Death certification reforms in England and Wales

Summary

NHS England and NHS Wales Shared Services Partnership started implementing the medical examiner system on a non-statutory basis in 2019. Medical examiners are now scrutinising almost all deaths in acute trusts and it has increasingly become standard practice for medical examiners to provide independent scrutiny of deaths not taken for investigation by a coroner.

From April 2024 new death certification reforms will come into force, there will be an independent review of all deaths in England and Wales, without exception either independent scrutiny by a medical examiner or by investigation by a coroner.

Other changes from April 2024 include a new medical certificate of cause of death (MCCD) to reflect the introduction of medical examiners, who will scrutinise the proposed cause of death and will include 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.
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 in order to inform relevant authorities of the presence of any devices or implants.

Background

The death certification system in England and Wales has remained largely unchanged for over 50 years. The importance of reforms whereby all deaths would be subject to either a medical examiner’s scrutiny or a coroner’s investigation has been underlined in numerous reports and inquiries including the:

It has long been established that, following a death, the case will either follow the path of medical certification by a medical practitioner or investigation by a coroner. This will remain the case in the new system, but with important differences.

Roles, responsibilities and information flows in the new system

Detailed guidance will be published in advance of April 2024, but set out below are the points.

Medical practitioner

From April 2024, a medical practitioner will be eligible to be an attending practitioner and complete an MCCD, if they have attended the deceased in their lifetime. The attending practitioner will propose a cause of death, if they can do so, to the best of their knowledge and belief. The introduction of medical examiners will see routine independent scrutiny of the cause of death proposed by an attending practitioner.

This represents a simplification of the current rules that enable medical practitioners to be an attending practitioner, to complete an MCCD, if they had attended the patient during their last illness but required referral of the case to a coroner for review if they had not done so within the 28 days prior to death or had not seen in person the patient after death.

Current guidance on completing a medical certificate of cause of death will be updated to reflect and coincide with the implementation of the statutory medical examiner system.

It is already a statutory requirement for an attending practitioner to complete the MCCD. The General Medical Council (GMC) sets out this obligation in Treatment and care towards the end of life: good practice in decision making (paragraphs 83 to 85), stating that this is part of the attending practitioner’s responsibility to their patients:

Your professional responsibility does not come to an end when a patient dies. For the patient’s family and others close to them, their memories of the death, and of the person who has died, may be affected by the way in which you behave at this very difficult time.
You must be professional and compassionate when confirming and pronouncing death and must follow the law, and statutory codes of practice, governing completion of death and cremation certificates. If it is your responsibility to sign a death or cremation certificate, you should do so without unnecessary delay.

(The reference to completion of a death certificate should be read as referring to completion of the MCCD.)

The main change is that attending practitioners must share the MCCD and proposed cause of death with a medical examiner, who will scrutinise these before submission to the registrar.

Medical examiner role

Medical examiners provide independent scrutiny of causes of death and will be a contact for bereaved people who wish to ask questions or raise concerns.

A medical examiner is a senior medical practitioner who is contracted for a number of sessions a week to provide independent scrutiny of causes of death, outside of their usual clinical duties. They are trained in the legal and clinical elements of death certification processes and will not have been involved in caring for the patient. Medical examiners, supported by medical examiner officers under delegation, carry out a proportionate review of medical records and give bereaved people the opportunity to ask questions and raise concerns.

Guidance on the national medical examiner system is available from NHS England (under ‘National medical examiner’s good practice guidelines’).

All guidance will be updated to reflect and coincide with the implementation of the statutory medical examiner system.

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 to the registrar. The representative of the deceased will be notified at the same time that they can now contact the registrar to arrange the registration of the death.

Medical certificate of cause of death (MCCD)

From April 2024, a new MCCD will replace the existing certificate to reflect the introduction of medical examiners, who will scrutinise the proposed cause of death.

The intended benefits of the change are to improve:

efficiency in the death certification system.
mortality data for use at a local level and nationally.

There will continue to be a statutory form to be used when a death occurs after 28 days of life, and a separate form to be used when a live born child dies within the first 28 days of life. Both forms will be available in bilingual format in Wales. The new MCCD will include details of the attending practitioner who certified the cause of death to the best of their knowledge and belief (as at present).

In addition, the new MCCD will include 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. This builds on learning from the COVID-19 pandemic. If the patient 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 a new line (1d) for the cause of death - bringing the MCCD in line with international standards.
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 in order to inform relevant authorities of the presence of any devices or implants.

A new paper version of the MCCD will be distributed before the introduction of the statutory medical examiners system. In addition, the Department of Health and Social Care (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 will be available later in 2024.

Medical examiner certification

In line with the framework set out in the Coroners and Justice Act 2009 and the draft medical certificate of cause of death regulations, government will introduce 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 not to investigate.

In these circumstances only, the senior coroner should refer the case to a medical examiner to certify the death by completing a medical examiner MCCD.

It will be 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.

Coronial process

While the draft medical certificate of cause of death regulations mainly provide for completion of the MCCD, in practice they reflect the flow of information between the attending practitioner, medical examiner, coroner and registrar in the new system.

The Notification of Deaths Regulations 2019 will remain in force (subject to minor amendments flowing from the changes). Attending practitioners should continue to notify deaths that meet the criteria in those regulations to the coroner, who will determine what further action is appropriate.

As at present, the attending practitioner can report a death directly to the coroner where they believe they are under a statutory duty to do so. In this scenario, there will be no regulatory requirement for the attending practitioner to inform the medical examiner that they have done this. Similarly, if the coroner declines jurisdiction, they will advise the attending practitioner. The attending practitioner will be expected to complete the MCCD and scrutiny will be undertaken by the medical examiner.

It is inherent in the design of the new system, agreed by the General Register Office, and implicit in the draft medical certificate of cause of death regulations, that coroners will no longer be expected to notify the registrar when they decide that their duty to investigate under section 1 of the Coroners and Justice Act 2009 is not necessary.

Death registration

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.

Informants should have had opportunity to discuss and be aware of the cause of death before registration. When 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.

Following implementation of the death certification reforms, the responsibilities of the registrar will change as there will be no requirement for registrars to refer deaths to the coroner. The attending practitioner or the medical examiner will determine which deaths need to be referred to the coroner. This changes the relationship between the registrar and the coroner as, unless the coroner is providing a certificate for registration following an inquest or a discontinued case, there will be no interaction between them.

The Registrar General will no longer have responsibility for providing an MCCD, as DHSC will take over the new form development and supply.

As there will be limited interaction between the registrar and coroner, the need for the form 100A will no longer exist and this form will be removed.

As set out in the draft medical certificate of cause of death regulations, there will be specific circumstances in which the coroner will be required to provide information to the medical examiner.

There will be a much wider class of cases where the coroner, having declined jurisdiction, will communicate that decision to the attending practitioner. The General Register Office, Ministry of Justice and DHSC will work together to ensure the new process operates satisfactorily and will review and amend coroner’s forms and certificates as appropriate.

The intention of the changes is to reduce uncertified deaths, with the attending practitioner certifying with medical examiner sign-off at first instance, or the medical examiner certifying in exceptional circumstances following referral by the coroner.

The changes will also introduce new categories of qualified informant to allow for the partner of the deceased and a representative of the deceased to register the death.

Cremation and burial

Currently, in non-coronial deaths, a medical practitioner (usually the attending practitioner) must complete form Cremation 4 (the medical certificate) to provide sufficient detail to enable the medical referee to understand the cause of death if the deceased is to be cremated. Once the statutory medical examiner system is implemented, the medical examiner’s scrutiny will make the form Cremation 4 confirmation obsolete and the regulatory requirement for the medical referee to scrutinise it will therefore be removed.

Information about medical devices and implants in the body of the deceased (which is currently recorded on form Cremation 4) will be included on the MCCD and in the certificate for burial or cremation (green form), as set out above.

In coronial cases that are followed by cremation, the coroner will continue to certify the cause of death using form Cremation 6 (certificate of coroner), as at present. As set out above, form Cremation 6 will be amended to enable the coroner to record information on the presence of medical devices and implants, where available, so that this is communicated to the cremation authority. The coroner’s order for burial (form 101) will also be amended to enable the coroner to record information on the presence of medical devices and implants, so that this is available to the burial provider.

Currently, medical referees are responsible for authorising that the cremation of the deceased can proceed, taking into account the medical certification provided.

Medical referees will remain in post while the statutory medical examiner system is embedded. During this transitionary period, the Ministry of Justice will gather evidence to determine the long-term status of medical referees. There will be opportunities for medical practitioners, coroners and funeral directors to contribute to that process.

NHS trusts, healthcare providers, ICBs and health boards

NHS trusts in England must ensure that the independence of medical examiners is respected. NHS Wales Shared Services Partnership (part of Velindre Trust) as the identified appointing body and provider of the all-Wales medical examiner service in Wales, should have finalised preparations for the statutory system from April 2024.

All other healthcare providers in England and Wales, including GP practices and independent healthcare providers, must ensure they make the necessary arrangements to inform medical examiners of deaths requiring independent scrutiny and share records of deceased patients with medical examiners in a timely manner.

Government has recommended that all healthcare providers set up processes with immediate effect to start referring deaths if they have not already done so. This will avoid disruption and distress when the regulations come into force, allow procedures to bed in, and enable issues to be identified and addressed:

In England, integrated care boards (ICBs) should contact all healthcare providers in their area and require them to establish processes to refer relevant deaths to medical examiner offices for independent scrutiny.
In Wales, health boards should work with all healthcare providers in their areas to establish timely processes to refer relevant deaths to medical examiner offices so that the legally required scrutiny of deaths can be undertaken. All healthcare providers should ensure they have processes in place to receive feedback from the medical examiner’s office and that these feed into the appropriate channels for learning and improvement.

Healthcare providers can already share records of deceased patients with medical examiners and will be mandated to do so when the regulations come into force. Currently, section 251 support has been granted for sharing records with medical examiners in England following recommendations of the Health Research Authority’s Confidentiality Advisory Group (CAG). The relevant approval documents are CAG21/CAG/032 for England and CAG23/CAG/0095 for Wales, which can be downloaded from the CAG register.

When the regulations come into force from April 2024, medical examiners will have a right of access to records of patients under section 3 of the Access to Health Records Act 1990, as amended by the Coroners and Justice Act 2009.

Mortality statistics

The published draft regulations make no changes to the existing legislative powers for the Office for National Statistics (ONS) to produce mortality statistics.

The Statistics and Registration Service Act 2007 transferred many of the functions relating to statistics from the Registrar General for England and Wales to the Statistics Board. This transfer of functions included the requirement within section 19 of the Registration Service Act 1953 to produce and provide to Parliament an annual abstract of life events, including deaths. In addition, ONS has legislative functions within section 20 of the Statistics and Registration Service Act 2007 to produce public good statistics on any matter.

The General Register Office transmits death registration data to ONS daily who then process it for statistical analysis and production. This includes:

quality-assuring the data through a combination of automated and manual checks and liaising with the General Register Office to resolve any errors that are found
transforming the text that explains the cause of death, as set out by the attending practitioner or coroner, into relevant codes from the International Classification of Disease version 10 (ICD10). The ICD10 classification itself is set out by the World Health Organization and we will be transitioning to ICD11 by 2027. The addition of ICD codes enables mortality records to be summarised and compared robustly, both domestically and internationally
transforming the text that describes occupation into Standard Occupation Codes. This enables robust comparison of mortality rates by occupation

Following implementation of the statutory medical examiner system, the data transmitted to ONS will include some of the new items being collected on the revised MCCD:

line 1d of the cause of death information.
the ethnicity of the deceased (where available).
whether the deceased was pregnant or recently pregnant.

ONS expects that the quality of the cause of death information will improve once all non-coronial deaths are receiving medical examiner scrutiny (rather than only a proportion as currently), and that quality will continue to improve as the medical examiner service develops.

Legislation

The death certification reforms planned from April 2024, and how the statutory medical examiner system will operate when these reforms come into force are the subject of the following draft regulations which have been published for information only and may well be amended before coming into force:

The underpinning primary legislation is:

section 21 of the Coroners and Justice Act 2009, which was commenced in June 2018
sections 19 and 20 of the Coroners and Justice Act 2009, which was commenced on 1 October 2023
section 169 of the Health and Care Act 2022, also commenced on 1 October 2023

There will also be additional primary legislation commenced to support the reforms.

The primary legislation that underpins the new statutory medical examiner system is the Coroners and Justice Act 2009 and since its passage, the act has been amended (most recently by the Health and Care Act 2022) to reflect changes to the health system.

The Coroners and Justice Act 2009 allows NHS bodies in England and Wales to appoint medical examiners. It also enables the governments to make regulations in several areas, and these regulations provide the detail of how medical examiners and the reformed death certification process will operate.

The regulations published in draft by the Welsh Government are The Medical Examiners (Wales) Regulations 2024.

Other regulations will also be made or amended in relation to the system.

All of these regulations will be laid in Parliament and, for Welsh regulations, in the Senedd, prior to the statutory system coming into force from April 2024.

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