A Health Service Safety Investigations Bill, which has been delayed for two years, would put the existing Healthcare Safety Investigation Branch on a statutory footing. Set up in 2017 to probe serious safety incidents, HSIB has faced criticisms of poor governance and cultural problems in recent months

The safety bill would also amend the Coroners and Justice Act 2009 to allow trusts to appoint medical examiners, whose job is to routinely review deaths.

Index

Introduction

The Form

The Right and Responsibility to Learn

The Clinical Course of a Death

What is Discretion?

ICD-10 Classification of Disease

Compliance

What is the Public Interest?

The Wettlaufer Inquiry

The Science

The Logic

The Shipman Inquiry

The Therapy Default

PTSD and Death Certification: Cure or Cause?

A Lawyer? Really?

Introduction

Public safety is among the most important issues in our lives. There are many ways to ensure it or undertake to ensure it. Often however, the mechanisms we already have in place tend to atrophy in favor of newer ideas. The old established ones are left to chug along as though they are second nature and guaranteed reliable. Death certification joins this group. Even a casual look at this vital tradition or service, reveals that it is eroding into hasty entries on to a boring form by young medical staff and viewed as paperwork that accompanies the close of a file. Somewhere along the way, the point of death certification has been lost which justifies the point of this blog. It’s my wish, as an ordinary citizen, to sound the alert on incomplete or sloppy death certifications. In speaking for our deceased loved ones, we must make sure that their deaths are accurately assessed and that their death event subsequently becomes a tool for public good.

Death certification is intended to individualize a death. It is intended as a learning opportunity, a data and research source, a checker of sudden and unexpected deaths, solid protection against medical homicide, closure for families, a validation of a life and death and pause for thought as to what just happened.

The Medical Certificate of the Cause of Death (MCCD) form itself is clearly laid out, providing spaces for every detail of the death. Most importantly, it must also be clearly filled out by an honest and respectful authority. The MCCD follows a format set out by the World Health Organization in order to standardize death classifications from disease progression to manner of death. The ample provision of lines, boxes and extra sections is engineered to deliver the path of the death. It is a self-checking system of narrative, sequence and physical deterioration to shutdown. I hope this blog will refresh this crucial service and bring to everyone’s attention the phrase “use it or lose it.” We need to know about this protection and ask for it. Thank you for your interest.

Right and Responsibility to Learn

That pesky paternalistic attitude to all things isn’t absent when it comes to death certification. The general approach to the task is that it will be done for you by someone who knows how to do it. Clearly, it’s an area where the consumer should learn the ropes.

To put it more generally, consensus is the idea behind democracy, progress, harmony and awareness. So to wall off areas of expertise can’t do anyone any good. How can we complain or question in that situation? We have to know about the way something should be in order to complain about it. What is the yardstick?

I hope this blog or monogram encourages consumer, citizen or layperson right and responsibility to find out about death certification. The alternative is that when we inquire or “complain” that a death certification is wrongly and insufficiently completed, all we can logically receive in response is therapy from those who are authorized to fill out lines (a) to (d). How can we expect to argue for quality if we don’t know what amounts to quality.

There are many places to learn how death certification should be filled out. Every government office connected with vital statistics will provide a handbook for this purpose. These instructions or guidelines are also on the internet.

I have to admit though, that there is a bit more to the completion of the death certificate than filling out the lines on the MCCD. The person authorized to do it is counted on to have a knowledge of physiological processes so the task falls to a doctor, some nurses or a coroner. Therefore, if we want a complete and honest death certificate for a family member, we pretty much have to understand the death sequence for that person ourselves before we can make a case that the certification has been done incorrectly. Fortunately the learning curve isn’t as tough as it appears.

The first thing to bear in mind is that the death has already happened so there is no urgency. The next step is to procure the hospital or forensic records. A dying sequence is easy to pick up from the medical records if you keep factors like negligence, malpractice, homicide, accident out of your assessment. These are actions while the dying process consists of physiological responses to actions. The death certification specifically records physiological conditions or failures.

On first glance, it appears that the MCCD amounts to an insufficient system however that is not the case. The form is very effective in painting a picture. It’s exactly like a recipe where certain things logically go together. For instance, you wouldn’t see listed in the ingredients for a cake: eggs, milk, flour… and then suddenly, “a tablespoon of gravel…” Likewise, you won’t see an ingredient like flour left out. A death sequence when honest and complete will make physiological sense and click into place. Unfortunately, this is the very reason, why it’s often done wrongly. There can be the motivation on the part of those authorized to fill it out, to rely on a general diagnosis, resort to the term “complications” or worse, to throw a wrench into the works to avoid scrutiny.

There are several aspects to a consumer’s right and responsibility to learn about death certification. However, the task is confined to only one death or “recipe” so it will be relatively easy to navigate. The gain here is to dignify the family member who has passed away and by extension to improve the quality of service and product to consumers. The informed consumer will by virtue of insistence on a case by case basis and across the spectrum of each and all family deaths, put a damper on sloppy death narratives. Considering that a death certification awaits each of us, there is no doubt we would prefer one that fits our needs and not those of someone else.


The Form

While no two death events are exactly alike, there is little difference in death certification formats worldwide. Apart from the deceased’s name, age, sex, date and place of death, the entry process for the death is standard. In Part I of the MCCD form the listing of death antecedents proceeds from the bottom (line `d’) or underlying cause to the immediate cause of death (line `a’). Time intervals are also provided for so that the duration of each stage is listed. A story of decline would be reported as the sequence of conditions or factors leading to death. The process serves as both a checklist for the specific death as well as a discharge summary. When done correctly, it can only be logical and therefore medically sound.

A section called Part II must list in order of significance, any other diseases or conditions which unfavorably influenced the course of the morbid process and contributed to the fatal outcome but were not part of the sequence of events directly leading to the death. An adverse event would be entered here. Any recent surgeries would be entered in a separate box lower down on the form. The outcome of the surgery must be stated.

The World Health Organization website provides samples of a correctly completed death certification. It is interesting to read these as well as appreciating how well the format is designed for both public safety and the dignity of the deceased. I suggest that readers refer to a copy of a family death certification they may have for comparison purposes.

To simplify:

Part I of the MCCD lists the disease or conditions directly leading to death.
Part II lists other significant conditions which contributed to, but did not directly cause the death.

Where this is completed correctly, the condition on the lowest completed line of Part I will have caused (or created the conditions for) all of the conditions on the lines above it. This initiating condition will usually be regarded as the ‘underlying cause of death’.

For Parts I and II, it is important to record (in the boxes on the right hand side of the form) the approximate time interval between the onset of each disease, injury, condition or event and death. This information provides confirmation that the entries are in the correct order and may be essential for the accurate classification of the causes of death.


The Clinical Course of a Death

The goal of a death certification form is to describe an individual death according to standard parameters so that reliable data can be drawn from the growing total. The way the death certification form is structured is fully conducive to this goal. Also the format is universal, covering the whole human family and making for interesting and vital comparisons between regions and services. The most important criterion to understand is where does the death narrative begin? In order to standardize the certification, the person entering the information would be part of the job description designated to do it. They would be operating under the same set of instructions as their counterparts worldwide. They would also be the person-designate who would know the most about the deceased’s illness, accident, homicide or suicide and trained to put into effect their witness of the decedent’s clinical course (medical doctor or nurse) or their knowledge of the death by means of investigation (coroner).

A death narrative does not start outside of the hospital or forensic facility. It starts from the time the certifier is made aware of the patient in question or in the case of a corpse, the reporting of the corpse to the coroner. To use the case of a person who dies in a hospital, the clinical course will start with the patient’s presentation upon arriving at the hospital. The cause of death sequence will embody both the stage of the patient’s illness and the medical care he receives. Recovery or death of the patient depends on the dynamic between the two from this point on. The death certification in this case is very important in understanding the nature of a disease or injury as well as the medical management or investigation of the presenting signs and symptoms. Healthcare is a learning process and the data provided by cause and effect on lines (d) up to (a) on the MCCD points out many ways that life saving interventions can be improved and envisioned.

What is Discretion?

The ultimate arrangement of the narrative components on the MCCD that is, line (d) to line (a) is done at the certifier’s “discretion.” Very often this role is misunderstood and taken to mean that the certifier can skip or alter these components. This is not the case and in fact, the very reason why the death certification is structured the way it is. The term “discretion” denotes the certifier’s explanation of the decline, not his invention, re-stating or omission of the events. The clinical course of the death is the path the certifier must reflect according to medical facts or forensic findings. The death certification format serves as a foolproof structure for this thought process.

An abuse of discretion is a failure to take into proper consideration the facts and law relating to a particular matter; an arbitrary or unreasonable departure from precedent and settled judicial custom. On appeal of an exercise of judicial discretion for example, “abuse of discretion” is a standard of review requiring a court to find that the lower court’s decision would “shock the conscience” of a reasonable person in order to reverse the decision below. Reasons and rationale must always be given.

The following explanation of certifier “discretion” is taken from the Ontario Handbook on Death Certification.

A diabetic man who had been under insulin control for many years developed ischemic heart disease and died suddenly from a myocardial infarction. Depending on the physician’s documented medical diagnosis, the following narratives are possible and would be acceptable:

1. If the physician considered that the heart condition resulted from the long-standing diabetes, the sequence would be:

Part I

(a) Myocardial infarction…………………………….…………1 hour

due to

(b) Chronic ischemic heart disease…………………………5 years

due to

(c) Diabetes mellitus………………………………………..…..12 years

2. If the physician considered that the heart condition developed independently of the diabetes, the certification would be:

Part I

(a) Myocardial infarction…………………………….…………1 hour

due to

(b) Chronic ischemic heart disease………………………….5 years

Part II Diabetes mellitus……………………………………..….12 years

3. If the man had instead died from some other expected complication of the diabetes, such as nephropathy, the heart condition playing only a subsidiary part in the death and the physician being uncertain that it arose from the diabetes at all, the sequence would be:

Part I

(a) Acute renal failure……………………………………………1 week

due to

(b) Nephropathy……………………………………………….…..4 years

due to

(c) Diabetes mellitus………………………………………..……12 years

Part II Chronic ischemic heart disease

Discretion is therefore restricted to clinical givens and does not mean physician, nurse or coroner freedom to deviate from the MCCD format or issue insufficient, mistaken or false clinical changes in the death event. Being trusted to complete a death certificate is a direct expectation of the certifier’s job description and his advantageous exposure to the bank of physiological knowledge. It is not about carte blanche in situations of hurry, inconvenience, paperwork or personal judgements.