Death certification changes: a social care perspective

Introducing a medical examiner system has been on the cards for a very long time (since the recommendations following the Shipman Inquiry in 2003) and, since 2019, a medical examiner system has been implemented on a non-statutory basis, beginning with deaths in acute hospitals, where medical examiner offices have been set up. This, however, did not address the original 2003 concerns about unnatural deaths in the community and, whilst some deaths in community settings were referred to medical examiners under the non-statutory system, medical examiner involvement was not mandated as it now is for all deaths that do not go to the coroner.

In this briefing, we look at the headline changes and what they might mean in practice for social care providers.

Previous system

Whilst involvement of medical examiners has been a feature of the death certification process in acute hospitals for some years under the non-statutory version of the system, this will be a new concept for many providers of care in community settings.

Prior to the recent changes, if the cause of death was thought to be natural and expected (i.e. not a case that required referral to the coroner), the system was as follows:

• A doctor who had attended the person in their final illness, and seen them within 28 days of the death or seen them in person after the death, completed a Medical Certificate of Cause of Death ('MCCD'), recording their opinion as to the likely cause of death.
• The MCCD was then submitted to the registrar, to enable the death to be registered. If the cause did not seem to be natural, the registrar would decline to register the death and usually then refer the death to the coroner.
• If the deceased was not attended by a doctor in their final illness, or if they were attended by a doctor but not within the 28 days before death (or seen after the death), the MCCD could not be completed and the death had to be referred to the coroner.

New system

It is worth emphasising that the circumstances in which a death must be referred to the coroner have not changed - i.e. if the cause of death is unknown or if there is reason to suspect that the death was unnatural, violent or occurred in state detention. 

For any death that is not referred to the coroner, the changes introduced from 9 September 2024 mean that independent scrutiny by a medical examiner is now a statutory requirement in England and Wales before registering the death. In practice, this means the MCCD will be signed by both the attending practitioner and a medical examiner. A new MCCD has replaced the previous certificate to reflect this change. Under this new system:

• The first step will be for the 'attending practitioner' to propose a cause of death, if they can do so, to the best of their knowledge and belief. This proposed cause of death will be entered onto the MCCD. Importantly, the pool of doctors who can do this has now been widened to include any doctor who has attended the deceased at any point in their lifetime, as opposed to just in their final illness, as previously. This should reduce the number of deaths being referred to the coroner simply because a doctor who attended during the final illness cannot be contacted. (In exceptional circumstances, the new system also allows for a coroner to request that a medical examiner certifies a death if all steps to identify an 'attending practitioner' have been exhausted).
• The attending practitioner must then send the MCCD to the medical examiner, who will scrutinise the MCCD. Medical examiners are senior medical doctors who are employed by NHS bodies and are contracted for a number of sessions a week to provide independent scrutiny of the causes of death, outside their usual clinical duties. They are supported by medical examiner officers.
• The purpose of medical examiner involvement includes giving bereaved people an opportunity to ask questions and raise concerns with someone who was not involved in providing care to the deceased person prior to their death. Scrutiny by the medical examiner will therefore include communication with the deceased's family, interaction with the doctor completing the MCCD, and 'proportionate' review of medical records.
• Through these activities, medical examiners will sometimes detect concerns or issues with the care provided to the deceased person, either during their last illness or historically. Medical examiners do not investigate concerns in depth, but should refer any concerns to established clinical governance processes for review.
• If, after making enquiries, the medical examiner decides that the death should be referred to the coroner (for example, if there are concerns about the standard of care which may be linked with the death), they must do so.
• However, if the medical examiner is satisfied with the MCCD (including that the death is due to a natural cause), they will add their signature and submit it to the registrar. The deceased's representative will be notified that they can now contact the registrar to arrange the registration of the death.
• If the registrar has any queries, they must contact the medical examiner.

Impact for social care providers

Practicalities following a death

This change does not have any direct impact on the steps that providers must take in circumstances when a person receiving care passes away. The death ought to be reported in the usual way and the requirement to notify a medical examiner rests with the 'attending practitioner' (often a GP who has had contact with the deceased at some point during their lifetime).

The scale of the change and extending the requirement to all deaths in England and Wales does create a potential resource challenge in ensuring there is sufficient capacity within the medical examiner system to review all deaths in a timely way and providers may see variation across geographical areas as to how well-resourced the system is and the extent of enquiries raised by medical examiners in relation to specific deaths.

Inquests

When medical examiner scrutiny began for deaths in acute hospitals, there was a concern that many more deaths would be referred to coroners, although the overall numbers of deaths investigated by coroners did not support this. What seems to be the case, is that the medical examiner is able to offer independent reassurance in relation to natural deaths (e.g. answering medical questions from the bereaved) so that those deaths are not referred to the coroner. On the other hand, medical examiners are also able to identify more of those deaths where there is a concern about the care which should be investigated by the coroner. Following the extension of the medical examiner system to all deaths, we may see a similar impact in relation to deaths in community settings. This could potentially mean an increase in death referrals from the community where there are concerns about the care provided, but perhaps a reduction in the number of deaths that require coroner involvement overall.

The changes should also reduce the administrative burden on coroners and their officers as they no longer need to deal with those death referrals in relation to the 28 day rule about who can complete the MCCD. They should also reduce the number of unnecessary post mortems because, previously, where an attending practitioner felt unable to issue an MCCD, the coroner usually proceeded to post mortem to ascertain the medical cause of death, but the medical examiner process will potentially offer a medical cause of death without the need for post mortem examination. If there is a reduction in the administrative burden, this is to be welcomed if it will free up time for coroners and their officers to work on the cases which do need to proceed to inquest, potentially enabling those to be heard more quickly.

How we can help

Our large national team of inquest lawyers have a wealth of experience supporting providers and individuals across the health and social care sector throughout the inquest process, from relatively straightforward medical deaths to the highest profile, complex Article 2 inquest cases involving a jury and multiple interested persons.