Select Committee on Health Second Report

9  Certification of death in care homes and in the domiciliary environment

173. About 92,000 (17%) of all deaths a year in England and Wales occur in registered care homes; approximately 38,000 in care homes and 54,000 in care homes registered for nursing care.[133] The majority of these relate to older people, although deaths do occur in care homes accommodating younger people. We wanted to know more about the certification processes and the extent to which an independent review of the cause of death was undertaken. We wanted to be clear that the process would, so far as possible, alert authorities to any evidence of abuse.

Care homes

174. All deaths of care home residents in England, including those that occur during a stay in hospital are required, by law, to be notified to the NCSC. This information must include the circumstances of the death. Compliance with the coroner's rules applies. No report has been published by the Commission to indicate the purposes to which these notifications are put, but potentially they serve to indicate trends in numbers or types of death and areas of concern in relation to care issues within a home. We therefore asked Anne Parker, the Chair of NCSC, about these matters. She told us that the notifications formed part of a database that provided information for the next inspection visit.[134]

175. We asked Frank Ursell for the Registered Nursing Home Association, and Nadra Ahmed, Chair of the National Care Homes Association, about local procedures. Both expressed concern about the continuing debate over the role of general practitioners in certifying death. They noted that the British Medical Association had produced a comprehensive set of notes indicating that GPs had no responsibility to certify death in care homes at all, and felt that this was unhelpful.[135] We accept the point also made by Mr Ursell that the GP going to a care home, at any time of day or night, in order to certify a death is in a position to observe anything that might be untoward, whereas if certification is left until much later that evidence might be lost. In relation to the changes to the primary care contracts from April 2004, these witnesses envisaged that many GPs would opt out of this cover, leaving a void for primary care trusts to fill.[136]

176. The Minister himself acknowledged that he was surprised and concerned to discover that the guidance indicated that if a person had been treated by a GP and they believed that the patient might have died from the illness for which they were treating them, there was no requirement for the GP even to look at the body.[137]

177. We note that this matter has been considered and addressed by Home Office in a recent review.[138] That review acknowledged that some doctors were reluctant to provide confirmation of death before the body could be removed from the home, both in- and out-of-hours. We are aware that in cases of expected death in a care home, it is not uncommon for there to be agreement — perhaps informal — that confirmation of the fact of death might be made by a first level nurse, allowing the body to be removed to an undertaker, and for death certification to be given by the doctor subsequently.

178. The Fundamental Review recommended that suitably qualified and trained personnel other than doctors, but including fully qualified nurses, should be able to confirm the fact of death in some cases, for example traumatic deaths in traffic accidents. The review concluded that even though fully qualified nurses were required to be employed in care homes providing nursing, they should not be able formally to confirm the death of a resident. It continued:

    We think it very important that the body should be seen and the death verified by a suitable professional person independent of the care home in which the death has occurred. This is consistent with much comment we have had, including from professional nursing interests.[139]

179. We concur with these views and the resulting recommendations, but draw the attention of the Government to the need to ensure that, if passed into law, the resulting arrangement will be monitored by the primary care trusts and relevant licensing bodies to ensure that care home managers can rely on the arrangements in raising standards of protection.

180. The Fundamental Review recommended that deaths in care homes should be:

    verified as promptly as is practicable by the general practitioner or emergency service doctor; under the new proposed contractual arrangements for primary healthcare, primary care trusts should arrange for suitably qualified and trained nurses independent of the home to attend to verify death. This may be particularly desirable in areas with high concentrations of care homes but would be advantageous more widely.

181. We recommend that in any code of practice based on the Fundamental Review, the limits of "as promptly as is practicable" should be defined.

182. We also support the recommendations of the Review, (i) that statutory medical assessors should identify, support and monitor care home death certification by first and second certifiers as a distinct sub-group of certification by doctors and practice; and (ii) that there should be regular exchanges between the NCSC/CSCI offices in each local area and their coroner and statutory medical assessor counterparts: to exchange information, to arrange, where appropriate, joint investigations and to identify any practical problems over verification and certification of care home deaths and draw them to the attention of PCTs and others as appropriate.

183. We support further recommendations of the Fundamental Review: that the NCSC, followed by CSCI, should be able to raise any anxieties about an individual death with the coroner; that these organisations should be given on a confidential basis any information from individual death investigations that would be relevant to their inspectorial and regulatory functions; and that they should have reciprocal arrangements with the coroner and the statutory medical assessor, and for their part should make available to the relevant material from their inspections and regulatory work.

The hospital and domiciliary environment

184. If a death occurs in hospital it will usually be a member of the medical team responsible for the deceased's care prior to death who will certify death. The Births and Deaths Registration Act 1953 imposes on the doctor who last attended the deceased a duty to issue a medical certification of the cause of death, whether or not the cause can be identified. In practice doctors issue a certification only if they can identify the cause of death with sufficient confidence. If they cannot, they report the death to the coroner. Doctors now regard it as a professional duty to report a death to the coroner if they are sufficiently uncertain of the cause of death or are aware of other reasons why the death should be reported.[140]

185. The case of Dr Harold Shipman highlighted the potential for abuse of the system of certification. Dr Shipman was able to perpetrate the murder of a large number of (generally older) patients and subsequently certify their deaths, thereby concealing the true cause of death. Inadequate checks within the system enabled Dr Shipman to continue this practice for many years before his eventual discovery. The inquiry, conducted by Dame Janet Smith, into the circumstances of the deaths at the hand of Dr Shipman identified a weakness in the system of death certification and registration. The present system has three main purposes: to provide an accurate record of deaths for administrative purposes; to identify, as accurately as practicable, the cause of each death; and to provide a safeguard against the concealment of homicide and neglect leading to death. Dame Janet concluded that the system, in the case of Dr Shipman, had failed on the third purpose, in that it did not deter him from killing his patients, nor detect that he had done so.[141]

186. There are possible conflicts of interest when a GP owns and runs a care home. If the GP has the authority to sign a medical certification of the cause of death, and is the perpetrator of abuse that resulted in the death of an older person in their care, the opportunity to hide the true cause of death is increased. We recommend that stricter controls be implemented to ensure that certification of the death of a resident in a residential or care home owned or managed by a GP, or a close relative, should be performed by a GP other than the owner/manager.

187. Another area of concern is the use of retaining fees by care homes for GPs. Such fees are paid so that residential homes are assured of a service by the local GP. We recommend that the practice of the payment of retainer fees is abolished, as every patient registered with the GP should have a right to a service from the GP without the payment of additional retainer fees.

133   Home Department, Death certification and Investigation in England, Wales and Northern Ireland: The Report of a Fundamental Review 2003, Cm 5831, June 2003, p 131 Back

134   Q 144 Back

135   Q 59 Back

136   Q 62 Back

137   Q 199 Back

138   Home Department, Death certification and Investigation in England, Wales and Northern Ireland: The Report of a Fundamental Review 2003, CM 5831, June 2003 Back

139   Ibid, p 132 Back

140   The Shipman Inquiry, Third Report, Death Certification and the Reporting of Deaths by Coroners, Cm 5854, July 2003, p 113 Back

141   Ibid pp 116-17 Back

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