1. Quality Education for a Healthier Scotland Death Certification is Changing Information for Doctors in Training March 2015

2. Quality Education for a Healthier Scotland WHEN is it changing? The Certification of Death (Scotland)Act 2011 will introduce a number of changes to the current system from: MAY 2015 WEDNESDAY 13th

3. Quality Education for a Healthier Scotland WHAT is changing? A new Scottish review system to provide independent checks on the quality and accuracy of MCCDs. An end to additional paperwork and fees for cremations to make the process the same for everyone. A requirement that all deaths must be registered before either a burial or cremation can take place.

4. Quality Education for a Healthier Scotland WHY is it changing? As part of recommendations arising from the Sheriff Brodie Burial and Cremations Review Group, the aims of the new system are to: Improve the quality and accuracy of MCCDs. Provide improved public health information about causes of death in Scotland. Ensure that the processes around death certification are robust and have appropriate safeguards in place.

5. Quality Education for a Healthier Scotland HOW will the review system be managed? The review system will be undertaken by the Death Certification Review Service (DCRS) under the auspices of Healthcare Improvement Scotland. The Service is led by a senior medical reviewer (SMR) working with a team of medical reviewers (MR), and supported by medical reviewer assistants (MRA).

6. Quality Education for a Healthier Scotland What FORMAT will the reviews take? : Level1 For Level 1 reviews the MR will check the MCCD and speak to the certifying doctor. Reviews are to be completed within one working day. Reviews will apply to a random sample of 10% of all deaths that are not reportable to the Procurator Fiscal. (Stillbirths are also excluded from the review process).

7. Quality Education for a Healthier Scotland What FORMAT will the reviews take?: Level2 For Level 2 reviews the MR will speak to the certifying doctor, AND check relevant clinical records, and may speak to the family or carer of the deceased. Level 2 reviews are to be completed within three working days and will apply to a minimum of 1,000 deaths per year. Level 2 reviews will be randomly selected, but will ALSO be applied where a Level 1 review reveals problems with the MCCD.

8. Quality Education for a Healthier Scotland The review is of the MCCD The review is of the content of the MCCD only It is not reviewing the patient care during the final care episode. (If there are concerns about the care provided these should be raised with a senior colleague)

9. Quality Education for a Healthier Scotland HOW are MCCDs SELECTED? National Records of Scotland (NRS) will use computer software to randomly select MCCDs to be reviewed by the Death Certification Review Service. Contingency plans will also be in place for IT failures and manual registry offices. A level 1 review can also be escalated to a level 2 review if the level 1 reveals any issues with the MCCD. In addition, MCCDs can be selected as part of a targeted review, e.g. to look at the trends of a particular condition causing deaths.

10. Quality Education for a Healthier Scotland The ADVANCE REGISTRATION Procedure Where the MCCD is selected for review, the MR can consider applications for advance registration in special circumstances, for example: Religious or cultural reasons Compassionate reasons Administrative or practical reasons The registration can go ahead if the MR decides the reason for application is valid and that the MCCD appears to be in order. In practice this means that the funeral can proceed while the Level 1 or Level 2 review continues in the background.

11. Quality Education for a Healthier Scotland What does this mean FOR ME? 1] Before certifying: check if & what to certify Think if you should be doing this -wherever possible MCCDs should be completed by a member of the team that knew the deceased i.e. not the out of hours team (unless the patient was just cared for by them). Check you know what to put – use the LearnPro module. You must discuss the cause of death with the senior doctor responsible for the case before completion of the MCCD and record this discussion in the clinical record.

12. Quality Education for a Healthier Scotland What does this mean FOR ME? 2] When certifying: things to note An illegible paper MCCD cannot be accepted by the Registrar of Births, Deaths, and Marriages and will lead to a postponement in registration and possible delay of the funeral An incorrect cause of death or sequence on the MCCD could trigger an escalated level 2 review. Please record the time sequence in PART C of the MCCD – do not tick the boxes You must discuss the case with the senior doctor responsible for the case prior to reporting a death to the Procurator Fiscal

13. Quality Education for a Healthier Scotland What does this mean FOR ME? 3] After certifying: necessary communication As the certifying doctor you are expected to explain to families and carers: the content of the MCCD (in line with the 2014 Vale of Leven Hospital Inquiry Report recommendations) to those who wish this. that the certificate may be selected for review (where the death does not involve a stillbirth or is reportable to the Procurator Fiscal). that applications for advance registration may be considered in special circumstances.

14. Quality Education for a Healthier Scotland What does this mean FOR ME? 4] After certifying: fulfilling the legal process For any selected MCCD, as the certifying doctor you are expected to communicate with the MR: ensure you can receive and respond promptly to calls from the MR to discuss a selected case. ensure, if you are going to be unavailable, that an appropriate alternative member of the clinical team is available and has the information to speak to the MR.

15. Quality Education for a Healthier Scotland Practical points to note NHS Boards will use the paper version of the MCCD prior to the introduction of the electronic MCCD in their area. The paper MCCD is double sided – take care if faxing. The paper MCCD will continue for use in home visits and as a back up facility in case of IT failures.

16. Quality Education for a Healthier Scotland Correction of minor errors on MCCDs The DCRS or the Registrar of Births, Deaths, and Marriages will request amendments to the existing MCCD document for any minor errors, for example: Wrong date of birth Use of abbreviations (with the exception of HIV and AIDS) or symbols Minor errors highlighted by the MR or Registrar will be rectified verbally and then confirmed by e-mail.

17. Quality Education for a Healthier Scotland Replacement MCCDs You will be asked by the review service to issue a replacement MCCDs with a new serial number if there is a major error on the MCCD, for example: An incorrect or missing cause of death An incorrect sequence of causes of death No signature present

18. Quality Education for a Healthier Scotland Summary Certificates for review are selected randomly. The LearnPro (or AT-Learning) module provides information on how to certify. Completion should be by the team normally looking after the case. The cause of death should be agreed with the Consultant/ Senior doctor in charge of the case, as should the referral and any information to be given to the Fiscal. The certifying doctor is expected to explain a) the possible selection for review to families or carers and b) the cause of the MCCD to those who wish this information. The certifying doctor must be available or ensure others who will know the case are available to take the call from the MR should their case be selected for review.

19. Quality Education for a Healthier Scotland Further Information and resources 1) LearnPro (or AT-Learning) module 2) Website www.sad.uk.net (from April / May 2015)www.sad.uk.net 3) Scottish Government (2014) Guidance for Doctors Completing Medical Certificates of the Cause of Death (MCCD) and its Quality Assurance http://www.sehd.scot.nhs.uk/cmo/CMO(2014)27.pdf 4) Breaking bad news video clip http://hospicefoundation.ie/education- training/video-wall/communication/

20. Quality Education for a Healthier Scotland Enquiries about training to NHS Education for Scotland: supportarounddeath@nes.scot.nhs.uk