Providing answers can help with the grieving process

Learning from the experiences of each year helps the Death Certification Review Service continue to make improvements in providing the most accurate and comprehensive information for loved ones – Dr George Fernie

The work of our Death Certification and Review Service (DCRS) is of the utmost importance when dealing with one of life’s most difficult situations – the death of someone close to you. The service helps to provide the clarity people need to process the most demanding information and help aid the grieving process. As the Annual Report for 2022/23 is published, Dr George Fernie, our Senior Medical Reviewer, explains the work of DCRS and the constant strive to provide the most comprehensive information.

When I wrote the overview to last year’s annual report it was with cautious optimism as we started to exit the pandemic and move gently to what would be the ‘new normal’. However, since then we have learned a number of lessons from dealing with COVID-19 in how we maintain quality and consistency of medical certificates of cause of death (MCCDs) whilst not overburdening general practice and secondary care at their busiest times. That experience helped in autumn last year when we saw a surge in coronavirus rates, coupled with a rise in flu and a number of norovirus cases in care homes. Taking into account the experiences of the past two years, we were able to make adjustments that maintained our high standards of accuracy whilst alleviating administrative pressures on primary and secondary care.

Over the past year an important area of our work has focused on progressing direct access to patient medical notes across the country to help with more detailed death certification reviews. This reduces the administrative burden within NHS Boards and improves the focus of reviews. We have now successfully connected to all Scottish Health Boards.

Looking ahead, we will continue to work with National Services Scotland and the Scottish Government to roll out eMCCD into hospital care. The first phase of the NHS Lothian pilot was successful and we are currently awaiting some IT system changes to support the second phase of testing.

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Standard of accuracy is continuing to improve

As we publish our latest annual report for 2022/23, we’re delighted to see that the standard of how doctors are completing death certificates continues to improve. Last year doctors wrote almost 63,000 Medical Certificates of Cause of Death (MCCD). The doctor explains the cause of death to families and emails it to the local authority registrar and the family, if they wish.

Of the certificates we deemed were 'not in order', 37% were due to the cause of death being too vague.

The monthly percentage of randomly-selected death certificates found to be ‘not in order’ – meaning that we have requested changes or clarification – remains at a similar level to last year at a current median of 21.4%. Of the certificates we deemed were ‘not in order’, 37% were due to the cause of death being too vague. ‘Too vague can mean failing to specify the location and type of cancers of strokes that were involved in a cause of death. It is important that this information is recorded accurately as it helps resources be directed to where they are most needed. Administrative errors such as spelling mistakes, use of abbreviations and failing to sign the certificate, were other reasons for DCRS asking for improvements to the certificate which was issued.

Doctors also get in touch with us for advice and we are available to them every day of the year, without exception, and that is particularly important to certain faith groups. In 2022/23 we dealt with 2,546 enquiries, up from 2,279 the previous year. The majority of calls (83.9%) were from doctors seeking clinical advice on how best to represent a death on a MCCD.

Repatriation and deaths abroad

We’re also responsible for approving burial or cremation in Scotland of people who have died abroad and their families want them to be repatriated to Scotland.

In 2022/23 the service received 191 repatriation requests which was an increase of 107 on the previous year, when we had 84 requests. The majority of repatriation requests this year were from Spain. All were approved and two post mortem applications were also granted.

Death certificate review requests from the public

Any member of the public can request a review of a death certificate, as well as registrars being able to refer a death certificate to DCRS for review if they fell the certificate isn’t accurate. We then carry out a Level 2 more detailed review, if the death has not previously been reviewed by us, or the death has not already been reported to the Procurator Fiscal. These type of requests remain low and last year four requests were received. Two were declined as the deaths had been previously considered by the Procurator Fiscal. One MCCD was found to be ‘not in order’.

We aim to provide families and loved ones with as much clarity and certainty around the cause of death as possible.

Possible challenges we face

Each year we have seen the amount of time it takes to carry out a review get shorter. However, we are aware this winter period, and the increased pressures that puts on the NHS, completing reviews in as timely a manner may be challenging. In 2022/23 our average time to complete a level 1 review was less than four hours, however 232 reviews took longer than our agreed eight hours timescale, with 196 due to difficulties reaching the certifying doctor to carry out the review. Deaths can’t be registered until DCRS complete the review and we are acutely aware of the impact that this can have on families trying to make burial or cremation plans. Over the coming months we will make every effort to minimise the disruption to loved ones, at what is already a difficult time.

What will the next year bring?

Over the next year we will focus on what we can do to further improve the service we provide. We aim to provide families and loved ones with as much clarity and certainty around the cause of death of their loved ones as possible. We will continue to work with NHS Boards to reduce the number of clinical and administrative errors on MCCDs and continue to educate on the appropriate reporting of deaths to the Procurator Fiscal.

Read the latest DCRS Annual Report for 2022/23

George Fernie is a Senior Medical Reviewer at Healthcare Improvement Scotland.