Death Certification and Medical Examiner

Death Certification

Update 26/11/24: It is not unusual for the ME process to take several working days, and for the ME to scrutinise a death 2-3 working days after GP referral due to high workload volumes. The informant should be told to refrain from making an appointment with the Registrar until they have had contact with the ME Office. The bereaved may contact the Funeral Director of their choice who will be able to provide guidance on making necessary arrangements. See NoK section below.

Statutory Duty for Medical Practitioners

When a patient dies it is the statutory duty of the attending practitioner to issue the Medical Certificate of Cause of Death (MCCD) [s22(1) Births and Deaths Registration Act 1953 (legislation.gov.uk)]. This duty is reiterated by the GMC in Treatment & Care towards the End of Life: Good Practice in Decision Making (para 83-85) Treatment and care towards the end of life - professional standards - GMC (gmc-uk.org). There is no provision under the new legislation to delegate this statutory duty to any non-medical staff. Therefore, only GMC registered medical practitioners (i.e. doctors) can legally sign MCCDs. 

Medical Practitioners are eligible to be an attending practitioner and complete the MCCD, if they have attended the deceased in their lifetime and feel able to propose a cause of death (attended means in person or via video consultation, but telephone consultations do not fulfil the definition). So, there will no longer be a requirement to have seen the patient within the 28 days before death, or to have seen the body after death.

Medical Certificate of Cause of Death (MCCD)

The new MCCD includes details of the attending practitioner who certified the cause of death to the best of their knowledge and belief (this has not changed). 

In addition, the new MCCD includes the following new information:

• details of the medical examiner who scrutinised the cause of death.
• ethnicity, as self-declared by the patient on the medical record. If the patient’s medical record does not include this information, then the attending practitioner can complete it as ‘unknown’ on the MCCD and should not in any circumstance ask for this information from the representative of the deceased.
• maternal deaths and whether the deceased was pregnant or recently pregnant.
• hazardous medical devices and implants will be recorded on the MCCD by the attending practitioner, and this will be transferred to the certificate for burial or cremation (contained in the green form) completed by the Registrar to inform relevant authorities of the presence of any devices or implants.
• a new line, 1d, for the cause of death.

Additionally, DHSC is developing an online version, which will enable the form to be more easily shared between the attending practitioner, medical examiner and registrar. The online version is currently under development and will be available in due course.

Medical Examiners

Background

The new statutory medical examiner system has been rolled out across England and Wales to provide independent scrutiny of deaths, and to give bereaved people a voice. The Department of Health and Social Care (DHSC) death certification reform changes are mandatory and came into force on 9^th September 2024.

NHS England » The national medical examiner system

There is also more specific guidance for primary care regarding deaths in the community:

NHS England » Information for primary care on extending medical examiner scrutiny to non-coronial deaths in the community

Medical Examiner Role

Independent scrutiny by a medical examiner [ME] is a statutory requirement prior to the registration of all non-coronial deaths in England and Wales from 9th September 2024.

Once the relevant attending practitioner and the medical examiner have completed their declarations of certification and scrutiny, and the cause of death is confirmed, the MCCD will be sent electronically to the Registrar by the ME Office. The representative of the deceased will be notified by the ME Office that the Registrar’s appointment can now go ahead. In Bristol and North Somerset, the representative needs to contact the Registrar to make the appointment but in South Glos the Registrar contacts the representative to make the necessary arrangements.   

The informant will no longer be required to collect the paper MCCD from the Practice. Under the Electronic Communications Act 2000 (legislation.gov.uk) the scanned MCCD is deemed to be the original so the paper copy should be held by the Practice for a period of 4 weeks (in case of any queries) and then destroyed. This position has been confirmed by the County Registrar for Somerset and North Somerset, and the Superintendent Registrars for Bristol and South Gloucestershire.

Medical Examiner Certification

The new legislation introduces medical examiner certification for the exceptional circumstances where either:

• there is no attending practitioner,
• an attending practitioner is not available within a reasonable time.

In either of these circumstances, the death is referred to the Senior Coroner by a referring medical practitioner (not a medical examiner) and the Senior Coroner decides whether or not to investigate.

It is set out in legislation and guidance that the medical examiner MCCD will only be used in exceptional circumstances where actions to identify an attending practitioner have been exhausted by the referring practitioner. Regulations and guidance will state that only the Senior Coroner (and not the referring medical practitioner) can refer the death for certification by the medical examiner.

GP and Medical Examiner Process

The Medical Examiner Service has endeavoured as far as possible to keep the process and communication within EMIS.

There is a useful “dummies” guide on how to navigate the process, with thanks to Dr Andrea Priestley from Charlotte Keel Medical Practice. Please click the link for CKMP Medical Examiner Service.

Process for GPs in orange and MEs in blue:

1. Complete template in EMIS  - Upon notification of death the referring GP should complete the “GP Referral to ME Service” template in EMIS and save as a consultation. An EMIS F12 protocol: BNSSG Medical Examiner F12 Launcher has been developed to make this process quicker. Please do not use any other type of template such as Ardens as it does not capture the necessary data. 
2. Inform NOK - Please tell the nominated family representative/next of kin to expect contact from the ME Service. If there is no NoK then please provide the ME service with details of whomever is registering the death or arranging the funeral. There is a NOK leaflet in the 'Information for NOK' section below.
3. Send Admin note task - Send cross organisational “Admin Note” task to the “BNSSG Medical Examiner Service referrals” EMIS Team with the patient’s name, NHS number and date of birth in the body of the note. If Urgent Release is required, please mark the task as URGENT and follow up with a telephone call.
4. Acknowledgement - On receipt of referral ME Service will send “Patient Note” task of acknowledgement to the referring GP and the Practice’s After Death Documentation EMIS Team.
5. 'Form to Complete' task sent - Once scrutiny has been completed, a “Form to Complete” task regarding the outcome will be sent to both the referring GP and the Practice’s After Death Documentation Team.
6. Outcome - The ME Service outcome will include:

• Agree with Cause of Death – GP should then please issue MCCD.
• ME has a query and would like to discuss the case – ME will call GP on contact number provided in referral.
• ME has identified a potential requirement to refer to HM Coroner - see coronial process in section below.

7. Complete MCCD and import into EMIS - If cause of death agreed then the GP should complete the MCCD. Once MCCD is completed by the referring GP, please import this into  EMIS, and notify the ME Service via “Patient Note” to the “BNSSG Medical Examiner Service referrals” team. Please do not give the paper MCCD to next of kin or email the scanned copy to the Registrar as they must be sent electronically via the ME Service. 
8. Communication with NOK- ME Service will speak with the nominated family representative/next of kin to explain the cause of death. Any feedback/concerns will be passed to the appropriate individual or organisation.
9. MCCD sent to Register Office - The ME Service will send completed MCCDs to Register Offices and notify next of kin when this has been actioned. 
10. Note of completion - The ME Service will send a “Patient Note” task to both the referring GP and the Practice’s After Death Documentation Team to advise that all actions are complete
11. Deduction of patient record - once note of completion has been received then the practice can deduct the patient record from EMIS. 

Link to Quick Guides:

Overview of the Process for Death Certification.

Creating a Cross Organisational Task.

GP Quick Guide.

Disputes

As all clinicians are aware, there are often differences in opinion in medicine but if, after reasonable discussion, the cause of death isn’t agreed between the attending practitioner and medical examiner then the cause of death is deemed unknown, and the case should be referred to HM Coroner.

Coronial process

The Avon Coroner website has information on when and how to report a death to the coroner. The Avon coroner area covers Bristol, North Somerset and South Gloucestershire as well as Bath and NE Somerset.

If you think a death might be unnatural contact the police as soon as possible. They will notify the Coroner’s Office if necessary.

Attending practitioners should continue to notify deaths directly to HM Coroner under the  Notification of Death Regulations where they believe they are under a statutory duty to do so. The Coroner will determine what further action is appropriate. All referrals to the Coroner will be online through a link on their website: www.avon-coroner.com under the ‘Report a death’ tab.

The information requirements for the referral remain unchanged. Access to the form is protected and the reference/password is: BS48 1UL. Please note the password must be entered exactly as it appears above i.e. capital letters and a space in the middle.  For any queries, or in the event of any technical issues, please contact the main office on 01275 461920 and press option 1 to speak to a Coroner’s Officer, or email: avoncoronersteam@bristol.gov.uk

In this scenario, there will be no regulatory requirement for the attending practitioner to inform the medical examiner that they have done this.

If the Coroner declines jurisdiction, they will advise the attending practitioner via a form CN1a who will then be expected to refer to the Medical Examiner Service through the usual process.

Information for Next of Kin

Healthcare providers may share (and Medical Examiner Offices may process) contact details of deceased patients’ next of kin in accordance with Article 6.1(e) UK GDPR (processing that is necessary for the exercise of a public task).

The next of kin should be advised that they will be contacted by the Medical Examiner’s Service (NoK printable leaflet or Information for the public on the ICB website) who will explain the content of the MCCD and provide an opportunity to ask any questions they may have regarding the care of the deceased or their last illness. This will help deter criminal activity, improve practice and ensure the right deaths are referred to coroners for further investigation. This contact is not intended to replace any bereavement telephone calls the Practice currently undertakes.

Managing the expectations of families is of utmost importance. It is not unusual for the process to take several working days, and for the Medical Examiner to scrutinise a death 2-3 working days after GP referral due to the high workload volumes. The Medical Examiner Service advises that the informant should be told to refrain from making an appointment with the Registrar until they have had contact with the ME Office. The bereaved may contact the Funeral Director of their choice who will be able to provide guidance on making necessary arrangements.

Next of kin may also use services such as “Tell us once” What to do after someone dies: Tell Us Once - GOV.UK (www.gov.uk) to notify relevant Government departments; The Bereavement Register or Stop Mail | Stop Unwanted Mail To The Deceased to help reduce unsolicited mail; Life Ledger is a free, easy-to-use death notification service to help notify other institutions such as banks, mobile phone services etc

Death registration

The death needs to be registered by the informant in person and they should arrange their appointment with the Register Office according to the district in which the patient died.

Deaths will not be registered until the Registrar receives notification of the cause of death from the Medical Examiner or the Coroner. This notification will also start the 5-day statutory time frame to register a death - this replaces the previous 5-day time frame which started with date of death.

Informants should have had opportunity to discuss and be aware of the cause of death before registration. If, at registration, they do raise issues of concern in relation to the cause of death, the issue will be raised with the Coroner or Medical Examiner as appropriate.

Register Office Contact Details

To determine which Register Office the informant will need to make an appointment with then visit Find a register office - GOV.UK (www.gov.uk) and enter the post code of where the patient died.

Bristol Register Office:  

• NOK can book their appointment to register the death in person by phoning 0117 922 2800 or on line at https://www.bristol.gov.uk/births-deaths-marriages/register-a-death  

North Somerset Register Office:

• NoK can book their appointment to register the death in person by phoning 01823 282251.

South Glos Register Office: 

• NoK will be contacted by the registrar once the MCCD has been received by the office. The ME Service will provide the relevant contact details in its communications with the register office.
• The NoK can call the office on 01454 863140 to book an appointment if they haven’t heard anything and will be asked to provide name, contact phone number and some brief details of the deceased for a call back by the registrar.
• Please also see some helpful tips on the process from South Gloucestershire register office.

Cremation forms

The medical examiner’s scrutiny makes the form Cremation 4 confirmation obsolete and the regulatory requirement for the medical referee involvement in deaths will therefore be removed.

Medical devices and implants will be recorded on the MCCD by the attending practitioner, and this will be transferred to the certificate for burial or cremation (contained in the green form) completed by the Registrar to inform relevant authorities of the presence of any devices or implants.

Please note that only hazardous devices and implants need be recorded. Please see below for a non-exhaustive list, taken from government guidelines.

Implants that could cause issues during a cremation include but are not limited to: 

• pacemakers
• implantable cardioverter defibrillators
• cardiac resynchronization therapy devices (CRTDs)
• implantable loop recorders
• ventricular assist devices (VADs):
  • left ventricular assist devices (LVADs)
  • right ventricular assist devices (RVADs)
  • biventricular assist devices (BiVADs) 
• implantable drug pumps including intrathecal pumps
• neurostimulators (including for pain and functional electrical stimulation) 
• bone growth stimulators
• fixion nails
• any other battery powered or pressurised implant
• radioactive implants used to treat tumours, such as metal wires, seeds or tubes
• radiopharmaceutical treatment (via injection)

Cause of Death

Please see some advice regarding acceptable cause of death on a death certificate:  G199-Cause-of-death-list.pdf (rcpath.org). This list in not exhaustive but provides a useful reminder of the difference between causes of death and modes of dying.

For full guidance see Guidance for doctors completing Medical Certificates of Cause of Death  in England and Wales.

Resources

• RCPath Link The role of medical examiners (rcpath.org)
• RCPath Webinar Link Death Certification Reforms Legislation – implications for the medical examiner system online information-sharing event (rcpath.org)
• Avon LMC podcast Understanding Changes to Death Certification: A Guide for General Practice | RSS.com
• NME Link Podcast https://soundcloud.com/nhsengland/what-the-changes-to-the-death-certification-process-and-introduction-of-the-statutory-medical?utm_source=clipboard&utm_medium=text&utm_campaign=social_sharing
• NHS England » National Medical Examiner’s guidance for England and Wales
• The Medical Examiner Service - BNSSG ICB website including information for the public.

Medical Examiner’s Office Contact Details

Queries regarding individual cases can be directed as below:

T: 0117 4140074             E: nbn-tr.medicalexaminer@nhs.net

For more general queries please join the Medical Examiner Team on MS Teams for the Medical Examiner Service Drop in Clinic – the first Wednesday of every month from 1 to 2 pm.

Meeting ID: 361 186 755 357                                                 Passcode: 8Crm3k

Website:

 Medical Examiner Offices for deaths in hospital:

• UHBW Medical Examiner’s Office (uhbristol.nhs.uk)
• NBT Medical Examiner Office (nbt.nhs.uk)

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.