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Healthcare Improvement Scotland submission of 10 December 2021

PE1894/D: Permit a medical certificate of cause of death (MCCD) to be independently reviewed

I would first like to outline the current role of the Death Certification Review Service (DCRS), part of Healthcare Improvement Scotland.

Arrangements for death certification and registration in Scotland changed in 2015, at which point the DCRS, which is run by HIS, was established.

The review service checks on the accuracy of a sample of Medical Certificates of Cause of Death (MCCDs), other than those already scrutinised by the Crown Office and Procurator Fiscal Service (COPFS) and stillbirths.

The DCRS normally reviews 12% (though this has fluctuated throughout the pandemic period) of randomly selected MCCDs before registration of death can take place, and carries out further possible reviews, including those referred by families as well as National Records of Scotland and registrars of births, deaths, and marriages where there are concerns that the MCCD is inaccurate or may not have been completed correctly.

As indicated in the DCRS annual report for 2020-2021, the service reviewed 4,427 cases in the 2020/21 period. 4,364 (98.6%) of these were randomised reviews, and 63 (1.4%) were non-randomised reviews.

The DCRS also has a role in providing education, guidance and support to doctors who certify the cause of death, and they liaise with other persons and bodies with a view to improving the accuracy of these certificates.

Additionally noted in the 2020-2021 annual report, the DCRS enquiry line handled 2,677 calls in the 2020/21 period, the majority of which (83.7%) were from doctors seeking clinical advice on how to represent a death on a MCCD. The senior medical reviewer, with input from others, has developed national standards for the operation of the system, supported by quality assurance activities such as audits, case discussions and peer review, to ensure consistency in the processes and minimise unnecessary delays due to the scrutiny. Since the service was established in May 2015, the monthly median percentage of cases ‘not in order’ (i.e. where the certifying doctor has made a clinical or administrative error) has reduced from 44% to 24.4%.

I note that the petition calls for the Certification of Death (Scotland) Act 2011 to be changed to permit an MCCD to be independently reviewed by a medical reviewer from the DCRS, where the case has already been reviewed by the Procurator Fiscal but not by a medical professional expert. In regards to the action called for in this petition, I wish to highlight the following points.

The establishment of the DCRS was not intended to alter the independent role of the Procurator Fiscal in Scotland to investigate deaths or the arrangements for reporting deaths to the Procurator Fiscal.

If the DCRS considers that a case should have been reported to the Procurator Fiscal in the first place, it should be reported by the certifying doctor after discussion between the DCRS medical reviewer and certifying doctor.

In addition, medical reviewers may also report cases to the local Procurators Fiscal if there is a suspicion of criminality in Scotland.

The DCRS is continually involved in supporting the work of the Procurator Fiscal. Subsequent to its inception, the DCRS was requested to use its enquiries line to support doctors in issuing MCCDs after deaths in the community that otherwise would require being seen by a forensic pathologist. This has been particularly successful in that we have been able to reduce the number of such cases being referred for either a ‘view and grant’ or invasive autopsy by over 1,000 per annum.

Furthermore, we are increasingly being tasked by the Scottish Fatalities Investigation Unit (SFIU) to help the certifying doctor structure the content of the MCCD when the cause of death has been agreed between them and the COPFS has invited a certificate.

As set out above, the arrangements currently in place seek to achieve an appropriate separation of the functions of the DCRS and the COPFS, while ensuring that the DCRS is able to contribute to improvement in the quality of death certification in Scotland.

In considering the petition, it will be important to reflect on risks in relation to potentially contradictory conclusions arising from any review process and the impact that would have on public confidence.