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
