Medical examiners in death certification: an open letter

Edin Lakasing is a GP, trainer and tutor in Chorleywood, Hertfordshire

Shalinee Patel is a GP Specialist Trainee in Hertfordshire

The national medical examiner system in England, ostensibly to scrutinise deaths in the community, has been a voluntary activity since 2021, meaning that GPs could exercise their discretion whether to involve examiners, but as of this year becomes compulsory. The opening line of its stated purposes on the NHS England website includes ‘to give bereaved people a voice’.¹ Beyond the incredulity that, taken at face value, one could form the impression that it was quite unusual for health professionals to communicate with the relatives of the dying and the deceased, we believe that this system offers poor value for public money, will needlessly increase practice workload, and risks having a corrosive effect on the trust fundamental to the relationship between healthcare workers and families.

Research shows that around 75% of people express a wish to die at home;² however, in the UK currently only about 18% do so.³ This suggests that managing deaths in the community does not constitute a large part of most GP’s workload. However, the problem with averages in a diverse country like the UK is that they belie wide variation in practice and outcomes in different localities. Our practice, located in a semi-rural commuter zone, is typical of many affluent non-metropolitan areas where patient attitudes are conservative, and primary care is quite traditional, with a culture of autonomous patient management, including end-of-life care. Our published data has consistently shown that around 50% of patients die either in their own home or in a nursing home under our watch.^4,5 The increased bureaucracy has already proven to be a burden for our practice, with the requirement of sending the death certificate to the examiner first then, assuming approval, to the registry office, as well as with the occasional conversation with the examiner at their behest. The legislation comes at a particularly difficult time with recruitment and retention problems ailing the entire NHS. Harsh as it may sound, chasing diagnostic precision for the deceased may well deflect resources away from caring for the living.

We aver that there are sound arguments why hospital-based specialists are not best placed to arbitrate on deaths in the community. Secondary care is highly subspecialised and geared to providing expert care in niche areas. If a nephrologist is indisposed, his or her trust would not accept an offer from the passing gastroenterologist to act as their locum, though both are members of the same college. So what makes an orthopaedic surgeon, subspecialised in foot and ankle surgery and who happens to be on that day’s rota, expertly qualified to opine on a death of someone they have never met from Lewy body dementia in a nursing home?   It is surely GPs, used to managing complexity and multi-morbidity in an ageing population, and communicating with other professionals, family members and carers, who are best placed to issue the death certificate or, in the case of significant uncertainty, refer the case to the coroner. Yet the requirement for the medical examiner to interview family members, scrutinise and sometimes question our certification demeans our expertise, and will have a deleterious effect on trust. Conversely, there is little gain; indeed, the added layer and potential delay may cause distress, especially to Jewish and Muslim families who desire next-day burial which, if not always practically achievable, should be done as swiftly as possible.

This begs the question of why this additional hurdle has been foisted? Though not officially acknowledged as the driver, the suspicion must be that the Harold Shipman scandal has driven this. Two decades after Dame Janet Smith concluded her enquiry,⁶ it is time for common sense to prevail, and for Shipman to be acknowledged as the statistical outlier that he was. With record waiting times for secondary care,⁷ poor staff morale epitomised by strikes and record numbers leaving the caring professions,⁸ worsening population health evidenced by record numbers of people on long-term sick leave⁹ and falling life expectancy – a trend which started 9 years before the Covid-19 pandemic accelerated it,¹⁰ politicians and NHS managers have a bulging in-tray. Appointing medical examiners should not have been in it.

Deputy Editor’s note: a discussion of the previous medical examiner system may be accessed here: https://bjgplife.com/learning-from-death-the-medical-examiner-system-in-england-and-wales/

References

1. NHS England 2024. The national medical examiner system. https://www.england.nhs.uk/patient-safety/patient-safety-insight/national-medical-examiner-system/#introduction-to-the-medical-examiner-system (accessed 28 Mar 2024).
2. Hoare S, Slote Morris Z, 1 Kelly MP, Kuhn I and Barclay S. Do Patients Want to Die at Home? A Systematic Review of the UK Literature, Focused on Missing Preferences for Place of Death. PLoS One 2015; 10(11): e0142723.
3. Gomes P, Higginson IJ. Where people die (1974–2030): past trends, future projections and implications for care. Palliat Med 2008 Jan;22(1):33-41.
4. Lakasing E, Sparkes C. A practice-based survey of mortality revisited – what trends in end-of-life care are emerging? Br J Community Nursing 2010 May;15(5):236, 238-40.
5. Lakasing E, James AE. A practice-based survey of mortality: what impact has Covid-19 had on mortality patterns? Pavilion Health Today, 22 Mar 2022. https://pavilionhealthtoday.com/gm/a-practice-based-survey-of-mortality-what-impact-has-covid-19-had-on-mortality-patterns/ (accessed 28 Mar 2024).
6. Smith J. The Shipman Inquiry. Fifth Report – Safeguarding Patients: Lessons from the past – Proposals for the Future. HMSO 2004. https://www.the-shipman-inquiry.org.uk/fifthreport.asp (accessed 28 Mar 2024).
7. NHS backlog data analysis. BMA 2024. https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/pressures/nhs-backlog-data-analysis (accessed 28 Mar 2024).
8. Essex R, Brophy SA, Sriram V. Strikes, patient outcomes, and the cost of failing to act. Strikes, patient outcomes, and the cost of failing to act. BMJ 2023; 380: e072719.
9. Office for National Statistics. Employment in the UK: September 2023. 12 Sep 2023. https://www.ons.gov.uk/employmentandlabourmarket/peopleinwork/employmentandemployeetypes/bulletins/employmentintheuk/september2023#economic-inactivity (accessed 28 Mar 2024).
10. National life tables – life expectancy in the UK: 2020 to 2022. ONS 2024. https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/lifeexpectancies/bulletins/nationallifetablesunitedkingdom/2020to2022(accessed 28 Mar 2024).

Featured photo by Annie Spratt on Unsplash