╨╧рб▒с>■  ;=■   :                                                                                                                                                                                                                                                                                                                                                                                                                                                ье┴[@ Ё┐и(bjbj44 4:ViVi·н      ИЎЎЎЎЎЎЎ ю ю ю 8& $J  ▀Br r r r r M M M ^``````$!Rs8ДЎЖ M M Ж Ж ДЎЎr r █ЩFFFЖ jЎr Ўr ^FЖ ^FFXОЎЎ┌r f а·Vе╒╟ю Ё dжJп0▀о,лTЪл┌  ЎЎЎЎлЎ┌pM >Л ,F╖ $█ лM M M ДД  фю юX  ю This important document was published on 24th July and calls for comments with a deadline for submissions at the end of October. It comes as part of the governmentТs response to Dame Janet SmithТs Inquiry into the criminal activities of the late Dr Harold Shipman. It is unusual for a Department of Health (DH) document in that it is ascribed to a named author and is written relatively well despite the Уissues aroundФ the inevitable influence of the DH house style. A Bill concerning death certification will be placed before Parliament in November and these proposals will be included in it. Other proposals will include the appointment of a Chief Coroner and a Coronial Advisory Council. National standards and training will be set for Coroners who will be more likely to be full-time in future and who will be placed in the local government structure. It will also be made the legal responsibility for the doctor completing a death certificate to report a death to the coroner under the same list of circumstances as at present. The document accepts that this is what happens in practice now but at present the de jure responsibility actually lies with the Registrar. The documents points out that, at present, it costs bereaved relatives г148.50 more in extra fees to cremate a body than to bury it. Seventy percent of all funerals are now cremations. Some religions require cremation and so their adherents have no choice but to pay the extra fees which is inequitable. It is also argued that the present arrangements mean that there are unequal safeguards in the process leading to permission to cremate compared with those leading to a burial. In the former three doctors are involved compared with only the one required to complete a death certificate for a burial. It is also argued, however, that the extra safeguards involved in the cremation certification process are unaudited and unreliable. Nevertheless it is also alleged that relatives planning a burial require better assurance that all the circumstances surrounding the death of their loved one were as they should be and so the proposed changes to the system are long overdue. With 500 000 deaths registered annually in the United Kingdom, this reviewer wonders how many families will really benefit from change. The crucial background is that one of Dame JanetТs key recommendations was that all deaths should be reported to the Coroner. This uncompromising recommendation was made more than three years ago. The reviewer believes that the government, in its response, was for once rightly concerned that such a move could cause unnecessary delay in arranging funerals and distress to relatives for little or no gain to the administration of justice. It is also aware that for some religions prompt burial, like cremation for others, is a crucial part of adherence to tradition. It is proposed that in future any death that would not normally be reported to the Coroner, as now, will be reported to a Medical Examiner (ME) by the doctor responsible for the patientТs care who will complete a death certificate. There are no changes proposed to the present certificate and, interestingly, the document specifically rejects the inclusion of data concerning ethnicity, so beloved by the DH in other fields. The ME will be a medical practitioner УattachedФ to the PCT clinical governance team and be of at least five yearsТ standing and who has undergone specialist training of three daysТ duration, revised every two years. The ME will be assisted by a ME Support Officer who will be responsible for collating information for the ME to Уinvestigate as necessaryФ the death. This will include speaking to the doctor who wrote the death certificate and other clinicians involved, reviewing medical records and speaking to relatives where required. All this will be done speedily and, when the ME is satisfied, he or she will be able to authorise burial or cremation which may then take place before registration of the death. If the ME is unsatisfied he will be responsible for reporting the case to the Coroner with a recommendation whether or not a post mortem examination would be helpful. The Registrar will also retain the duty to report to the Coroner. Because of the close working relationship with the Coroner that will be necessary for the process to work smoothly it is suggested that MEТs might be co-located with Coroners. Interestingly, however the proposals stop short of suggesting an integrated system which would be more in the spirit of Dame JanetТs draconian recommendation but rather that there be a separate service set up to provide independent medical advice to Coroners. There are quite detailed assessments of the initial impact of these changes and, rather touchingly, they are naively estimated to be cost neutral. This is because funding will come from those paying for funerals. It is estimated that г42m is raised annually from cremation fees in England and this will fund the service. The current cremation form system will be replaced with lower fee (sic) that will be added to the cost of all funerals. In other words, it is claimed that a cremation will cost less than now but a burial will cost more because the new fee will be payable. The proposals, subject to Parliamentary approval of primary legislation will come into force in 2010. The questions for which answers are requested are as follows: To avoid unnecessary delays, and upon receipt of authorisation from the ME, would it be desirable to allow the deceased to be buried or cremated before the death is registered (as is the case now when the Coroner issues a cremation certificate or burial order)? The reviewer recommends that the answer be УyesФ not least to mitigate the effects of delay that this new system seems likely to add, especially when it is newly introduced. In order to attract medical practitioners with the right level of expertise and experience, and also to maximise flexibility of the service to minimise any delays to funeral arrangements, would it be desirable to appoint MEs on a part-time basis? It would appear to be contrary to a policy of equal opportunities in employment to recommend anything else. The reviewer is seriously considering applying to be a part-time ME and a part-time GMC Affiliate under the new revalidation and recertification arrangements. Would it be beneficial to co-locate MEs with Coroners where this was agreed locally? If so, what would be the specific benefits? Please see above where Dame Janet SmithТs recommendation that all deaths be reported to the Coroner is discussed. Would it really be beneficial to have another service offering independent medical advice to CoronerТs when local MEs could provide it? Are we really to believe that Уlocal agreementФ will play any part in nationally directed legal requirements? Would it be appropriate and practical to have a professional line of accountability between the National Medical Advisor to the Chief Coroner and MEs? What do you consider to be the advantages and disadvantages of this proposal? As far as this rather opaque question goes, it seems that it may in fact be hinting at exactly the point made above i.e. having a single ME service rather than two. To ask the question, УQuis custodiet ipsos custodes?Ф may be going too far even for this government in this context. After all, not even Inspector Morse had to solve a murder where the Coroner did it. Would it be appropriate for MEs to be contacted to provide medical advice to CoronerТs in certain cases? See 3 & 4. Are there circumstances where deaths are discussed with the Coroner unnecessarily and should, in the future, more appropriately be discussed with an ME? Is a qualifying period necessary to achieve the desired aim of ensuring the Coroner investigates appropriate cases? The obvious answer here concerns the 14 day rule, where the doctor completing the death certificate has not seen the deceased but where the patient was looked after by another practitioner, perhaps absent on leave at the time of death, or by other members of the health care team, for example district nurses or nursing home staff.     Consultation on Improving the Process of Death Certification A Long Expected Document...or a Solution in search of a problem? Farewell to Ash Cash. +-D O S . 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