Guidance

An overview of the death certification reforms

Updated 14 August 2024

Applies to England and Wales

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Introduction of medical examiners and reforms to death certification

The death certification system in England and Wales is overdue for reform - it has remained largely unchanged for over 50 years. Introducing a robust system in England and Wales whereby all deaths would be subject to either a medical examiner’s scrutiny or a coroner’s investigation has been an ambition of successive governments and ministers.

The importance of death certification reform and the introduction of medical examiners has been underlined in numerous reports and inquiries including the:

It has long been established that, following a death, the case will either follow the path of medical certification by a medical practitioner or investigation by a coroner. This will remain the case in the new system, but with important differences.

Medical examiner scrutiny is not mandated in the non-statutory system. However, NHS England and NHS Wales Shared Services Partnership started implementing the medical examiner system on a non-statutory basis in 2019.

It has increasingly become standard practice for medical examiners to provide independent scrutiny of deaths not taken for investigation by a coroner. Medical examiners are now scrutinising almost all deaths in acute trusts and a growing proportion of deaths in all other healthcare settings (including the community).

The new death certification reforms require an independent review to be carried out for all deaths in England and Wales, without exception. This will either be provided by independent scrutiny by a medical examiner or by investigation by a coroner.

This page summarises the death certification reforms planned from 9 September 2024, and how the statutory medical examiner system will operate when these reforms come into force. Regulations introducing changes to the death certification process were laid before Parliament on 15 April 2024.

This page includes references and links to current and relevant guidance. All guidance will be updated to reflect, and coincide with, the statutory medical examiner system coming into force.

This page primarily focuses on deaths registered after completion of a medical certificate of cause of death (MCCD) but will also reference other relevant parts of death management, including where the case is notified and/or referred to a coroner.

Legislation

The underpinning primary legislation is:

The primary legislation that underpins the new statutory medical examiner system is the Coroners and Justice Act 2009. Since its passage, the act has been amended (most recently by the Health and Care Act 2022) to reflect changes to the health system.

The Coroners and Justice Act 2009 allows NHS bodies in England and Wales to appoint medical examiners. It also enables the governments to make regulations in several areas, and these regulations provide the detail of how medical examiners and the reformed death certification process will operate.

Primary legislation has been commenced and several sets of regulations have been made or amended in relation to the system. These are set out in the annex.

The 3 sets of regulations made by the Department of Health and Social Care (DHSC) are:

The Welsh Government has also made The Medical Examiners (Wales) Regulations 2024.

This guidance makes clear what the legal requirements will be in each area, ahead of the publication of more detailed guidance. It should be read together with the regulations to support those involved in the death management system to understand and prepare for the reforms.

Roles, responsibilities and information flows in the new system

Medical practitioner

As part of the reforms being introduced from September 2024, a medical practitioner will be eligible to be an attending practitioner and complete an MCCD, if they have attended the deceased in their lifetime. The attending practitioner will propose a cause of death, if they can do so, to the best of their knowledge and belief. The introduction of medical examiners will see routine independent scrutiny of the cause of death proposed by an attending practitioner.

This represents a simplification of the current rules that enable medical practitioners to be an attending practitioner, to complete an MCCD, if they had attended the patient during their last illness but required referral of the case to a coroner for review if they had not done so within the 28 days prior to death or had not seen in person the patient after death.

Current guidance on completing a medical certificate of cause of death will be updated to reflect and coincide with the implementation of the statutory medical examiner system.

It is already a statutory requirement for an attending practitioner to complete the MCCD. The General Medical Council (GMC) sets out this obligation in Treatment and care towards the end of life: good practice in decision making (paragraphs 83 to 85), stating that this is part of the attending practitioner’s responsibility to their patients:

Your professional responsibility does not come to an end when a patient dies. For the patient’s family and others close to them, their memories of the death, and of the person who has died, may be affected by the way in which you behave at this very difficult time.

You must be professional and compassionate when confirming and pronouncing death and must follow the law, and statutory codes of practice, governing completion of death and cremation certificates. If it is your responsibility to sign a death or cremation certificate, you should do so without unnecessary delay.

The reference to completion of a death certificate should be read as referring to completion of the MCCD.

The main change is that attending practitioners must share the MCCD and proposed cause of death with a medical examiner, who will scrutinise these before submission to the registrar. This is a change to the current system where the MCCD is sent to the registrar by the attending practitioner.

Medical examiner role

Under the medical examiners regulations, medical examiners:

  • provide independent scrutiny of causes of death
  • give bereaved people an opportunity to ask questions and raise concerns with someone not involved in providing care to the deceased person prior to their death
  • review medical records and work with doctors to complete the MCCD to help ensure this is accurate and to highlight any concerns about the care of the deceased person prior to their death

A medical examiner is a senior medical practitioner who is contracted for a number of sessions a week to provide independent scrutiny of causes of death, outside of their usual clinical duties. They are trained in the legal and clinical elements of death certification processes and will not have been involved in caring for the patient.

Medical examiners have been carrying out independent scrutiny of causes of death since implementation of the non-statutory medical examiner system. They will continue to carry out these activities in the same way in the new death certification process, but independent scrutiny by a medical examiner will become a statutory requirement prior to the registration of all non-coronial deaths in England and Wales. 

Once the relevant attending practitioner and the medical examiner have completed their declarations of certification and scrutiny, and the cause of death is confirmed, the MCCD will be sent to the registrar by the medical examiner rather than the attending practitioner. The representative of the deceased will be notified at the same time that they can now contact the registrar to arrange the registration of the death.

Medical certificate of cause of death

From September 2024, a new MCCD will replace the existing certificate to reflect the introduction of medical examiners, who will scrutinise the proposed cause of death.

The main benefits of doing so are to improve:

  • efficiency in the death certification system
  • mortality data for use at a local level and nationally

There will continue to be a statutory form to be used when a death occurs after 28 days of life, and a separate form to be used when a live born child dies within the first 28 days of life. Both forms will be available in bilingual format in Wales. The new MCCD will include details of the attending practitioner who certified the cause of death to the best of their knowledge and belief (as at present).

In addition, the new MCCD will include the following new information:

  • details of the medical examiner who scrutinised the cause of death
  • ethnicity, as self-declared by the patient on the medical record. This builds on learning from the COVID-19 pandemic. If the patient medical record does not include this information, then the attending practitioner can complete it as ‘unknown’ on the MCCD and should not in any circumstance ask for this information from the representative of the deceased
  • maternal deaths: there are 2 new questions regarding the pregnancy status of the deceased:
    • was the deceased person pregnant within the year prior to their death?
    • if the deceased person was pregnant within the year prior to their death, did the pregnancy contribute to their death?
  • a new line, 1d, for the cause of death - bringing the MCCD in line with international standards
  • medical devices and implants will be recorded on the MCCD by the attending practitioner, and this will be transferred to the certificate for burial or cremation (contained in the green form) completed by the registrar in order to inform relevant authorities of the presence of any devices or implants

Distribution of new paper version of MCCD

On 25 June 2024, DHSC published guidance on receiving the new MCCD and a distribution list. The guidance also includes what to do if you do not receive copies of the new MCCD but think you should, or if you receive them in error. Guidance on how to order additional MCCDs and a passcode will be sent separately to organisations who appear on the published list or who successfully request to be added.

In addition to this, DHSC is developing an online version, which will enable the form to be more easily shared between the attending practitioner, medical examiner and registrar. The online version will be available later in 2024 or 2025.

Medical examiner certification

In line with the framework set out in the Coroners and Justice Act 2009 and the medical certificate of cause of death regulations, we are introducing medical examiner certification for the exceptional circumstances where either:

  • there is no attending practitioner
  • an attending practitioner is not available within a reasonable time

In either of these circumstances, the death is referred to the senior coroner by a referring medical practitioner (not a medical examiner).

In these circumstances only, where the senior coroner decides not to investigate, they should refer the case to a medical examiner to certify the death by completing a medical examiner MCCD.

The medical examiner MCCD will only be used in exceptional circumstances where actions to identify an attending practitioner have been exhausted by the referring practitioner. Regulations make clear that only the senior coroner (and not the referring medical practitioner) can refer the death for certification by the medical examiner in such circumstances.

When medical examiners complete a medical examiner MCCD, there may not be an interaction with an attending practitioner, but all other elements of medical examiner scrutiny will remain in place. Medical examiners, supported by medical examiner officers, will continue to offer representatives of the deceased the opportunity to ask questions and raise concerns. They will carry out a proportionate review of medical records. In those circumstances where the medical examiner concludes that they are unable to establish the cause of death, the case will be referred back to the senior coroner.

Coronial process

While the medical certificate of cause of death regulations mainly provide for completion of the MCCD, in practice they reflect the flow of information between the attending practitioner, medical examiner, coroner and registrar in the new system. 

The Notification of Deaths Regulations 2019 will remain in force (subject to minor amendments flowing from the introduction of the statutory medical examiner system). Attending practitioners should continue to notify deaths that meet the criteria in those regulations to the coroner, who will determine what further action is appropriate.

As set out above, there will be provision, in exceptional circumstances, for the medical examiner to certify a death where there is no medical practitioner who is qualified to do so, and the coroner’s jurisdiction is not engaged.

As at present, the attending practitioner can report a death directly to the coroner where they believe they are under a statutory duty to do so. In this scenario, there will be no regulatory requirement for the attending practitioner to inform the medical examiner that they have done this. Similarly, if the coroner declines jurisdiction, they will advise the attending practitioner. The attending practitioner will be expected to complete the MCCD and scrutiny will be undertaken by the medical examiner.

It is inherent in the design of the new system, agreed by the General Register Office, and implicit in the medical certificate of cause of death regulations, that coroners will no longer be expected to notify the registrar when they decide that their duty to investigate under section 1 of the Coroners and Justice Act 2009 is not engaged.

There will be little change in terms of coroner interaction with the registrar where an investigation is discontinued following a post-mortem examination, and this process will be extended to include the notification of investigations which are discontinued without a post-mortem examination. The process for the coroner’s interaction with the registrar after inquest will be largely unchanged. 

Death registration

Deaths will not be registered until the registrar receives notification of the cause of death from the medical examiner or the coroner. This notification will also start the 5-day statutory time frame to register a death.

Informants should have had opportunity to discuss and be aware of the cause of death before registration. When at registration they do raise issues of concern in relation to the cause of death, the issue will be raised with the coroner or medical examiner as appropriate.

From 9 September 2024, the responsibilities of the registrar will change as there will be no requirement for registrars to refer deaths to the coroner. The attending practitioner or the medical examiner will determine which deaths need to be referred to the coroner. This changes the relationship between the registrar and the coroner as, unless the coroner is providing a certificate for registration following an inquest or a discontinued case, there will be no interaction between them.

The Registrar General will no longer have responsibility for providing an MCCD, as DHSC will take over the new form development and supply.

As there will be limited interaction between the registrar and coroner, the need for the form 100A will no longer exist and this form will be removed.

As set out in the medical certificate of cause of death regulations, there will be specific circumstances in which the coroner will be required to provide information to the medical examiner.

There will be a much wider class of cases where the coroner, having declined jurisdiction, will communicate that decision to the attending practitioner. The General Register Office, Ministry of Justice and DHSC will work together to ensure the new process operates satisfactorily and will review and amend coroner’s forms and certificates as appropriate. 

As discussed above, the intention is to reduce uncertified deaths, with the attending practitioner certifying with medical examiner sign-off at first instance, or the medical examiner certifying in exceptional circumstances following referral by the coroner.

The changes also introduce new categories of qualified informant to allow for the partner of the deceased and a representative of the deceased to register the death.

Cremation and burial

Currently, in non-coronial deaths, a medical practitioner (usually the attending practitioner) must complete form Cremation 4 (the medical certificate) to provide sufficient detail to enable the medical referee to understand the cause of death if the deceased is to be cremated. Once the statutory medical examiner system is implemented, the medical examiner’s scrutiny will make the form Cremation 4 confirmation obsolete and the regulatory requirement for the medical referee to scrutinise it will therefore be removed. 

Information about medical devices and implants in the body of the deceased (which is currently recorded on form Cremation 4) will be included on the MCCD and in the certificate for burial or cremation (green form), as set out above.

In coronial cases that are followed by cremation, the coroner will continue to certify the cause of death using form Cremation 6 (certificate of coroner), as at present. As set out above, form Cremation 6 will be amended to enable the coroner to record information on the presence of medical devices and implants, where available, so that this is communicated to the cremation authority. The coroner’s order for burial (form 101) will also be amended to enable the coroner to record information on the presence of medical devices and implants, so that this is available to the burial provider.

Currently, medical referees are responsible for authorising that the cremation of the deceased can proceed, taking into account the medical certification provided.

Medical referees will remain in post while the statutory medical examiner system is embedded. During this transitionary period, the Ministry of Justice will gather evidence to determine the long-term status of medical referees. There will be opportunities for medical practitioners, coroners and funeral directors to contribute to that process.

Medical examiner implementation

National medical examiner

Section 21 of the Coroners and Justice Act 2009 requires the national medical examiner to provide guidance and professional leadership to medical examiners in England and Wales. The national medical examiner oversees:

  • regional medical examiners and regional medical examiner officers in England
  • the lead medical examiner and lead medical examiner officer for Wales

These structures provide a route for medical examiners, if they judge it is necessary, to escalate concerns outside the established clinical governance processes operating in their organisation or health system.

NHS trusts, healthcare providers, ICBs and health boards

NHS trusts in England, which have a medical examiner office, should ensure the medical examiner office is supported in the operational rollout of the medical examiner system before the regulations come into force on 9 September 2024. They must ensure that the independence of medical examiners is respected. NHS Wales Shared Services Partnership (part of Velindre Trust) as the identified appointing body and provider of the all-Wales medical examiner service in Wales, should finalise their preparations for the statutory system coming into force on 9 September 2024.

All other healthcare providers in England and Wales, including GP practices and independent healthcare providers, must ensure they make the necessary arrangements to inform medical examiners of deaths requiring independent scrutiny and share records of deceased patients with medical examiners in a timely manner.

It is recommended that all healthcare providers set up processes with immediate effect to start referring deaths if they have not already done so. This will avoid disruption and distress when the regulations come into force, allow procedures to bed in, and enable issues to be identified and addressed.

Similarly, medical examiner offices should work with regional medical examiners in England and the lead medical examiner in Wales to facilitate processes with all healthcare providers in their area which have responsibility for medical practitioners completing medical certificates of cause of death. 

In England, integrated care boards (ICBs) should contact all healthcare providers in their area and require them to establish processes to refer relevant deaths to medical examiner offices for independent scrutiny.

In Wales, health boards should work with all healthcare providers in their areas to establish timely processes to refer relevant deaths to medical examiner offices so that the legally required scrutiny of deaths can be undertaken. All healthcare providers should ensure they have processes in place to receive feedback from the medical examiner’s office and that these feed into the appropriate channels for learning and improvement. 

Healthcare providers can already share records of deceased patients with medical examiners and will be mandated to do so when the regulations come into force. Currently, section 251 support has been granted for sharing records with medical examiners in England following recommendations of the Health Research Authority’s Confidentiality Advisory Group (CAG). The relevant approval documents are CAG21/CAG/032 for England and CAG23/CAG/0095 for Wales, which can be downloaded from the CAG register.

When the regulations come into force, medical examiners will have a right of access to records of patients under section 3 of the Access to Health Records Act 1990, as amended by the Coroners and Justice Act 2009.

The national medical examiner’s good practice guidelines make clear that medical examiners must complete training. When the regulations come into force, it will be a requirement that when medical examiners are appointed, they complete such training as is appropriate.

NHS England has:

Information on the medical examiner service in Wales is available from NHS Wales Shared Services Partnership.

Mortality statistics

The regulations make no changes to the existing legislative powers for the Office for National Statistics (ONS) to produce mortality statistics.

The Statistics and Registration Service Act 2007 transferred many of the functions relating to statistics from the Registrar General for England and Wales to the Statistics Board. This transfer of functions included the requirement within section 19 of the Registration Service Act 1953 to produce and provide to Parliament an annual abstract of life events, including deaths. In addition, ONS has legislative functions within section 20 of the Statistics and Registration Service Act 2007 to produce public good statistics on any matter.

The General Register Office transmits death registration data to ONS daily who then process it for statistical analysis and production. This includes:

  • quality-assuring the data through a combination of automated and manual checks and liaising with the General Register Office to resolve any errors that are found
  • transforming the text that explains the cause of death, as set out by the attending practitioner or coroner, into relevant codes from the International Classification of Disease version 10 (ICD10). The ICD10 classification itself is set out by the World Health Organization and we will be transitioning to ICD11 by 2027. The addition of ICD codes enables mortality records to be summarised and compared robustly, both domestically and internationally
  • transforming the text that describes occupation into Standard Occupation Codes. This enables robust comparison of mortality rates by occupation

Following implementation of the statutory medical examiner system, the data transmitted to ONS will include some of the new items being collected on the revised MCCD:

  • line 1d of the cause of death information
  • the ethnicity of the deceased (where available)
  • whether the deceased was pregnant or recently pregnant

These fields will be integrated into statistical processing and will allow ONS to improve its mortality statistics.

ONS also expects that the quality of the cause of death information will improve once all non-coronial deaths are receiving medical examiner scrutiny (rather than only a proportion as currently), and that quality will continue to improve as the medical examiner service matures.

In preparation for these new data flows, ONS is redeveloping its own processing systems and is working closely with the General Register Office to align its systems with theirs. This will ensure a smooth transition that safeguards timely and accurate mortality statistics for the public good.

Updated guidance

On 9 September 2024, updated guidance will be published specific to those involved in each stage of the death certification process:

  • guidance for medical practitioners completing MCCDs in England and Wales

  • guidance for medical practitioners on the notification of deaths regulations

  • Chief Coroner guidance

  • guidance for funeral directors on cremation regulations and forms

  • guidance for cremation managers on cremation regulations and forms

  • guidance for crematorium medical referees on cremation forms

  • guidance on applying for a cremation of the remains of someone who has died

  • guidance on how to register a death

NHS England has published the National Medical Examiner’s guidance for England and Wales, for use from 9 September 2024.

Annex: other legislation

Primary legislation

Provisions relating to section 169 of the Health and Care Act 2022 and schedule 21 to the Coroners and Justice Act 2009 were commenced on 15 April 2024:

These make amendments to the:

Secondary legislation

Cremation and notification to coroners

The Cremation, Coroners and Notification of Deaths (England and Wales) (Amendment) Regulations 2024 were laid on 21 May 2024. These will come into force on 9 September 2024.

These regulations:

  • update statutory forms
  • amend the roles of those involved in scrutiny of death before a cremation
  • amend the duty for a consultant medical practitioner to notify the coroner of a death in certain circumstances (as well as the form and content of the notification)
  • ensure that information about the presence of medical devices or implants in the deceased person’s body (where known) is passed on to the relevant authority

Registration of deaths

Amendments to The Registration of Births and Deaths Regulations 1987, which deal with how registrars may register a death, will be laid to reflect interactions with medical examiners. These regulations will be laid in August to come into force on 9 September 2024.

The amendment regulations will set out the steps registrars should take on receipt of a confirmed attending practitioner’s MCCD, or a medical examiner’s MCCD. In these cases, registrars will no longer make any referrals to the coroner and, if any queries arise, they will contact the medical examiner for further consideration and discussion. The amended regulations also enable a coroner to provide the information required for registration where an investigation has been discontinued and an informant is unwilling or unable to come forward.

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