Problems with the current system
Errors in recording the cause of death
3.7It is very important that the cause of death recorded on the MCCD is as accurate as possible. As described above, that information is used to inform decisions on future health programmes and policies, which may involve setting priorities and targeting interventions. On a private level, the cause of death gives family members information relevant to their own health and gives insurance companies information necessary for determining insurance claims.
3.8Unfortunately, errors in recording the cause of death are fairly common. This is a worldwide problem. International examinations of the rate of error by doctors on death certification documents have found error rates of 24–37 per cent, with major errors (which may require reissuing the document) amounting to the bulk of errors. In New Zealand, the error rate has not been seriously studied, possibly because there has been no central agency responsible for death certification. However, we reported in Issues Paper 23 that a “mini audit” of 1,331 MCCDs by the Ministry of Health found errors in 24 per cent, with errors ranging from non-specific causes of death, failure to correctly differentiate between underlying, proximate and contributory causes of death and failure to provide critical information such as the primary site of cancer.
3.9The nature of errors in recording the cause of death can include incomplete forms, illegible handwriting, inattention to detail and inaccurate causes of death. Inaccurate causes of death can include errors such as listing the mode of death (for example, cardiac failure) without an underlying cause; failing to note recent major surgery; or failing to specify the site or organism of infection. Anecdotally, we were told that myocardial infarction (heart attack) was often the default diagnosis of the cause of death where there are no indications of other causes. In some of those cases, a brain aneurism or pulmonary embolism may have been equally likely to have caused the death.
3.10There are many factors that contribute to a high rate of error in recording the cause of death. They include a lack of experience; the task of death certification being given a low priority; a lack of education around death certification; fatigue; time constraints; unfamiliarity with the deceased’s medical history; frustration with the forms (in particular questions that are difficult to answer and are duplicated across different forms); only one doctor commonly completing all the documentation; and not viewing the body.
3.11In addition, there are potential conflicts of interest in the system that could also contribute to this high rate of error. We have been told that the purposes of the death certification system, described above, and the importance of accurately recording the cause of death are not always clear to doctors. This may result in other interests or considerations influencing how doctors record cause of death. For example, doctors may feel some duty to the bereaved family when determining the cause of death. That may lead them to hide or minimise certain factors that contributed to the death, for example, alcoholism, or where the death was a suicide. It may also lead them to determine too easily that the death was of natural causes so that the family can have the body for funeral preparations rather than have to wait for the coronial process. Alternatively, the doctor’s own interest may influence the determination of the cause of death, for example, if the doctor feels the need to hide negligent or wrongful behaviour.
3.12Another type of error that can occur when completing death certification documents is failing to identify the death as reportable to the coroner. For most deaths (deaths in hospitals or after an illness), doctors are the gatekeepers to the coronial jurisdiction. A death must be reported to the coroner if the cause of death is unknown or if it is suicide; unnatural or violent; or if the death occurred during medical, surgical or dental treatment. If a doctor has not completed a MCCD in respect of a death, it must be reported to the coroner.
3.13We found significant confusion among doctors as to when a death must be reported to the coroner. While some of the forms completed after death aim to assist doctors to make that determination, they are not required in every case. The MCCD requires a doctor to consider whether a death is reportable under the Coroners Act but does not give guidance as to what the legislation requires. When a death occurs in a hospital, the doctor completes the Record of Death form, which is designed specifically to help the doctor determine whether the death must be referred to the coroner. No such document is currently provided for deaths in the community, although one is in development. When the body is to be cremated, the Cremation Certificate asks similar questions designed to determine whether the death requires further investigation by the coroner. However, there is no equivalent certificate or set of questions for when the body is to be buried.
3.14As we described in Chapter 2, where a doctor has doubt about whether he or she should certify death, the usual practice is to telephone the coroner and discuss the death. The level of certainty to be reached by the doctor as to the cause of death is a difficult issue. That level is not specified in the Act. The MCCD requires the doctor to provide the information to the best of his or her knowledge. However, the Permission to Cremate form requires the medical referee to confirm that the cause of death has been definitely ascertained. Submissions from doctors on Issues Paper 23 were very clear that determining the cause of death in the absence of an autopsy is never definite and is often a view taken on the balance of probabilities. We consider that the legislation could provide clearer guidance about the level of certainty required for a doctor to be able to certify death as a natural consequence of illness.