A response on behalf of the Association of Anatomical Pathology Technology to the consultation on 'Improving the Process of Death Certification'.

The Association of Anatomical Pathology Technology welcomes the intention of Government to modernise the process of death certification and fully support the need to change the current system. We are pleased to see that this consultation proposes the introduction of Medical Examiners, who would be well placed to advice doctors on such issues as, appropriate referral to Coroners and how to better certify deaths.

In response to the questions posed:

Q1. It would seem sensible to allow the deceased to be released for burial or cremation upon authorisation from the Medical Examiner (ME). Consideration needs to be given to allow the full facts of each case to be properly investigated by the ME prior to issuing disposal documentation.

Annex C would need to be amended as it is therefore incorrect.

If the requirement to register the death were not part of the overall disposal process, may it then lead to a number of deaths never being registered.

Point 5.7 suggests the registrars duty to report deaths to the Coroner, at the point of registering the death, would endure if family and or friends of the deceased were to raise concerns. This approach may lead to an increase in the need to exhume the deceased and would be considerably more problematic if the deceased had been cremated. We therefore suggest that the family and friends be informed that all matters of concern should be considered by the ME prior to the deceased being authorised for cremation or burial and not at the time of registration.

The issue of embalming of the deceased would also need to be considered, at present it is common practice not to embalm a deceased person until such time as the death has been registered. This is due to the fact that until that point the death may still be reported to the Coroner.

Q2. The employment of part-time ME’s would be desirable to encourage the maximum number of appropriate applicants to the posts. The number of ME’s and or Medical Examiner Support Officer’s required for an area would be wholly dependant on the needs of the community and population.

We consider it essential that a ME’s office should be contactable on a 24 hour basis. This could be made possible by utilising an on call system to allow for emergency and out of normal working hours services.

If however an area were to employ one part-time ME who was also a practising clinician, it would inevitably lead to further delay in the process. This may also pose problems with the need for General Practitioners issuing MCCDs to be able to speak with the ME as schedules and work plans may inadvertently be incompatible due to night and weekend shift requirements by both parties.
It would therefore be advisable to have, where required, adequate whole time equivalent cover of the ME’s role in order to meet the demands of the local population, ensuring sufficiently trained ME staff to cover periods of absence. In order to achieve this level of service and economies of scale, it may be advisable to utilise already established medical services within NHS Trusts.

Pathology Departments within NHS Trusts could be charged with ensuring full time clinical cover of this role and adjust job plans accordingly, Pathologists would seem well suited for this role due to the nature of their knowledge base.

This model would deliver even greater cost savings if the ME’s office were to be incorporated into the Hospital Trusts end of life service. In many instances this approach would achieve the speedy establishment of efficient service’s that are well placed to take on these new duties with the minimum of disruption negating the need to establish new offices.

Q3. In many areas the co-location of the ME’s and Coroners service would prove beneficial to the bereaved and assist with communication between the two services. The two services would need to keep professional roles separate and ensure that Coroners Officers and Medical Examiners Support Officers roles and responsibilities were clearly defined. The separation of roles would need to be maintained to ensure adequate staff cover for both services and that the officers were not used for cross cover should a local authority see a potential for cost saving by amalgamating the two roles.

In many areas there will also be an opportunity to co-locate the ME’s office with NHS Trusts End of Life Services (where they exist) by utilising already existing Bereavement Offices and staff. Additional funding for an increase in staffing and the appropriate training for the officers would be required. Utilising the staff and services within a hospital will allow for development of this service as they at present have no official duties to perform on behalf of the Coroner.
Bereavement Officers generally have an already good understanding of medical terminology and will have established links with local authorities, GP’s and Coroners services. The majority are already established departments with existing links to appropriate governance structures, an understanding of working with the bereaved and communicating with relevant authorities involved with the process of death. The service is therefore well placed to be modified in order to encompass this office and not impinge on the workings of the local Coroners service.

Co-location of ME’s office within NHS Trusts would also allow the ME to have greater access to medical records and be more available to junior doctors who may be required to complete MCCDs. The deaths that occur in the local community would neither benefit nor be disadvantaged by this approach which would not be the case if the ME’s office were co-located with Coroners Offices.

Q4. A professional line of accountability between these two offices would be advisable in order to standardise national policy and guidance on related issues. Joint working between these offices would also further assist with audit of national data and help to better inform public health monitoring and policy.
We do not believe that the Medical Examiner should be accountable to a PCT or NHS Trust as this could undermine their independent practice and would not present an impartial perception to the public.

Q5. It would be entirely appropriate for ME’s to be contracted to provide medical advice to Coroners. We believe the Coroners service would benefit from independent medical advice in many circumstances surrounding an individual’s death.

There will also be advantages to offering medical advice to the Coroner where decisions on local policy for reporting deaths or verification of death protocols are required.

Q6. Yes. There are many instances where deaths are discussed with the Coroners office unnecessarily. This tends to occur when the treating doctor is unable to complete the MCCD through lack of experience and/or appropriate guidance. There is also occasion where family may disagree with the information that has been written on the MCCD and/or make complaints about treatment. In this instance an independent doctor will be better placed to hear the families concerns and establish the circumstances surrounding the death without the need for a Post-Mortem examination. Similarly family and or friends may, at present, be reluctant to voice complaints about treatment as they are increasingly more aware that this may lead to the deceased being referred to the Coroner and a post-mortem examination then being held.

In cases of deaths that are not subject to criminal investigation, such as postoperative or infectious disease outbreaks it may be more appropriate to discuss these with the ME in the first instance.

Q7. We believe that a qualifying period is not required as the medical history and circumstances surrounding the death are more important factors than the last occasion a patient was seen by a medical practitioner.

Any system that allows for the relaxation of this qualifying period must also have sufficient safe guards to ensure that the deceased did not suffer any trauma or neglect prior to death. This may therefore require the ME to perform an external examination of the deceased. The ME would then need to be sufficiently qualified to perform such an examination.

This type of system would also raise additional issues such as where would the deceased be examined, which in turn would pose problems such as the ME travelling to the deceased or vise versa.

In the event of the deceased needing to be brought to the ME for external examination this would need to be performed in an appropriate facility. This will incur additional cost to the service as the storage facility would need to be sufficient to accommodate extra deceased persons and the cost of the transportation of the deceased would need to be considered. This will also raise issues of family and friends wishing to see the deceased at the facility and funeral directors ensuring that they collect the deceased once released in a timely manner.

If there is a need for external examinations to be performed it is also possible that the ME could utilise existing services from Consultant Pathologists as does the Coroner.

Additional comments:

Q. What is the proposed system of dealing with deaths in the community if there were no on call service for the ME’s office?

E.g. In the event a GP attends a community death but is unable or unwilling to complete an MCCD until having discussed the case with the ME’s office. What then would happen to the deceased? Would they be taken to a funeral director, left at home or taken to a local mortuary (NHS or Local Authority run).

6.1 Please be advised that currently any deceased patient who has undergone a consented post-mortem examination by a Consultant Pathologist does not require part C of the cremation form to be completed, thus lowering the overall cost to the family.

In addition to this it is common practice for hospital doctors completing parts B & C of the forms for a baby or child not to accept a fee thus again lowering the cost that the family are required to pay for the funeral. This is anecdotally seen by many clinicians to be part of their duty in caring for the family and the baby/child at the end of their life.

James Lowell
Vice-Chair
Association of Anatomical Pathology Technology
October 2007