A guide to the new medical examiner system

With the new medical examiner system starting next week, Dr Grant Ingrams explains what this means for GPs and how they can prepare

From 9 September the processes to be followed after death of a patient are undergoing the greatest shake up since the Births and Deaths Registration Act 1953 – including the introduction of the medical examiner service.

The role of medical examiners is to provide independent scrutiny of the cause of death and an opportunity for the bereaved to speak about care and treatment in the lead-up to a death. The changes are designed to give assurance to relatives and reduce the risk of NHS scandals or malicious action by medical practitioners. Whether they will achieve this is yet to be seen.

The main changes that will affect GPs are: 

• The loss of the cremation form;
• A new version of the Medical Certificate of Cause of Death;
• The requirement to send the completed MCCD to a Medical Examiner.

Completing the new medical certificate

To complete the new Attending Practitioner Medical Certificate of Cause of Death (APMCCD) you will need to: have ‘attended’ the deceased sometime prior to the death (not necessarily during the last illness); know ‘to the best of your knowledge and belief’ the cause of death; and know there is no requirement to report the death to the coroner. There is no longer any requirement for the certifying GP to have seen the deceased within 28 days prior to death, after death, or even face to face/in person at any time prior to death.

There is no clear legal definition of ‘attended.’ But it could include if you had talked to the patient or liaised with a relative or specialist palliative care team – even if you had not seen the patient in person.

These flexibilities will help if urgent certification for same day burial for faith/cultural reasons is needed, but all areas should also have developed a ‘fast track’ ME process for the same reason.

The APMCCD includes the following changes:

• Details of the ME who scrutinised the death;
• Ethnicity, as self-declared by the deceased during their life (or otherwise mark as ‘unknown’). Relatives or other representatives of the deceased should NOT be asked for this;
• If the deceased was pregnant;
• An additional line (1d) for cause of death;
• Record of medical devices and implants;
• The question ‘last seen alive by me’ has been removed.

Differences between the APMCCD and the cremation form 

There is an anomaly with the revised APMCCD as it asks: ‘Did the deceased have any implantable medical fitted devices during their lifetime’; whereas the cremation form asks whether there was any ‘hazardous’ implants. National draft guidance makes reference to ‘relevant’ implants and I would suggest limiting it to the implants listed in ‘The Cremation (England and Wales) Regulations 2008 Guidance to medical practitioners completing form Cremation 4’:

• Pacemakers 
• Implantable Cardioverter Defibrillators (ICDs) 
• Cardiac resynchronization therapy devices (CRTDs) 
• Implantable loop recorders 
• Ventricular assist devices (VADs): Left ventricular assist devices (LVADs), Right ventricular assist devices (RVADs), or Biventricular assist devices BiVADs) 
• Implantable drug pumps including intrathecal pumps 
• Neurostimulators (including for pain & Functional Electrical Stimulation) Bone growth stimulators
• Hydrocephalus programmable shunts 
• Fixion nails 
• Any other battery powered or pressurised implant 
• Radioactive implants 
• Radiopharmaceutical treatment (via injection)

Sending the APMCCD to the medical examiner

From 00.01am on 9 September 2024, all deaths must be certified using the new APMCCD – even if the death occurred before then. Once completed, the GP must send the APMCCD to the medical examiner service, together with a brief summary of the events leading to the death and any other relevant information.

Referring to the coroner

One of the proposed benefits of the new process is a reduction in the number of deaths referred to the coroner. If a death was natural and you are unsure of the cause rather than refer to the coroner, discuss it with a medical examiner first. Appendix 1 below shows a list of circumstances in which there is a duty to inform the coroner of death.

The regulations give medical examiners two choices: either to accept the cause of death on the APMCCD; or to refer the death to the coroner. In practice, it is likely that if the medical examiner feels that the cause of death is inappropriate or wrong that they will discuss it with the certifying GP and request that they issue a replacement.

To make sure practices are ready for 9 September, they should accustom themselves to their local process to refer to the medical examiner process, make sure they have received a book of the new APMCCDs, and familiarise yourself with them.

Dr Grant Ingrams is Managing Partner of a practice in Glenfield, and Executive Chair of LLR LMC