Pressure on GPs to complete death certificate without knowing cause has increased

Exclusive More than one-third of GPs are under greater pressure to complete a death certificate when they are unsure of a patient’s cause of death, a Pulse survey has found.

Of 972 respondents, 37% said that pressure to fill out Medical Certificates of Cause of Death (MCCDs) despite not knowing why a patient died has significantly or slightly increased, since changes to the process were brought in last year.

Under the new system, GPs are required to engage with local medical examiners to agree death certificates for all non-coronial deaths. NHS England hailed the process as having ‘improved accuracy’ of recorded causes of death through greater scrutiny, after some areas trialled the process before its statutory implementation last September.

But 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 have questioned GPs’ hesitancy to propose a cause of death or sent forms back to practices with erroneous changes.

One GP said: ‘We frequently get emails back saying, “Are you really sure you can’t provide the cause of death?”’

Another described the system as ‘terrible’, causing ‘major issues with coroners’ officers and medical examiners bouncing patients back and forth’.

‘We had a patient where no GP was able to complete the cause of death because the last to see the patient was on maternity leave,’ the GP said. ‘The medical examiner told us to contact the coroner, but the coroner said this wasn’t needed and the medical examiner should write a cause of death.

‘By the end of the process it had been several weeks after the patient died.’

As a result, GPs are faced with additional unfunded workload and families are left in limbo, unable to register their loved one’s death or make funeral arrangements.

‘This is the worst thing ever for relatives, especially those from faith groups, like Muslims, as it is made a long-winded process,’ commented one respondent. ‘Having to wait to plan a funeral for three weeks is unacceptable in some cases.’

Commenting on Pulse’s survey findings, the RCGP said the issue of GPs feeling pressured to complete a death certificate without a clear cause ‘needs addressing urgently’.

Professor Kamila Hawthorne, the College’s chair, said: ‘When a patient passes away, GPs want to be able to support their families to the best of our abilities. Whilst as a College we are largely supportive of the new system for death registration, prior to its roll out we did express concerns about the potential challenges of the changes.

‘We are now seeing some of these concerns play out, and we are hearing reports that some families are facing delays in the death registration of their loved ones as a result.

‘We know many GP practices are finding ways to make the new system work, but what we need to see is clearer guidance on the respective roles and responsibilities of GPs and medical examiners to ensure the system can be implemented smoothly and compassionately.’

Some survey respondents also reported instances where medical examiners have refused requests for deaths to be referred to a coroner.

One GP said: ‘None of us had seen a patient for over seven years and I was asked to write they died of myocardial infarction. I refused and thought the patient should go for a postmortem, but this was declined.

‘It’s complete guesswork in some cases. It’s an unsafe shambles.’

Nick Grundy, a GP in southwest London, called the MCCD system ‘a disaster’ adding that often, medical examiners ‘fundamentally don’t know what they’re doing’.

‘Our experience of the MCCD system is that it’s largely protocol-driven, and although the people looking at the forms have been through training they are, perhaps understandably, nervous about taking decisions,’ he said.

‘What this means in practice is that entirely expected deaths in palliative care patients are being bounced around where they want repeated changes to forms for bureaucratic reasons.

‘These add nothing at all to the situation beyond letting them tick a few more boxes to say stuff has been filled in.’

However, earlier this year a London coroner accused GPs of holding up death certification because they ‘simply do not understand the medical examiner process’. He criticised GPs’ inability to determine a cause of death despite the ‘very low evidential threshold’ doctors must meet when suggesting one.

Fewer than 10% of respondents to the Pulse survey said the requirement to engage with medical examiners had decreased pressure to offer a cause of death when it wasn’t known, and around one-third said it has stayed the same.

A GP in Cornwall said the changes have in fact ‘improved confidence and consistency in certifying deaths’.

‘The new MCCD system has brought clarity and structure to the process, making it more streamlined and easier to navigate,’ he commented.

‘It supports clinicians in making informed decisions and helps ensure documentation is completed more efficiently and accurately.’

LLR LMC chief executive Dr Grant Ingram said that despite a few early teething problems he has seen few issues, but that England-wide, LMCs’ experience of the system is varied.

‘In LLR we have two very approachable senior coroners and we did a lot of work prior to the new system going live to make implementation as smooth as possible,’ he said.

‘The process was designed to try and reduce the number of people who have died of natural causes requiring an inquest. There should not be any ping-ponging.

‘Our Lead ME wrote to all MEs around December 2024 advising them that unless the cause of death given on the MCCD is incorrect to accept it rather than asking for minor amendments.’

He added that although the new system increases unfunded workload for GPs, relatives have welcomed the new process overall and that most comments have been complimentary.

A Department of Health and Social Care spokesperson said: ‘Last year’s reforms have enhanced patient safety and offered greater clarity to grieving families.

‘GPs were also responsible for filling in the medical certificate of cause of death before the reforms and should only certify the death if they feel able to do so. We have made this more flexible and have removed associated time limits.’

This survey was open between 2 July and 21 July 2025, collating responses using the SurveyMonkey tool. The survey was advertised to our readers via our website and email newsletter, with a prize draw for a £1,000 John Lewis voucher as an incentive to complete the survey. The survey was unweighted, and we do not claim this to be scientific – only a snapshot of the GP population.