with a plethora of form filling, and no contact but a memorable evening lecture to the assembled GPs where it was made clear that we could not be trusted. Unsurprisingly GPs may react to this approach with considerable caution when asked to offer an opinion.
Conversely, I think the quality of coroners has gone downhill far more. Nowadays, most coroners are ex-lawyers and it is a shame we get so a few doctors going into it.
And as for the ridiculous system where we are writing MCCDs on paper forms and then scanning and emailing them. I mean, what an earth is going on? Surely, it would be trivial to do this directly from the GP systems – it would pull the relevant information to generate the form and it could be sent directly.
Remember that the coroner does not have to order a post-mortem. If the process is so easy, why don’t they just do that?
I think the GPs are right. How would you know if it is a ruptured eroded aorta, a peptic ulcer or varices etc? Post mortem provides valuable information on the cause of death and training for pathologists. We would not need post mortems if GPs have x ray eyes. In reality, the system change is poorly thought out and now we have all these problems and bureaucracy.
What a dramatic performance! Extraordinary…
Is he essentially saying: If you don’t know the likely cause of death, just make it up – especially if they’re old?
Slightly undermining of the entire, grand, medicolegal process perhaps?
Is the real story here that there aren’t sufficient pathologists or resources to meet demand at their end?
And by removing the open facility to discuss cases on the phone with the coroner’s office to mutually agree a likely cause in borderline cases and feel supported in that decision, formal referrals might have increased a bit?
I doubt GP as a profession has suddenly lost the ability to certify death – much more likely, it will be the numerous system changes that have affected the outputs in unintended ways
Still don’t get what age has got to do with it when you don’t know the likely cause…
My first question is how do they know the medical examiner results are more accurate? I have had occasion to disagree with the ME. They often correct unnecessarily. The new system takes 10x as long as it used to. There is little time difference between ME and coroner and more toing and froing. Ours wants us to write out the MCCD first then asks for it changed. Why not discuss what you are writing and agree before writing. If saying you can’t say is quicker then funny how there is an increase in this line. As a Junior we had to add ICD codes to discharges. W\e all learnt a small list of bucket codes as we had little investment and less time to look through 2 fat volumes for accurate codes. V700 physicians investigations was always useful. So if you want something to be used it needs to be the easiest path to use. If people find a shortcut they will use like the corner cutting path across the grass on the corner of the road. Cremation forms took some time but we also got paid to do it. Now we have the work for no payment and also face abuse for delays in funerals that are not of our making.
This is what I would put if forced by coroner:
1a upper GI haemorrhage
1b god only knows what (but coroner says it’s natural so that’s OK then)
In jest of course. Sounds like bullying to me and undermining GPs professional role. Isn’t that what the GMC should protect us from?
Another example of the proliferating body of overpaid, unhelpful ‘criticisers ‘ and overbearing regulatory bodies avoiding any high-risk decision making themselves and criticising others from a very long distance. Who is there to criticise the coroner themselves or does everything these perhaps perfect after the event individuals state, have to be accepted as being reliable?
The next case before the coroner ‘ GP signs death certificate without sufficient information’ and the cycle continues
GPs must be able to use their discretion when making referrals to the coroner based on their own judgement and clinical expertise-End of ……
This appears to be very unfair criticism, and it appears that there are people other then the GPs who do not understand the Medical Examiner process.
GPs are still required to report to the Coroner deaths in certain circumstances, for which GPs are not allowed any leeway in deciding it ‘does not matter’ on grounds of age! One of these, and which prohibits the GP from issuing a Death Certificate, is where the case is already being dealt with by a Coroner after being referred by anyone else.
There also seems to be confusion about the rules for evidential certainty in completing causes of death, but it is the Medical Examiner who would have been responsible for approving one, not the GP, had the case not been under jurisdiction of the Coroner. Some Coroners are much better than others, it seems, at communicating and having good relationships with their local Doctors, and informing them if the process is held up or not by being under control of the Coroner.
I have dealt with several Coroners over the years, and all but one (who over-ruled another Coroner and got egg on their face) have been excellent, and have come to mutual arrangement for rapid provision of MCCD or furtherance of investigations – which in some situations are a legal duty of Coroner, and not of GP !
Yes, an article in Pulse explaining the ME process would be useful – but would probably need annual updating, and the introduction was indeed an absolute mess.
But perhaps have it published or send copies to all the MEs, Coroners, and Police and Ambulance staff also for compulsory reading ?
From GovUK Website
“Under the Notification of Deaths Regulations 2019 medical practitioners have a legal obligation to report cases to the coroner where there is reason to suspect that:
the cause of death is unknown”
So looks fairly clear cut ie if you are unsure of the cause of death, refer to the Coroner – and like them ascertain the background – which may/may not indicate the need for a post-mortem examination. To speculate about the cause of death simply to appease the Coroner would be unwise and probably unethical.
I’m now an ageing locum. Over the years we had an excellent relationship with the coroner’s officers. I did try and contact the coroner’s for guidance over the phone last year….impossible. it sounds a very adversarial atmosphere…lambasting GPs. There is a strong hint in the article that the family may have questioned the GP but the coroner wanted the GP to carry the can for there not being a PM. I’ll lie low!
In Scotland this kind of death happens often. I will discuss with the family and give them a likely cause – probably haemorrhage of upper Gastrointestinal tract and advise I cannot be sure, and a post mortem may not be able to decide either. But do they want that or for me to issue?
I think coroner was extremely unreasonable in his remarks.
We had a 86 years old patient who died in hospital 6 days after admission. There was provisional diagnosis of ichaemic colitis. Had all sort of investigations and HDU stay. Hospital doctors refused to sign death certificate. Coroner office tried almost bullying tactics to push us to issue death certificate which was refused.
Hear hear! Govt systems can’t make up their minds. First there was shipman, then more scrutiny. Then two doctors needed for a death certificate, now this new system. On one hand they claims GP’s can’t be trusted with death certification, then when GP’s make referrals, generalisations and attacks like these are made. I think Dr Singh raised valid concerns in his reply re the patient’s abdominal pains followed by death. Due diligence should not be discouraged in such a sweeping manner.
If it is all so obvious and straightforward, why bother with death certificates? If you don’t know you don’t know.
I get really annoyed with the idea of them being 94 makes a difference. The biggest mass murderer in the UK preferred victims who are elderly – are we really going to all agree to make that possible again…. Or even easy.
Coroner scapegoating these GPs and trying to make an example of them when he’s probably fed up with the consequences of a poor rollout of the APMCCD process. The GPs appear to have an ethical position and should defend it.
It is not possible to know the cause of a sudden unexpected death in the community in someone who hasn’t been seen for months.
The coroner here is undermining a legal process by saying make an educated guess and make it up – as we are getting too much work in my office now and I want to play golf.
If a GP makes it up and the medical examiner challenges this – the next step a minority GP would be facing is a fitness to practice hearing questiuoning why they are making up causes of death.
If you don’t know then a post mortem is the right outcome. If they want to play 20 guesses – have the medical examiner trawl through the records and allocate a random cause
If there is no capacity in the system GMC and BMA need to urgently get the Government, Labour and all parties, Sir Keir to put this process right. Also, doctors will want to know what caused the abdo pain and vomiting blood as a ‘learning’ concern , and to reduce any risks to other patients going forwards; for instance what previous contacts has Mrs Johnson had with the surgery? were there any more recent appeals for help or appointments requested? Was there anything to indicate this event might have happened to Mrs Johnson due to a deficiency in GP capacity nationally and throuughout London which the coroner might be concerned about? What was there in the ‘polypharmacy’ that could have a link to the abdo pain and vomiting blood, Ibuprofen,Brufen link for instance, especially in the elderly?, so the London GPs may have had really good reasons for wanting a post-mortem to be carried out. More info is required, What was wrong with the old system, speaking with the coroner or coroner’s officer, when these days, this new system is causing such great problems, and great delays too? These new processes would seem to be more than an annoyance for so many people involved, and not very scientific either, especially if a GP feels bullied into giving a guess about the cause of death , and then just ‘bury the evidence’ so to speak.
Labour, Health Sec., Justice, Law Sec should just come out and admit it if Britain cannot afford proper scientific processes; or here’s a clue as to what can be the remedy: just change things back to the way these things were once managed: correctly, with less cost, and without so much upheaval, or disturbance to GPs and coroners and everyone else.
Not least, relatives of the deceased should have a say too, especially when the deceased is very old and they expect dignity.
coroner misunderstands legal process shock ;
It used to be that the coroners officers were experienced,
as the quality changed more confused queries and bullying approaches were tried.
The coroner themself was usually able to sort out these issues.
Now it seems the coroners are as confused as their assistants.
If they can explain the set up of the ME system perhaps they have been reading too much Lewis Carroll.
If it is what I say it is then that is what it is (even if it isn’t).
I’m sure that the trial in Alice in Wonderland has not been an example of good jurisprudence?
Doing a DC on anyone who you last saw months ago is asking for trouble.