Agenda item

            The Committee considered the undernoted report:

 

“1.0Relevant Background Information

 

1.1The purpose of this report is to inform Members that the Department of Health, Social Services and Public Safety (DHSSPNI) has commissioned a consultation exercise on a review of the current arrangements for death certification in Northern Ireland.

 

1.2Appended to the report is the draft written response which is submitted for review and comment by Members.  The deadline for submitting the response to the Department is 11 March 2011.

 

1.3Current arrangements for death certification in Northern Ireland are being reviewed which is the first time since 1976 that a review has been undertaken.

 

1.4The review follows changes in England, Scotland and Wales in the wake of the Shipman Inquiry and the Luce Review.

 

1.5Both Shipman and Luce recommended the introduction of a single system for death certification, regardless of whether the deceased was to be buried or cremated.  They also found that the scrutiny of medical certificates for cause of death fell short of what is required to provide adequate protection for patients.

 

1.6Significant developments have taken place in England and Wales to implement the Shipman and Luce recommendations in respect of death certification processes and the Scottish Government has recently consulted on proposals to strengthen arrangements for death certification in Scotland.

 

1.7It is important therefore that current practice in respect of certifying deaths in Northern Ireland be reviewed in light of these developments to ensure that it remains fit for purpose.

 

1.8Registration of death here is governed by the Births and Deaths Registration (N.I.) Order 1976, but the process of registration itself has changed little since 1927.  A death should normally be registered within five days, to allow funeral arrangements to be made.  This is with the exception of deaths which have been reported to the coroner.

 

1.9Registrars are based in district council offices, and each death is registered with the district in which the person died, or in the district in which the person normally lived, if this is within Northern Ireland.  A  Medical Certificate of Cause of Death (MCCD), signed by a registered medical practitioner, must be provided to enable the death to be registered.

 

1.10   Under current arrangements in Northern Ireland, differing levels of scrutiny apply depending on whether the body of a deceased person is to be cremated or buried.

 

1.11   In the case of a cremation, the certificates are then submitted to the medical referee appointed by Belfast City Council, who is required to satisfy him/herself that the certificates and all other necessary documents are in order before issuing an authority for the cremation to take place.

 

1.12   This second level of scrutiny does not apply in the case of a burial, where there is no opportunity for further challenge to the cause of death.  The current arrangements mean in effect that there is disparity in the level of scrutiny applied to certification of deaths, depending upon the method of disposal.

 

1.13   For the majority of deaths in Northern Ireland burial is the preferred method of disposal, and therefore no further scrutiny takes place after the initial completion of the MCCD, unless the death is referred to the Coroners Service.

 

2.0Key Issues

 

2.1The government’s response to the Shipman Inquiry in 2007 included the publication of a consultation document on Improving the Process of Death Certification, which outlined a programme of work to design, pilot and implement a rigorous and unified system of death certification for both burials and cremations in England and Wales.

 

2.2Both Shipman and Luce concluded that it is unacceptable to have different certification processes according to whether the deceased was to be buried or cremated, and recommended the introduction of a single system for death certification.

 

2.3This consultation sets out recommendations made by an Inter-Departmental Death Certification Working Group for Northern Ireland which was established in November 2008 to review local death certification processes, and to make recommendations for improvement. 

 

2.4The consultation document is 33 pages and poses 17 specific questions (copies of which can be provided to Members on request).  It proposes 2 options neither of which propose that the current requirement in the cremation process for deaths to be registered before disposal be extended to all deaths:

 

      Option 1: The first option would see an enhancement of the existing assurance arrangements for death certification, with a view to strengthening and improving the current processes.

 

      Option 2: Includes the suggestions in option 1 along with the introduction of a new post of Medical Examiner (along with necessary support staff), with appropriate accompanying accountability and governance structures, with a view to strengthening existing assurance and clinical governance arrangements.

 

2.5The Council’s response focuses in the main on potential impact on future service delivery and the need for sustained public confidence in death certification.  An officer group of bereavement service and administrative staff and including the medical referee met to review the document and develop the draft response.  The consensus was that:

 

§         The options provided did not have sufficient detail to make an informed decision or sufficiently connected key recommendations included in the report which were emerging in England, Wales, and Scotland or referred to in any of the inquiry reports.

§         There were discrepancies in how the information was presented in the main and summary documents.

§         Officers also believed there was opportunity to share learning on the council’s provision to inform the options that were presented.

 

2.6For these reasons there is no preferred option being confirmed in the draft response which does take the opportunity to highlight the council’s interest from a service-delivery perspective, for example:

 

      Time period for disposal - It is clearly presented in the council response that there should be no unnecessary delay caused from registration of death to disposal where possible.

 

      Cost - general costs were provided in the consultation however it was difficult with the information available to fully appreciate whether or not they were value for money.

 

      Public confidence - one of the drivers for change noted in the death certification review is to ensure another ‘Shipman’ situation does not take place. The method and level of scrutiny required to retain public confidence needs confirmed more clearly to enable it to ensure the process is fit for purpose.  What is being proposed in both options provides retrospective scrutiny of patterns and trends experienced in the process of death certification; it is more likely to identify potential cases however not prevent them.

 

2.8The complete and more detailed response is attached at Appendix 3 for Member review and feedback.

 

3.0    Resource Implications

 

     None.

 

4.0Equality and Good Relations Implications

 

4.1The draft response makes reference to the need for the council to be able to manage requests for disposal of the dead within 24 hours – including the required levels of sign-off (scrutiny) - as this is preferred by some cultures now resident in Northern Ireland.

 

5.0Recommendations

 

5.1Members are asked to:

 

(i)    note the content of the report

(ii)   review and approve the draft response subject to any amendments or comments they may wish to provide.

 

BelfastCity Council response to:

The review of death certification in Northern Ireland

 

      Death certification impacts each citizen at some point in their lives and BelfastCity council is a key agent in providing for the disposal of dead through both burial and cremation. The council is currently the only provider of Cremation services in Northern Ireland.

 

      The council welcomes the opportunity as a key service provider to be consulted on the review of death certification in order to preserve and improve the quality of its bereavement service. It considers that it is timely for a comprehensive review of requirements to ensure effective future service delivery.

 

The Council’s Bereavement services

 

      The Council provides both burial and cremation services to the citizens of Belfast and the wider region, governed by Statutory Legislation i.e. the Burial Ground Regulations (Northern Ireland) 1992 for burials and Statutory Rules and Orders (N.I.) 1961 No. 61 Cremation, Northern Ireland for cremations.

 

·         The Council is currently responsible for eight Cemeteries.  Some of these Cemeteries were inherited from churches. The first Council owned Cemetery was BelfastCity Cemetery which was opened for burial in 1869, followed by Glenalina Extension in 1915, DundonaldCemetery in 1905 and RoselawnCemetery in 1954.

 

·         The City of Belfast Crematorium commenced operation in 1961.

 

·         The Cemeteries/Crematorium Central Office in BelfastCity Hall is responsible for overseeing all administrative processes for burials and cremations.  This is managed centrally but is operated in conjunction with the Cemetery Site Offices and the Crematorium Office.

 

·         The medical referee role – a requirement under the provisions of the Cremation (NI) Order 1961 – is an intrinsic element of the service and necessary for the Council (as the Cremation Authority). For over 25 years the medical referee service for Belfast Crematorium was provided through the remit of the Director of Public Health, Eastern Health & Social Services Board.  From 1st July 2009 this service ceased.  In May 2009 a quotation process was completed and a new medical referee service provider was appointed by the Director of Parks and Leisure, and commenced in June 2009.

 

      Recent trends show that demand for burials is on the decline within the Council’s cemeteries while cremation numbers are slowly increasing. The levels of burials in 2009 were 1051 and 1056 in 2010. The levels of cremations for the same period were 2685 and 2732.  Total figures are 3736 in 2009 and 3788 in 2010.

 

      In summary the council’s response welcomes the opportunity to comment and seeks to continue to play a key role in the review of death certification. The main purpose of the council’s response is two fold, to preserve and improve the quality of bereavement services and to promote and improve public confidence in the death certification process in the future.

 

      The key messages in the council response are as follows:

 

·         The Council recommends the need for greater detail on the options provided in order to be able to make the most informed judgement on the best option for change.

 

·         The Council supports in principle greater levels of administrative and medical scrutiny being applied to ensure public confidence in death certification however requires greater detail on how this would be achieved.

 

·         The Council considers that option 1 provides mainly ‘better practice’ suggestions which present minimal change to the current practice; although additional training would benefit the council’s cremation service.

 

·         In principle the additional scrutiny suggested in option 2 is welcomed however greater clarity is required on what is being proposed; timeframe and costs to make an informed decision. In option 2, it appears a discrepancy exists between information in the consultation summary and the full document with reference to the role of medical examiner.

 

·         The medical referee considers there is potential for serious implications in terms of the time period from death certification to disposal; the level of suitably qualified staff to scrutinise cause of death and the likely costs involved if the medical examiner examines every cause of death as referenced in the consultation document.

 

·         The council recommends greater review of other methods of scrutiny which could be considered and refers to its own cremation service for learning points.

 

·         Greater scrutiny is the preferred option however both options do not provide a feasible advance on the current position in terms of immediate scrutiny.

 

·         The council is not in a position with the level of information provided to comment or support a death certification fee being applied as there is no detail on what added value the two options will bring to the quality of service and public confidence.

 

      The council does not feel there is sufficient information provided around the options and costs to make an informed recommendation however believes option 1 does not go far enough to realise the full benefits that a review of death certification could deliver. The council would like the review to consider more fully recommendations from the Scottish model to move towards electronic administration as a way to create consistency and potentially improve levels of administrative scrutiny. Greater clarity on how option 2 would be achieved is required to understand its full impact on the council’s services and the general public.

 

      The council believes its current cremation service may provide a unique example of how levels of scrutiny could be built into any future change. For this reason the council recommends the suggestion in question 5 is a further option worth exploring which is a graduated process of change to transform the current system with greater levels of scrutiny both administratively and medically. The council seeks further involvement in the review of death certification in particular when forms and processes are considered before being committed to new legislation.

 

ANNEX 1

 

REVIEW OF DEATH CERTIFICATION

IN NORTHERN IRELAND

 

CONSULTATION RESPONSE QUESTIONNAIRE

 

OPTION 1

 

Q1.      Is Option 1 your preferred model?

 

·         The council considers option 1 and the actions summarised within it to be standards that should be applied to the current system as a matter of course.

·         There is a need for further information to be supplied to fully understand the impact of this option.

 

·         The council considers there may be a demand for clarity or change to current legislation applicable to death certification to enable future administration to embrace new technologies. For example this option could have included the review of the administration system and introduction of electronic systems (referred to in the Scottish approach and in place in the Republic of Ireland) as an opportunity to improve methods of administrative scrutiny and efficiency of service.

·         This may become more prevalent if the medical examiner role is adopted to alleviate any potential delays from an additional level of scrutiny.

 

Q2.      What do you view as its potential advantages over the present arrangements?

 

·         Through the sampling of statistics retrospectively the Medical referee will not prevent another case similar to Shipman however the role may be more likely to detect patterns or trends of concern more quickly.

·         The sampling of data would be welcomed to ensure effective data management.

·         It may create an environment whereby it may prevent others from repeating the crime as the fear of being caught may increase.

·         Improved training is welcomed as form completion is a key challenge for the council’s cremation service.

·         The tasks listed in option 1 are all considered standards that should be in place for such a significant process as death certification.

 

Q3.      What do you view as potential disadvantages?

 

·         The disadvantage to option 1 is that with most aspects of training it is in the application and enforcement where variation can occur and therefore quality is affected.

·         Similarly in sample data analysis of medical certificates success is more likely to be achieved in how poor performance is addressed.

·         The main disadvantage of option 1 is that there is no immediate scrutiny of the cause of death applied.

·         The option does not confirm whether or not the administration involved in the disposal of bodies can embrace new developments like electronic forms etc which is in place in the Republic of Ireland and under consideration in Scotland.

 

Q4.      Do you think it offers value for money?

 

On the basis of the figures provided it is difficult to understand if the costs will realise any added value.

 

It may have been useful to provide different cost options for option 1 and 2 to see if a different way would bring about potential savings.

 

Q5.      Do you think Option 1 should be introduced as a transitional measure, with a view to subsequently introducing a more comprehensive system of scrutiny?

 

It is considered that this option is the one most suitable for the current climate and local setting however further information is required to make an informed decision on what difference to managing the identified risks detailed as the drivers for change.

 

The council would welcome a more comprehensive system of scrutiny which effectively minimises the risks involved and would be at minimal cost to citizens. However the Council does not feel there is sufficient information provided to make an informed choice at this stage of the review.

 

OPTION 2

 

Q6.      Is Option 2 your preferred model?

 

The council would welcome a greater level of scrutiny which effectively minimises the perceived risks and balances where possible the level of scrutiny for disposal.

 

Option 2 in its current form provides insufficient information for council to support where it will add cost but has not confirmed the added value to the death certification process.

 

The queries the council seeks further clarity on are:

 

·         It appears there are two explanations of what a Medical Examiner role involved - reviewing all deaths to viewing all bodies as presented in the consultation documents.

·         Secondly does the Medical Examiner scrutinise the administration of all deaths and/ or causes of death.

 

Retrospective scrutiny is not considered as a deterrent for cases like Shipman and the viability of an immediate scrutiny is detailed below.

 

The medical referee considers the scrutiny of all causes of death will present serious issues to be overcome, in particular ensuring there are no delays to the time period from death certification to disposal. This is a key issue for council to ensure this traditional norm is not affected by the proposals.

 

Similarly the medical referee would consider there are issues in relation to the number of suitably qualified medical practitioners who can scrutinise the cause of deaths and the costs involved in one hundred per cent verification of all causes of death.

 

The only way the council believes there is viability in the option is if a partial verification process is introduced which includes one hundred per cent verification of all bodies for cremation however we would suggest further detail is provided to scrutinise the potential in the option further.

 

The council realises the need to build scrutiny into the administration and medical elements of death certification and is willing to share the lessons it has learned over the years of managing a burials and cremation service.

 

Q7.      What do you view as its potential advantages over the present arrangements?

 

A further tier of scrutiny has been beneficial for the cremation service.

It will depend on how it is rolled-out as to whether it will minimise the risk that has been noted through the current local death certification.

 

Q8.      What do you view as potential disadvantages?

 

The cost of a 100 per cent verification of all causes of death would be considered difficult to manage and to afford. In order to pass the cost on as a death certification fee there would need to be clear added value the customer can recognise. 

 

Q9.      Do you think it offers value for money?

 

It is not possible for the council to comment on whether the costs in the consultation are value for money as there is not sufficient detail to make an informed decision.

 

The council can provide detail on the cost of its administration service which may present other opportunities to develop administrative verification as part of the death certification process.

 

LOCATION OF MEDICAL EXAMINER

 

Q10.    Do you agree that these options (ie, the Health and Social Care Board or the Public Health Agency) are the most suitable locations for the role of Medical Examiner?

 

For over 25 years up to the formation of the Public Health Agency the medical referee service was provided through the remit of the director of Health, Eastern Health & Social Services Board. 

 

From the information provided it is not possible at this point for the council to determine the advantages or disadvantages of either location.

 

Q11.    If yes, do you think the Medical Examiner role would be more appropriately located in the Health and Social Care Board or the Public Health Agency?  Please explain.

 

No further comment.

 

Q12.    If no, where do you think the Medical Examiner role should be located?

 

No further comment.

 

FEES

 

Q13.    Should bereaved families or the deceased’s estate pay a fee to cover the costs associated with introducing a system of improved scrutiny of death certification?

 

The council would not be in support of additional costs being transferred to its citizens. In particular if added value was not realised to the quality of the existing service.

 

Both options still do not provide enough evidence to appreciate whether or not they will improve the current situation and as such it would be unfavourable to pass on costs for no greater value for money; improved service or safeguards in death certification.

 

Q14.    If such a fee were introduced, should it be standardised,   regardless of the method of disposal employed?

 

It would have been useful for the consultation to breakdown the different costs it felt would be applied for an informed decision to be made.

 

Q15.    If a fee were not introduced, can you suggest any other ways of funding these improvements?

 

It is not known whether any of the cost can be written-off by adding a duty for medical practitioners to verify deaths as well as certify deaths. The Department could consider separating administrative and medical tasks to reduce costs similar to the council’s cremation service.

 

EQUALITY IMPLICATIONS

 

Q16.    Are any of the options presented likely to have an adverse impact on any group of people correlating to one or more of the nine distinctions made in Section 75(1) of the Northern Ireland Act 1998?

 

The council considered the reference to generating a balance in certification for both disposal through burial and cremation. It would appear at first glance that three signatories is burdensome, however due to the finality and level of discrepancies in forms completed by medical practitioners, it is considered essential.

 

The council encourages the review to be mindful of the potential implications of applying scrutiny to the management of requests for disposal within 24 hours (dictated by some cultures now resident in Northern Ireland).

 

Q17.    Please provide any general comments or evidence on the possible health, economic and social impacts of the proposed changes, whether adverse or beneficial.

 

Adding a cost for death certification will not be a popular move and be considered as having a detrimental impact initially for families and individuals.

 

Socially the impact of any change on the traditional norm for funeral arrangements caused by an increase in administration or medical scrutiny would not be welcomed in particular where delays to the time period for disposal are created.”

 

            After discussion, the Committee approved the contents of the response and agreed that it be forwarded to the Department of Health, Social Services and Public Safety as the Council’s official response thereon.