Auditing cause of death determinations
England and Wales
8.12New systems to review death certification have been developed in the United Kingdom. Legislation was passed in Scotland in 2011 and has come into force this year. The review system for England and Wales has been developed and trialled but not yet implemented.
8.13Under the English and Welsh trialled system, all deaths that were not investigated by the coroner underwent scrutiny by locally appointed medical examiners to confirm the cause of death or identify cases that need further investigation by the coroner. Medical examiners also reviewed the medical records; examined the body (in most cases); sometimes discussed the death with a relative or other appropriate person; and discussed and agreed the confirmed cause of death with the certifying doctor.
8.14A study in 2012 of the trialled system compared the cause of death determined by the certifying doctor against the cause of death confirmed by the medical examiner. The study concluded that almost 20 per cent of death certificates had a different underlying cause following scrutiny by the medical examiner. Scrutiny resulted in amendments to the number, sequence and type of conditions mentioned on the cause of death certificate, and that is likely to affect trends in reported causes of death.
8.15In Scotland, the system is similar, but the reviewers are called “medical reviewers”. They are centrally appointed but operate locally, and they review a random sample of all deaths prior to disposal of the body. Medical reviewers conduct either a level one or a level two review. In a level one review, in addition to reviewing the cause of death certificate, the medical reviewer discusses the death with the certifying doctor. In a level two review, the medical reviewer may also examine the medical records, view the body and speak to other professionals involved with the deceased person or the family.
8.16An evaluation of two Scottish pilot sites was published in 2013 after a year of operation, but it focused on the processes of the new system rather than its overall effectiveness at increasing the accuracy of death certification. Within the evaluation period, medical reviewers found that only 3 per cent of cause of death certificates were not up to standard. However, that high rate of accuracy could, in part, be due to the fact that doctors in these areas knew their certifications would be subject to additional scrutiny.
8.17The evaluation made the following findings in relation to the new processes:
- In most cases, both level one and level two reviews were completed within the expected time scale (30 minutes and up to three hours respectively), but delays were also frequent, caused by difficulty in locating the certifying doctor, accessing the medical records or contacting the responsible consultant. Also, the evaluation was not able to assess any delays in commencing the reviews.
- Key attributes important for medical reviewers included strong communication skills, the ability to negotiate and compromise, a willingness to be flexible, an ability to act decisively and an ability to take on an educative role with doctors.