Death Certification Test Site Evaluation

Executive Summary

1. The Certification of Death (Scotland) Act 2011 makes provision for a new process of independent reviews of Medical Certificates of Death (MCCDs) whereby registrars will refer a random sample of deaths (excluding deaths which are referred to the Procurator Fiscal) to the newly created post of Medical Reviewer (MR) who will review the quality and accuracy of the MCCDs. Generally this review will have to be complete before the death can be fully registered.

2. Between May/June 2012 and February 2013 the Scottish Government established two test sites, in Dundee and Dumfries & Galloway, to pilot the new approach. Both areas employed a 0.5 FTE MR and 0.5 FTE Medical Reviewer Assistant (MRA). The MRs were overseen by a Senior Medical Reviewer (SMR) who is a Senior Medical Officer at the Scottish Government.

3. In July 2012 the Scottish Government commissioned Blake Stevenson Ltd to undertake an evaluation of the test site processes and stakeholder experiences with a view to identifying lessons learned and informing national implementation. The evaluation involved interviews with all key stakeholders, analysis of data gathered from the test sites by NHS ISD and 18 short case studies of reviews undertaken to explore any issues arising in more depth.

4. The evaluation had a number of limitations as it did not take place in 'real time' and did therefore not affect any funeral taking place so there was no immediate impact on the public. When the process is implemented nationally reviews will need to be completed before funerals can take place and the public will also be charged a fee towards the costs of the review process. As this did not happen in the test site process the views of the public were not included in the evaluation.

5. The majority of MCCDs reviewed were found to be in order. Only 3% were found to be not in order across both level 1 and 2 reviews. Given the scrutiny of the test site process this is a very positive result. The main reasons given for the MCCDs that were considered not in order were as follows (with more than one reason being given in some circumstances):

• incorrect or incomplete cause of death (88%);
• information about the certifying doctor omitted (41%);
• incorrect sequence of cause of death (32%); and
• inaccurate or missing personal details about the deceased person (27%).

6. The duration of the reviews was generally in line with what had been estimated (30 minutes for level 1s and up to three hours for level 2s) but there were some delays in terms of elapsed time so that some reviews took in excess of seven days. The main reasons for the delays were difficulties in contacting the certifying doctors and in accessing medical records. It is anticipated that when the process is implemented nationally the delays in contacting doctors will be reduced, as less time will have elapsed between the death and the review so the doctors will not have moved jobs or be on holiday to the same extent as happened in the test sites. There are practical issues relating to accessing medical records that may also reduce the time taken to complete the reviews, in particular if they can be accessed electronically.

7. The evaluation raised some other practical issues that could be addressed: ensuring that registrars can email (and have access to scanners) rather than fax through referrals as problems were found with faxing; the importance of locating the MRs in NHS buildings as this assists with IT communications and internal mail systems; and clarity around completion of the ISD data forms so that there is consistency across areas.

8. The test sites have shown that the new process creates some further work for registrars. This includes time to prepare documents for referral, to communicate with the MR, to file documents away after the review and to send a replacement MCCD (where this occurs) to National Records Scotland and change the cause of death in the register if this is required. (In the national implementation registrars will also require time to communicate with the public about the review process and to gather and administer the fees being charged).

9. The evaluation identifies good communication between the key stakeholders as being critical for the process to work well. For this reason the person specification for the MR/MRAs provided in the evaluation report identifies communication and people skills as essential.

10. The importance of consistency across all areas has been highlighted by some of the differences found between the two test site areas. This links to the need for thorough training of the new MRs and MRAs once they are appointed. The Senior Medical Reviewer will have responsibility for the overall consistency across Scotland.

11. Training and education will also be required for registrars and doctors. There will be a need for general awareness-raising about the new process with the public.

12. Once the national implementation is in place it will be important to undertake regular reviews:

• to check that there is consistency across all areas;
• to check whether there are unnecessary delays happening that could be resolved; and
• to check whether the overall sample size (at this stage it is intended this will be at 25%) is proportionate to the numbers of inaccurate MCCDs being found.