Reforms to Death Certification & Coronial Law.

On 9 September 2024, reforms were brought in which brought about a fundamental change in the UK's death certification process and which altered coroners’ responsibilities nationwide.

The principle of the reformed death certification system is that natural deaths outside custody or state detention are now to be scrutinised by an independent medical examiner. This, in part, was as a consequence of the actions of notorious serial killer, Harold Shipman, who abused his position as a GP to target and murder vulnerable elderly people, and then cover up their deaths by falsifying their death certificates.

The system of ensuring that all natural deaths are now scrutinised by an independent medical examiner ensures:

1. Accuracy: Medical examiners provide a second, independent review of the cause of death, reducing errors or omissions.
2. Transparency: Independent review helps build trust in the death certification process by providing unbiased oversight.
3. Accountability: Examiners ensure compliance with legal and medical standards, particularly in non-coronial deaths.
4. Consistency: Standardising scrutiny across regions to ensure uniform application of the law.
5. Public health insights: Reviews help identify trends or public health issues, contributing to broader health data analysis.

In contrast, if Section 1 of the Coroners and Justice Act 2009 (CJA 2009) applies (such as in cases of violent or unnatural death; where the cause of death is unknown; or where a person died in custody or state detention), the death will be investigated by a coroner who may carry out a post-mortem and who may go on to conduct an inquest. An inquest is a fact-finding inquiry designed to answer four questions: who died, and where/when/how did they die.

The number of deaths reported to coroners varies markedly by coroner area. The number of deaths reported in each area will be affected by its size, resident population, demographic breakdown and profile. In 2023, 194,999 deaths were reported to coroners nationally. It is estimated that referrals to coroners will still continue under the new reformed system, but it is anticipated that the numbers will reduce and which will subsequently enable coroners to focus on deaths which need to be investigated in accordance with coronial law.

In conclusion, from 9 September 2024, there is now a clear delineation between medical and judicial certification of death which establishes a boundary between the medical and judicial roles in death certification, and ensures that each entity has distinct responsibilities based on the nature and circumstances of the death.

For more details, visit Judiciary UK.

If you wish to discuss matters in confidence with our Clinical Negligence Team, please call us on 0800 652 3371.