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 such that a fee is charged for any functions associated with the new system. No such regulations have been made and no such fee can be charged to the public.
Any applicable fees for the registration of death are unrelated to, and unchanged by, the new 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 section 20 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 license to practise 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 Healthcare Improvement Scotland determine to be an appropriately senior level across the four key areas of: leadership, clinical practice, management and communications.
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
3.3.1 Whilst uncommon, it is not unusual in the UK that a death is registered in one country but the cremation or burial takes place in another country. It is difficult to determine precise numbers of cases, although it is likely to be in the low hundreds every year, where an individual will die in Scotland and be moved, after death, to another part of the UK, or vice versa, for the funeral.
3.3.2 Different legal systems operate across the UK and Scotland has a completely separate death certification and scrutiny process, registration, reporting to Crown Office Procurator Fiscal Service and disposal than currently operates in England and Wales, or in Northern Ireland. There is however 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 or cremation), that death would 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 will have been subject to review (Level 1 or Level 2), or will not have been selected for review. 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 Form 14 is issued by the registrar 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 of Deaths Abroad
3.4.1 Section 17 of the 2011 Act gives medical reviewers the power to check documentation related to deaths abroad where remains are being returned to Scotland for burial or cremation.
3.4.2 Section 25 of the 2011 Act makes it an offence for persons having charge of a cemetery or crematorium 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.
3.4.3 Anyone wishing to arrange the burial or cremation 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 Medical reviewers will check whether the relevant documents are authentic and equivalent to the documentation which would be required to dispose of the body of a person who died in Scotland and, if so, will issue the aforementioned certificate.
3.4.5 Unless requested to do otherwise by the medical reviewer certified copies of the original documents can be provided instead of the original documents. Any copies should be certified by a third party in a professional capacity.
3.4.6 Certified copies must be signed and dated by a person described above and should be a true copy of the original. To certify, the applicant should take the photocopied and original copy of the certificate or document to the person certifying who should write "Certified to be a true copy of the original seen by me", sign and date it, print their name under the signature and add their occupation, address and telephone number.
3.4.7 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 General Practitioner (in another country of the UK) and/or the Foreign and Commonwealth Office or equivalent.
3.4.8 Medical reviewers have the additional function of ensuring that it is safe to cremate the body of anyone who dies overseas and who is to be cremated in Scotland.
3.4.9 The medical reviewer will check medical records for any hazardous implants or a pacemaker that would need to be removed prior to cremation. In carrying out this function, section 14 also gives medical reviewers powers to require documents or require a person (such as a family member or funeral director) to produce relevant documents (including access to health records). The offence provision in section 15 in relation to the provision of such documents applies.
3.4.10 Where it is determined that it is not safe for the deceased to be cremated, 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.
3.4.10 Anyone wishing to arrange the burial or cremation 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 Annex C).
|REPATRIATION OF DEATHS ABROAD (Process 5)|
|Death occurs outside the UK|
|Step 1||Applicant contacts the Medical Reviewers Office about repatriation where the deceased died out with Scotland and is to be disposed of in Scotland.|
|Step 2||Medical Reviewers Office logs the enquiry and provides the Request For Repatriation Form and associated guidance outlining any documents required.|
|Step 3||Form is completed and returned to the Medical Reviewers Office along with all required documents. Medical Reviewers Office checks that all documents have been received and logs the case. The application is passed to Medical Reviewer for consideration|
|Step 4|| Medical Reviewer checks to ensure documentation is in order and is appropriate, specifically: |
|Step 5|| Medical reviewer carries out a level 2 review of the relevant documentation related to the death of the individual who has died abroad. 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 General Practitioner 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.
|Step 6|| Medical reviewer determines documentation is in order and issues disposal certificate. |
Medical reviewer determines documentation not in order. Senior medical reviewer evaluates case. Medical reviewer then acquires any missing documents and makes all reasonable enquiries, including contacting the Foreign and Commonwealth Office if necessary.
|Step 7||If the medical reviewer has evidence of any criminality in Scotland 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 of the deceased the medical reviewer will make a decision as to whether or not it is safe to cremate. The decision will be based on |
|Step 9a|| Medical reviewer determines that it is safe to cremate and issues a certificate under section 18. |
Medical reviewer determines that it is not safe to cremate. If cremation 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
3.4.11 The 2011 Act includes provisions which enable 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 where a cause of death cannot be ascertained despite reasonable attempts to do so.
3.4.12 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 the making of 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.
3.4.13 The 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 UK Foreign and Commonwealth Office. 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: |
|Step 5||If the request is eligible medical reviewer decides whether or not to (a) provide assistance in 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 process repatriation as appropriate. See Process 4|
3.5 Monitoring and Quality Assurance
3.5.1 The new 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.
3.5.3 All formal transactions between the public and the DCRS should be logged. This includes:
- all standard reviews and outcomes
- all requests for review by interested person 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 on 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.
In the case of Advance registration - how many requests were made, reasons given, time taken to complete, number refused and reasons for them with all decisions peer reviewed. In addition, it is important to monitor the number of changes required to be made to the MCCD, the types (minor, major, several minors), how many replacement MCCDs required, and how many should have been and were reported to the PF by the certifying doctors and how many of those required investigation by the PF.
For deaths abroad - the time taken to process, number of times translations required by an external agency and why, number of times post mortems were requested, refused/agreed, and reasons, time taken to receive post-mortem reports and their quality, etc.
For other activities, number of contacts by certifying doctors for advice, contacts by others and the reasons, time taken and outcomes of the contact, etc.
3.5.6 The Quality Assurance of the independent scrutiny system is a matter for the senior medical reviewer and Healthcare Improvement Scotland. 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.
3.5.7 Other particular aspects of the system may benefit from more regular review, such as complaints, random assessment of cases and telephone interactions.
3.5.8 All requests to not stay registration and the medical reviewer decision in each case should be peer reviewed at regular and pre-determined intervals to ensure consistency in approach.
3.5.9 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 will not be altered by the establishment of the new scrutiny system. Deaths which would ordinarily require to be reported to the Procurator Fiscal will continue to be reported as per 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, medicals 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 Procurators Fiscal if there is a suspicion of criminality in Scotland.
Email: Sarah Dillon