Certification of Death (Scotland) Act 2011 Statutory Guidance

Part 3 – Guidance Other

3.1 Fees to the Public

3.1.1 The 2011 Act provides Scottish Ministers with the power to make regulations about the charging of fees in respect of any functions associated with the review system. No such regulations have been made and no such fee can presently be charged to the public. Any applicable fees for the registration of death are unrelated to, and unchanged by, the review system.

3.2 Qualifications, Training and Experience of the Senior Medical Reviewer and Medical Reviewers

3.2.1 The minimum requirement, as set out in schedule 1 of[KM1] the 2011 Act, is that a person appointed as either senior medical reviewer or medical reviewer must be a medical practitioner and must have been so continuously throughout at least five years prior to appointment. For the avoidance of doubt, ‘medical practitioner’ should be taken to mean GMC registered with a licence to practise medicine in the UK.

3.2.2 In addition to this, the senior medical reviewer and medical reviewers should, prior to their appointment, already possess qualifications, training and experience at what HIS determine to be an appropriately senior level across the four key areas of: leadership, clinical practice, management and communication.

3.2.3 The initial appointment process, as well as subsequent continuous professional development linked to appraisal and revalidation arrangements, should seek to ensure that medical reviewers, in particular, have the skills to deal empathetically with the bereaved and to facilitate and foster good relations with the other professionals who support them in their work or are impacted by their work.

3.2.4 Once appointed, it is critical that the work and decisions of medical reviewers are consistent across the country. This should be ensured through use of this guidance and any other applicable guidance; initial and on-going training including regular audits, peer review and case assessment (including telephone interactions); as well as through the leadership of the senior medical reviewer.

3.3 Cross-Border Transfers

Background

3.3.1 There are occasions where a death is registered in one UK country but the burial, cremation or hydrolysis takes place in another UK country.

3.3.2 Different legal systems operate across the UK and it should be noted that Scotland has completely separate processes for death certification and scrutiny, registration, reporting to COPFS and disposal than currently operates in England and Wales, or in Northern Ireland. Other UK nations have robust procedures in place and there is a general principle across the administrations that each country will respect the policy and processes adopted by other countries.

Cross-Border Transfer into Scotland

3.3.4 Where a death is registered in another part of the UK and the deceased is then moved to Scotland for the funeral (including the associated burial, cremation or hydrolysis), that death will already have gone through the requisite review processes that exist in that country, and further review in Scotland will not be required.

Cross-Border Transfer Out Of Scotland

3.3.5 Where a death is registered in Scotland and the deceased is to be moved to another UK country for the funeral, the MCCD may or may not have been selected for and subject to review (Level 1 or Level 2). In either case – whether the MCCD has been subject to review or not – the death will have been subject to the Scottish scrutiny process.

3.3.6 Once registration can proceed - either after a completed review or where the MCCD has not been selected for review – the registrar will complete the registration and issue the Certificate of Registration of Death (Form 14).

3.3.7 Once the Form 14 is issued by the registrar in Scotland, the informant / relatives can make arrangements with the relevant funeral director for the transfer of the deceased to other parts of the UK.

3.4 Guidance on Repatriation of Deaths Abroad and Requests for Post Mortem

Repatriation to Scotland of Deaths Abroad

3.4.1 Section 17 of the 2011 Act places a duty on medical reviewers, when requested, to check documentation related to deaths abroad where remains are being returned to Scotland for burial, cremation or hydrolysis.^[14] Medical reviewers do not check documentation for stillbirth repatriation.

3.4.2 Section 27A of the 1965 Act^[15], makes it an offence for persons having charge of a place of burial, cremation or hydrolysis to dispose of a body without the required documentation; in cases where the death occurred outside the UK, the document required for disposal will be a certificate issued by a medical reviewer.^[16]

3.4.3 Anyone wishing to arrange the burial, cremation or hydrolysis of a body in such a case must apply to the medical reviewer. A medical reviewer must, on the request of a relevant person such as the next of kin or funeral director, determine whether the documentation relating to an individual’s death is in order.

3.4.4 For the documentation to be in order it must appear to the medical reviewer to be authentic and equivalent to the documentation which would be required to dispose of the body of a person who died in Scotland^[17]. If so, the medical reviewer will issue the certificate mentioned at 3.4.2 above.

3.4.5 The medical reviewer will carry out a Level 2 review of the documentation related to the death of the individual who has died abroad. Where the deceased does not have a care record held within Scotland it will not be possible to carry out a Level 2 review. In these circumstances the medical reviewer should contact the deceased's GP (in another country of the UK) and/or the Foreign, Commonwealth & Development Office (FCDO) or equivalent if necessary.

3.4.6 Medical reviewers have the additional function of ensuring that it is safe to cremate or hydrolyse the body of anyone who dies overseas and who is to be cremated or hydrolysed in Scotland. ^[18]

3.4.7 The medical reviewer will check medical records for any hazardous implants, metal or a pacemaker that would need to be removed prior to cremation or hydrolysis. Medical reviewers have powers to require any person who is able (such as a family member or funeral director) to produce relevant documents (including access to health records)^[19]. A person commits an offence under section 15 of the 2011 Act if that person deliberately alters, suppresses, conceals or destroys any document, or refuses or fails to produce any document, which a medical reviewer requests of them. However, it is a defence for a person charged with such an offence to prove that there was a reasonable excuse for the refusal or failure; and a person is not obliged to produce any document which that person would be entitled to refuse to produce in a court in Scotland.

3.4.8 Where it is determined that it is not safe for the deceased to be cremated or hydrolysed, a certificate of disposal specifying burial will be issued. In all cases of repatriation, medical reviewers will check whether the body of the deceased poses a risk to public health and advise any relevant person as necessary.

3.4.9 Anyone wishing to arrange the burial, cremation or hydrolysis of a body in such a case must apply to the medical reviewer using the specified application form and declaration. All fields on the form must be completed for the application to progress. Applications can be submitted by email or post (see Form Y, Annex C).

Repatriation of Deaths Abroad (Process 5)

Death occurs outside the UK

Step 1

Applicant contacts the DCRS about repatriation where the deceased died outwith the United Kingdom and is to be disposed of in Scotland.

Step 2

The DCRS logs the enquiry and provides the Request For Repatriation Form (Form Y) and associated guidance outlining any documents required.

Step 3

Form Y is completed and returned to the DCRS along with all required documents. The DCRS checks that all documents have been received and logs the case. The application is passed to a medical reviewer for consideration

Step 4

Medical reviewer checks to ensure documentation is in order and is appropriate, specifically:

• The person has died outwith the United Kingdom.
• The body is to be disposed of in Scotland.
• Documentation is authentic and equivalent to the documentation required under section 27A of the Registration of Births, Deaths and Marriages (Scotland)

Act 1965 as amended to dispose of the body of a person who has died in Scotland.^[20]

Step 5

Medical reviewer carries out a level 2 review of the relevant documentation related to the death of the individual who has died outwith the United Kingdom. Where there is no care record held for the deceased in Scotland and a level 2 review cannot be carried out, the medical reviewer will contact the deceased’s registered GP or equivalent (where available).

The medical reviewer should identify any hazards which may affect disposal of the deceased e.g. contamination, radioactivity, some infections, etc. (see Step 8 below)

Step 6

Medical reviewer determines documentation is in order and issues disposal certificate (Form X).

or

Medical reviewer determines documentation is not in order. Senior medical reviewer evaluates case. Senior Medical reviewer then acquires any missing documents and makes all reasonable enquiries, including contacting the FCDO if necessary.

Step 7

If the medical reviewer has evidence of any criminality in

Scotland, or someone ordinarily resident whose death was sudden, suspicious or unexplained, or occurred in circumstances giving rise to serious public concern (see the Inquiries into Fatal Accidents and Sudden Deaths etc. (Scotland) Act 2016), then the application must be reported to the Procurator Fiscal. This decision must be authorised by the senior medical reviewer.

Step 8

Where the applicant has requested cremation or hydrolysis of the deceased, the medical reviewer will make a decision whether or not it is safe to cremate or hydrolyse. The decision will be based on

• Whether the body of the deceased poses a risk to public health.
• Is there a cardiac pacemaker or any other potentially explosive device present?
• Is there radioactive material or other hazardous implant present in the deceased?

Step 9a

Medical reviewer determines that it is safe to cremate and issues a certificate under section 18 (Form Z).

or

Medical reviewer determines that it is not safe to cremate or hydrolyse. If cremation or hydrolysis is not authorised the medical reviewer will communicate this, and any reasons for the decision, back to the applicant as soon as that decision is made.

Requests for Post-mortem

3.4.10 The 2011 Act enables medical reviewers to assist in arranging for a post-mortem to be carried out on an individual who has died outside of the UK and is to be disposed of in Scotland and where a cause of death is not available at the time of the request.^[21]

3.4.11 Requests for post-mortem examinations on individuals who meet the criteria set down in section 19(1) of the 2011 Act should be made on the specified form – the Request for Post-Mortem Form (see Annex D). The specified form requires the relevant person to set out (a) the request for assistance in making arrangements for a post-mortem examination and (b) whether or not there is a request for the costs of such an examination to be met by the DCRS.

Process

3.4.12 The 2011 Act allows for relevant persons to make an application to a medical reviewer for assistance in the making of arrangements for a post-mortem examination (although the death will not normally be registered in Scotland unless specifically requested via the FCDO). Such applications must be made to the medical reviewer on the Request for Post-mortem Form. These principles can be summarised in the following process:

Request For Post-Mortem on Death Outside UK (Process 5)

Death occurs outside the UK

Step 1

Relevant person contacts DCRS about assistance in seeking a post-mortem examination.

Step 2

DCRS logs the enquiry and provides the Request For Post-mortem Form and associated guidance.

Step 3

Form is completed and returned to DCRS. Return of completed form is logged and form is passed to medical reviewer for consideration.

Step 4

Medical reviewer checks to ensure request is appropriate and eligible, specifically:

• The person has died out with the United Kingdom;
• The body is to be disposed of in Scotland; and
• No cause of death is available.

Step 5

If the request is eligible, the medical reviewer decides whether or not to (a) provide assistance in making arrangements for a post-mortem; and (b) to provide financial assistance to meet the costs of the post-mortem, if such assistance is requested.

Step 6

The decision of the medical reviewer is logged by the DCRS and communicated back to the relevant person.

Step 7

DCRS makes arrangements for a post-mortem to be undertaken, liaising with the relevant person (including consent to receive a copy of the post-mortem report) and the funeral director as necessary.

Step 8

DCRS receive a copy of the post-mortem and processes the repatriation as appropriate.

3.5 Monitoring and Quality Assurance

3.5.1 The independent scrutiny system of MCCDs in Scotland is intended to improve the quality of MCCDs. It is important that the scrutiny system itself is quality assured on an on-going basis and that any training or development needs, or any necessary system developments, are identified. This is a role for the senior medical reviewer.

3.5.2 This guidance sets out general principles for monitoring and quality assurance. This will be supplemented by national standards, operational guidance and standard operating procedures developed by the senior medical reviewer.

Monitoring

3.5.3 All formal transactions between the public and DCRS should be logged. This includes:

• all standard reviews and outcomes
• all requests for review by interested persons and outcomes
• all requests to not stay registration (advance registration) and outcomes
• all repatriations of deaths abroad and outcomes
• all requests for assistance in carrying out a post mortem examination and outcomes
• all enquiries, comments, compliments, complaints and outcomes

3.5.4 The details of all cases that are selected for review must be recorded for monitoring purposes by the DCRS. Data should be collected and stored in such a way that supports regular audit of practice. Data collection on standard review cases should capture data in areas such as:

• type of review (Level 1 or Level 2)
• registrar’s office where death is registered
• key metrics of timescales of the review from selection to registration of death
• number of MCCDs which were altered and the types of alterations e.g. personal data incorrect/missing; incorrect/questionable underlying cause of death; illogical sequence of other conditions; incomplete/illegible MCCDs; location and times of death; the types of certifying doctors, others.
• the number of replacement MCCDs requested

3.5.5 In the case of reviews requested by an interested person, the monitoring information should record:

• the classification under which the applicant made the request and
• the reason for the request.

3.5.6 In the case of advance registration requests, monitoring information should record:

• the number of requests made
• the reasons given
• the time taken to complete
• the number refused and the reasons for them with all decisions to be peer reviewed.

In addition, it is important to monitor the number of changes required to be made to the MCCD, the types of changes made (minor, major, several minors), how many replacement MCCDs were required, and how many should have been and were reported to the Procurator Fiscal by the certifying doctors as well as how many of those required investigation by the Procurator Fiscal.

3.5.7 For deaths abroad, the monitoring information should record:

• the time taken to process requests
• the number of times translations were required by an external agency and the reasons for that
• the number of times post mortems were requested, refused/agreed, and the reasons for these outcomes
• the time taken to receive post-mortem reports and their quality, etc.

3.5.8. For other activities, the monitoring information should record the number of contacts by certifying doctors for advice, contacts by others and the reasons for that as well as the time taken and outcomes of the contact, etc.

Quality Assurance

3.5.9 The quality assurance of the independent scrutiny system is a matter for the senior medical reviewer and HIS. At a minimum, the Scottish Government expects that the senior medical reviewer will undertake reviews of all key monitoring information at least quarterly to ensure the review system is operating effectively and efficiently, and to identify any development needs.

3.5.10 Other particular aspects of the system may benefit from more regular review, such as complaints, random assessment of cases and telephone interactions.

3.5.11 All requests to not delay registration and the medical reviewer decision in each case should be peer reviewed at regular and pre-determined intervals to ensure consistency in approach.

Annual Report

3.5.12 Under section 23 of the 2011 Act the senior medical reviewer has a responsibility to produce to Scottish Ministers, and publish, an annual report for each financial year on the activities of the medical reviewers. This report should include at a minimum a high-level summary of key monitoring information, an analysis of any trends or issues identified and actions taken, and proposals with action plans for the improvement and developments in the service for the coming year.

3.6 Role of the Procurator Fiscal

3.6.1 The independent role of the Procurator Fiscal in Scotland to investigate deaths is not altered by the DCRS scrutiny system. Deaths which would ordinarily require to be reported to the Procurator Fiscal continue to be reported as usual.

3.6.2 In any instance where a case is reviewed by the medical reviewer or senior medical reviewer and it is considered the death should have been reported to the Procurator Fiscal in the first place, it should be reported to the Procurator Fiscal by the certifying doctor, after discussion between the medical reviewer and certifying doctor.

3.6.3 In addition, medical reviewers may provide advice to certifying doctors on whether a specific case should be reported to the Procurator Fiscal and may also report cases to the local Procurator Fiscal if there is a suspicion of criminality arising from the review of a MCCD in Scotland.