6We encountered overwhelming support for significant reform of the process for determining the cause of death and ensuring that appropriate deaths are referred to the coroner. The current process involves a plethora of paper documents, which often duplicate the required information and ask questions that are unnecessarily difficult for doctors to answer.
7We recommend that the current documents should be combined into one online process managed by the Ministry of Health. The process should have sections covering:
8As much as possible, the questions should have pre-coded options to standardise responses and so reduce errors. The determination of the cause of death should be able to be sent directly from the online form to the Registrar-General of Births, Deaths and Marriages so that funeral directors will no longer be required to relay that information. Relevant parts of the form should be accessible to people who embalm, bury or cremate deceased bodies so they can check that the cause of death has first been determined.
9In addition to the problems with the forms completed by doctors after a death, we found a number of problems with the current statutory duties on doctors and funeral directors.
10We received strong submissions from families and funeral directors about delays experienced in getting a doctor to certify that a death was from natural causes. The delays are caused by doctors being busy and prioritising treatment of sick patients, doctors being away, a lack of understanding by doctors of the complicated rules around when they must or must not certify the cause of death and perhaps a lack of understanding of the importance of the task of determining cause of death.
11One of our recommendations to address this problem is that some nurses should have the power to determine the cause of death in some circumstances. This option will be particularly useful in rest homes and hospice facilities and in rural medical practices. However, we also recommend that there need to be controls around the competency of nurses to perform the task, together with support from experienced doctors.
12The current rules around examining or viewing the body before determining the cause of death are inconsistent and often ignored. A doctor is only required to examine the body if he or she is not the doctor who attended the deceased person during their illness or if the body will be cremated. Also, we are told that doctors often only “view” the body, despite the Act requiring them to “examine” the body, because they consider that an examination will not elicit useful information and would be distressing for the bereaved family.
13We recommend that it should be up to the attending doctor to decide whether he or she needs to examine the body in order to determine the cause of death. There will be many deaths that were expected, and examining the body is not warranted. However, if it is not the deceased person’s usual doctor who is determining the cause of death, that person should still be required to examine the body.
14We recommend that doctors should have a statutory duty to determine the cause of death to the best of their knowledge and belief.
15We also make recommendations about timeframes and the degree of certainty required for cause of death certificates by doctors to help address the difficulty in getting doctors to attend to this task. Currently, the Act says that doctors must give their certificate immediately after learning of the death. That is clearly unworkable. In relation to the degree of certainty required, the current Act is very unclear. We have found that, while the antecedent and underlying causes of death can be accurately determined, the complication that actually caused the death will often be an educated opinion (or “best guess”).
16We recommend that the new statute provides a new, more practical timeframe and clarifies the degree of certainty required of doctors. Our suggestion is that the doctor should be required to certify the cause of death to the best of the doctor’s knowledge and belief within 24 hours of learning of the death or as soon after that as is reasonably practicable.
17Currently, there are complicated rules as to when a doctor who was not the doctor attending the person during their illness may determine the cause of death. The result is that hospitals and other facilities often wait 24 hours for the attending doctor to return before the cause of death is determined. This is an unnecessary delay.
18We recommend that the law should be pragmatic in this case and provide that an alternative doctor may determine the cause of death simply if the attending doctor is unavailable. However, in doing so, the alternative doctor must view the person’s medical notes and view the body.
19Currently, the Act states that a body may not be disposed of, nor may a person transfer the charge of the body, unless the cause of death has been determined. While we consider that the first requirement should be continued, the second requirement results in some problems. First, there are some complicated exceptions in the Act that are very difficult to understand. Second, waiting to move a body from the place of death until a doctor determines that the person died of natural causes can present practical issues, particularly when the person died in their home or in a rest home.
20Instead, we consider that the second requirement should be repealed and replaced by a requirement that a body may not be embalmed unless the cause of death has been determined. In most cases, embalming a body is more likely to remove signs of the cause of death than moving the body from the place of death.
21We found that there is likely to be a high rate of error in the determinations of cause of death in New Zealand, but the current system does very little to address this. Medical referees are currently charged with determining that cremation certification (including the cause of death) is accurate. However, they usually cannot do this confidently because they do not have access to the deceased person’s medical notes. There are currently no checks at all on the documentation when a person is buried. Also, there is no formal education for doctors certifying cause of death and no process for feedback to them on the quality of their determinations.
22As a result, we recommend that the medical referee system should be abolished and replaced by a national audit system for cause of death determinations. Experienced medical practitioners should be appointed as “cause of death reviewers” to review a random sample of all deaths except deaths that have been referred to the coroner. Deaths that occur in hospitals could also be excluded to reduce the workload and cost if hospitals implement their own reviews of cause of death determinations. The purposes of these random sample reviews would be to:
23In addition, cause of death reviewers should undertake targeted reviews designed to detect problems with certifying deaths with particular characteristics. For example, deaths occurring in a particular aged care facility could be reviewed if there was concern about a disproportionate prevalence of a particular cause of death or circumstance accompanying deaths.
24The Ministry of Health should be responsible for this audit system, including for measuring rates of error in cause of death certification and using information gleaned from audits to educate certifying doctors.