Death Certification Review Service. Annual Report

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1 Death Certification Review Service Annual Report

2 Healthcare Improvement Scotland 2017 First published August 2017 This document is licensed under the Creative Commons Attribution- Noncommercial- NoDerivatives 4.0 International Licence. This allows for the copy and redistribution of this document as long as Healthcare Improvement Scotland is fully acknowledged and given credit. The material must not be remixed, transformed or built upon in any way. To view a copy of this licence, visit nd/4.0/

3 Contents About the Death Certification Review 4 Senior Medical Reviewer Report 6 Recommendations for Our findings 10 Case type overview 10 Standard Level 1 and Level 2 reviews 12 MCCDs not in order 13 Medical reviewer for cause reviews 16 Interested person reviews 17 Advance registration applications 18 Registrar referrals 19 Deaths outwith Scotland 20 Breached cases 21 Training and information function 22 Service evaluation 22 Complaints, concerns, comments, compliments 22 Stakeholder reflections 23 Adverse events and lessons learned 25 Annex A 26 3

4 About the Death Certification Review Service Each year in Scotland, there are approximately 57,000 deaths. Every death in Scotland must be certified by a doctor who completes a form called a Medical Certificate of Cause of Death (MCCD). The MCCD provides a permanent legal record of the death, records information about the death (including the cause of death) and allows the death to be registered. The arrangements for death certification and registration have been extensively reviewed. The Certification of Death (Scotland) Act introduced a number of changes to the system. In particular, it strengthened checks on the accuracy of MCCDs by setting up a new national system of proportionate, independent scrutiny of those deaths not reported to the Procurator Fiscal, namely, the Death Certification Review Service (DCRS). The review continues to be free at the point of delivery. Healthcare Improvement Scotland is named in the Act as the organisation responsible for running the service and for certain other specific duties, including managing the process of administering and authorising the burial and cremation of people who have died outside the UK and are returned (repatriated) for burial or cremation in Scotland. The aims of the Death Certification Review Service are to improve: the quality and accuracy of MCCDs public health information about causes of death in Scotland, and clinical governance in relation to death certification

5 The review process MCCDs are randomly selected for review by National Records of Scotland. The statistical randomisation model necessarily results in daily workload which is unpredictable. The review of MCCDs is carried out by medical reviewers, all of whom are experienced and trained doctors from both a general practice and secondary care background. The review process enables the medical reviewer to speak to the certifying doctor about the certificate and case history. The purpose of the review is to determine if the MCCD completion is in order rather than look at the quality of care provided to the deceased prior to their death. The Senior Medical Reviewer leads this work for Scotland. Certificates not randomly selected for review, or previously reported to the Crown Office and Procurator Fiscal Service, are eligible to be considered for an interested person review, where individuals with a clear link to the person who has died have questions about information contained in the MCCD. 5

6 Senior Medical Reviewer Report I am delighted to present the Death Certification Review Service annual report for This report marks the end of the service s second year of operation, delivering a national system of proportionate, independent scrutiny of those deaths in Scotland not reported to the Procurator Fiscal. Through our work, we improve the accuracy and quality of completion of Medical Certificates of Cause of Death (MCCDs), provide better public health information and contribute to safer clinical practice. The service continues to successfully fulfil its function and meet the required targets in a cost effective manner. We have been able to demonstrate an improvement in the quality of MCCDs in year two. The percentage of MCCDs found to be 'not in order' decreased from 47.1% in 2015 to 39.6% in Of those not in order, 12.1% in 2015 required replacement due to either a more major error, or the unavailability of the certifying doctor, but this reduced to 6.4% in We have maintained a focus on improving the accuracy and quality of MCCDs through education, both during one-to-one educationally-focused case review conversations with certifying doctors and more formal sessions delivered to GP practices, hospices, hospitals and NHS boards. In year two, we developed NHS board comparative data across Scotland to support continuous improvement at local NHS board level. Again, we have promoted the use and benefits of the electronically completed MCCD (emccd) at our 6-monthly meetings with NHS boards and to certifying doctors, as there is an advantage to both bereaved relatives and individual doctors in using this facility. Use of the emccd means that when the informant presents to the Registrar, the review will have already been completed in the vast majority of cases. Legibility along with fuller completion also makes the review easier for the certifying doctor. As a result, it is difficult to see why there has been occasional resistance to using the process and we look forward to the roll-out of emccds to secondary care. However, monitoring of the extension of the emccd will be required in case there is unintended consequential impact on the service workload due to the randomisation process increasing the number of cases selected at the beginning of the week and, especially, after public holidays. 6

7 Consideration is being given to linking the service data to the Community Health Index identifier data set with Information Services Division of NHS National Services Scotland for wider trends and themes analysis so as to better contextualise the work we are doing at the service. Once more, we can report high levels of certifying doctor satisfaction with the service from our 6-monthly SMART survey results. However, a very small number of certifying doctors have enquired about the benefits of the service. A 'gathering views' exercise seeking the opinion of the bereaved will be conducted with the support of the Scottish Health Council later in 2017 and a report will then be published. An Emergency Care Summary (ECS) access for Level 1 review pilot concluded in January 2017 which demonstrated clear benefits in terms of supporting case reviews, achieving a better focus, improving the quality of case review and negating the need for medical records requests in some cases. In July 2017, a recommendation was made to the Death Certification Review Service Management Board to incorporate ECS access for the more basic Level 1 reviews. This year, in collaboration with NHS Education for Scotland, we developed an interactive scenario-based educational tool for certifying doctors. The tool is due for release mid We have shared our 'tips for certifying doctors' guidance with all undergraduate Medical Deans in Scotland with a view to engaging with final year undergraduate medical students. We completed a lean review of the service which resulted in an extended medical reviewer assistant role to support medical reviewers. During our first 2 years of operation, we have also contributed to Scottish Government consultations Management of Deaths in the Community, The Burial and Cremation (Scotland) Act 2016 and the Inquiries into Fatal Accidents and Sudden Deaths etc. (Scotland) Act The service continues to work successfully in collaboration with partner organisations National Records of Scotland, NHS 24, NHS National Services Scotland and NHS Education for Scotland, in addition to wider stakeholders including public partners. Although repatriation deaths are a small component of our work, they are often especially distressing for the bereaved because of their unexpected nature and greater uncertainty as to the cause of death. Interpreting Section 19 of the Certification of Death (Scotland) Act 2011 as to what constitutes a cause of death not being "available" and justification for paying for an autopsy through the public purse has been challenging. However, we continue to reflect on our experience, lessons learned and adapt our standard operating procedure to ensure consistency across the service. It will be necessary to be mindful of the extension of the role of the Scottish Fatalities Investigation Unit now that there is a possibility of a Fatal Accident Inquiry in certain cases where death has occurred outwith Scotland. 7

8 Effective governance arrangements of the service is through the Death Certification Review Service Management Board 2 without whose collective assistance this positive outcome would not have been achieved and I would like to extend my particular thanks to partner organisations, stakeholders and everyone in the service for their hard work and commitment in delivering our objectives. Dr George Fernie Senior Medical Reviewer Death Certification Review Service 2 See Annex A for membership of group. 8

9 Recommendations for Continue to effect improvement on 'not in order' rate. 2. Make it easier for certifying doctors to complete MCCDs through the use of electronic MCCD (emccd). Promote uptake of emccd within primary care during case review discussions, educational session delivery and NHS board 6-monthly review meetings. Continue to work with partner organisations to support extending emccd to secondary care. 3. Actively monitor the service workload with extension of the emccd system due to the anticipated impact from the true randomisation of cases which is likely to accentuate peaks and troughs of demand. 4. Consider Iinking service data to the Community Health Index (CHI) data set for wider trends and themes analysis. 5. Incorporate an Emergency Care Summary (ECS) check for all Level 1 reviews. 6. Liaise with the Scottish Fatalities Investigation Unit to look at how they will be extending their role to include discretionary Fatal Accident Inquiries of those normally resident in Scotland who have died overseas. 9

10 Our findings Year one reporting period is 13 May 2015 to 31 March Year two reporting period is 1 April 2016 to 31 March Case type overview The service reviewed 5,963 cases during year two compared to 5,111 during year one. A breakdown by case type is detailed below (Table 1). Table 1: Number (and percentage) of cases received Case type Year 1 3 Year 2 Standard Level 1 and Level 2 4,641 (90.8%) 5,566 (93.3%) Advance registration 278 (5.4%) 189 (3.1%) Repatriation 152 (2.9%) 174 (2.9%) Interested person 7 (0.1%) 6 (0.1%) Registrar referral 27 (0.5%) 21 (0.3%) Medical reviewer for cause reviews 6 (0.1%) 7 (0.1%) Total 5,111 (100%) 5,963 (100%) Data source: Death Certification Review Service case management system (Sugar) The percentage of advance registration cases reviewed was lower in year two (3.2%) compared to year one (5.4%). We believe this is due to us having built confidence that the review will be conducted timeously. The number of cases reviewed in each NHS board for year one suggested the distribution of cases was proportional to the population death data held by National Records of Scotland. 3 Year 1 is only a partial year as the service did not commence until 13 May Also, the reporting period going forward will be the financial year in order to comply with s23 of the Certification of Death (Scotland) Act

11 The number of cases reviewed in each NHS board for year two also highlights that the distribution is proportional (see Table 2). Table 2: Number of reviews in each NHS board compared to population deaths DCRS reviews Deaths a NHS board 1 April March January December 2016 Ayrshire & Arran 433 (7.2%) 4,492 (7.9%) Borders 140 (2.3%) 1,277 (2.2%) Dumfries & Galloway 189 (3.1%) 1,858 (3.2%) Fife 375 (6.2%) 4,091 (7.2%) Forth Valley 355 (5.9%) 3,179 (5.6%) Grampian 572 (9.5%) 5,468 (9.6%) Greater Glasgow and Clyde 1,360 (22.8%) 12,445 (21.9%) Highland 324 (5.4%) 3,505 (6.1%) Lanarkshire 673 (11.2%) 7,097 (12.5%) Lothian 782 (13.1%) 7,761 (13.6%) National 6 (0.1%) - Orkney 18 (0.3%) 223 (0.3%) Shetland 25 (0.4%) 232 (0.4%) Tayside 509 (8.5%) 4,741 (8.3%) Western Isles 24 (0.4%) 359 (0.6%) Cases not allocated to an NHS board b 178 (2.9%) Total 5,963 (100%) 56,728 (100%) a Death data are based on provisional figures for deaths registered in Scotland in b Cases not allocated to an NHS board are repatriation or interested person cases. Data source: Death Certification Review Service case management system (Sugar) and National Records of Scotland The range of cases reviewed for each certifying doctor is from 0 27, where the highest number was from a doctor working in the palliative care setting. However, most certifying doctors have now had a few cases selected. 11

12 Standard Level 1 and Level 2 reviews Standard Level 1 and Level 2 reviews are designed to check the quality and accuracy of MCCDs and to improve the way that information about deaths is recorded. Medical reviewers examine a random sample of about 10% of all deaths through a Level 1 review which are normally completed within one working day and an additional small number of MCCDs are examined through a Level 2 review usually completed within 3 working days. The bereaved can still make initial funeral arrangements while the review is under way. However, the funeral itself cannot take place until the review is completed and a Certificate of Registration of Death (Form 14) is produced. The service reviewed 5,566 cases as standard Level 1 and Level 2 reviews during year two compared to 4,641 cases in year one. The number of standard Level 1 and Level 2 reviews are detailed in Table 3. This means 6.5% of the total deaths that occurred in Scotland were reviewed as Level 1 in year one and 7.9% in year two, based on 57,000 deaths each year. Table 3: Number of Level 1 and Level 2 reviews Year 1 Year 2 Level 1 3,725 4,508 Level ,058 Total 4,641 5,566 The above numbers are in line with pre-implementation forecasts of approximately 4,000 Level 1 and 1,000 Level 2 reviews a year, and is an indication that the case selection method is working as expected. In year two, the service escalated 173 (3.6%) of standard Level 1 cases to a Level 2 review and advised 185 (3.3%) of standard Level 1 and Level 2 reviews to be reported to the Procurator Fiscal by the certifying doctor. This is a slight increase on year one, where 112 (2.4%) of standard Level 1 and Level 2 reviews were advised to be reported to the Procurator Fiscal by the certifying doctor. 12

13 MCCDs not in order We found 39.6% of MCCDs reviewed to be not in order in year two, compared with 47.1% in year one 1. The not in order percentage changed significantly throughout the first year of operation, particularly in the first 3 months where a hybrid manual/electronic review system was introduced, and medical reviewers became familiar with the review process. Run chart analysis of weekly percentage not in order rates from August 2015 indicates a probability based indication that the percentage of MCCDs not in order decreased from December 2015 and again in June 2016 a reduction from 52.5% to 39.6%. Since June 2016, the percentage of MCCDs not in order continues to vary around 39.6% (Figure 1). Figure 1: Run chart showing weekly percentage of MCCDs not in order between 13 May 2015 and 31 March 2017 Data source: Death Certification Review Service case management system (Sugar) There did not appear to be an increase in the not in order rate at the time of junior doctor change over. MCCDs reviewed by the service and found to be not in order can be further classified by the seriousness of errors detected. Of those not in order in year two, 93.6% had minor errors requiring an amendment and 6.4% had major errors requiring a replacement MCCD (Figure 2). 1 In year two the method of measuring not in order excluded those referred from the non-random route, for example PF referral, interested person referral or medical reviewer referral as this group are already identified as having or potentially having errors. The numbers involved (34) do not affect the ability to compare year on year changes. 13

14 Figure 2: Percentage of MCCDs with major or minor errors for reporting years one and two Data source: Death Certification Review Service case management system (Sugar) MCCDs deemed not in order can have more than one error category. Figure 3 illustrates the prevalence of various errors observed in cases requiring a replacement MCCD. Cause of death too vague was the most common recorded error and was observed in 40% of cases requiring a replacement MCCD. Inaccuracy in the cause of death being correct and timescales were also common observed errors in cases requiring a replacement MCCD. Figure 3: Percentage of closure categories for MCCDs with errors Data source: Death Certification Review Service case management system (Sugar) 14

15 The service compared the quality of MCCDs completed by hand, and those completed electronically (emccd). We observed significantly fewer errors in emccds, with 36.3% of emccds found to be not in order in year 2 compared to 45.6% of paper MCCDs. We also observed a reduction in the number of emccds requiring replacement (Table 6). As anticipated, the number of registrar errors which are typically due to transcription, will become minimal with the introduction of emccd into secondary care. Table 6: Impact of Paper MCCD and emccd in reporting year two Review outcome paper MCCD emccd Ability to correct by amendment Requiring replacement MCCD 75.8% 95.0% 7.6% 4.6% of which registrar error 16.6% 0.4% emccd is available within primary care and uptake as at 31 March 2016 is approximately 44.3%. The service promotes the use of emccd during one-to-one educational discussions with certifying doctors, 6-monthly meetings with NHS boards, and educational sessions delivered to GP practices, hospices, hospitals and NHS boards by medical reviewers and the Senior Medical Reviewer. emccd functionality will be made available to secondary care in

16 Medical reviewer for cause reviews Standard Level 1 and Level 2 reviews are designed to check the quality and accuracy of MCCDs and to improve the accuracy of death certification. Under Section 3 of the Certification of Death (Scotland) Act 2011, for cause reviews may be identified by the medical reviewer, senior medical reviewer or through other intelligence (for example data trends, feedback from registrars, Scottish Government). Eligible MCCDs are selected for a Level 2 for cause review and these are typically where a concern has been identified about an individual case that it is believed would merit more detailed consideration. A prospective review of the next 6 to 10 MCCDs is agreed with the certifying doctor, and supervising consultant or medical director where appropriate, with the aim of demonstrating improvements in the areas highlighted to the doctor. Progress is discussed between the certifying doctor and medical reviewer at the time of each review. If there is insufficient improvement after reviewing half of the agreed quota, the medical reviewer informs the supervising consultant or medical director. If there is insufficient improvement at the end of the review period, the Senior Medical Reviewer contacts the supervising consultant or medical director to establish the NHS board's intended course of action. The service conducted 7 for cause reviews during the reporting period, where there was sufficient concern about the quality of MCCD completion by 3 certifying doctors. Out of the 3 certifying doctors whose certificates are being reviewed, 2 remain under review as no further certificates have been completed by them. One has concluded and the medical reviewer has fed back to the certifying doctor and supervising consultant that insufficient improvement has been made. The relatively small number of for cause reviews is unsurprising as most errors detected are understandable and whilst important to correct, justification of prospective reviews on grounds of proportionality has to be taken into consideration so that the process remains educative rather than being deemed punitive. 16

17 Interested person reviews MCCDs not randomly selected for review, or previously reported to the Crown Office and Procurator Fiscal Service, are eligible to be considered for an interested person review. To apply for an interested person review, the applicant must have a clear link with the person who has died. Those who can apply include family members of the deceased, healthcare professionals who were involved in the care provided and the funeral director who arranged the funeral. An interested person review does not assess the quality of care provided to the person who has died. Any application for an interested person review must be made within 3 years of the death of the person who died. Applications can only be made in relation to people who have died after 13 May The service received 6 interested person applications in year two (Table 4): 2 applications were declined as previously reviewed by the Procurator Fiscal and therefore outwith the service s remit, 1 application was received prior to death registration, and 5 applications were received after death registration. 1 case was considered to be in order and 3 not in order. Table 4: Number of interested person applications Applicant category The person having charge of the place of disposal of the body of the deceased A healthcare professional (or other carer) who was involved in the deceased's care prior to the deceased's death A person who under the Registration or Births, Deaths and Marriages (Scotland) Act 1965 is required or stated to be qualified to give information concerning the deceased's death Number Data source: Death Certification Review Service case management system (Sugar) The service received fewer interested person applications than expected during its first 2 years of operation. 17

18 Advance registration applications If an MCCD is selected for review and the bereaved need the funeral to go ahead promptly, in special circumstances, they may apply for an advance registration. Special circumstances identified during the Scottish Government consultation include: if there are religious or cultural reasons to bury a person s body quickly if holding up the funeral would cause a significant additional distress, and for other reasons, like the family have travelled from abroad for the funeral. The service will usually approve or decline an advance registration application within 2 hours. If the application for advance registration is approved, the funeral can go ahead. If the application for advance registration is not approved, the funeral will have to wait until the Level 1 or Level 2 review is finished. The service received 189 advance registration applications in year two, of which 68% were approved. The number of applications made on faith/religious grounds has remained low at around 12%, although a slight increase on the number of faith/religious grounds applications in year one. The percentage of approved applications for advance registration has declined by 19%, compared to the first reporting period when 87% were approved. A number of those declined were because the review was already completed or close to being finalised. The service received fewer vexatious advance registration applications than expected. A summary of advance registration applications for years one and two is detailed below (Table 5). 18

19 Table 5: Summary of advance registration applications Request outcome Year 1 Year 2 Approved 242 (87%) 128 (67.7%) Not approved 36 (12.9%) 61 (32.2%) Review outcome In order 135 (48.5%) 102 (53.9%) Not in order 140 (50.3%) 83 (43.9%) Procurator Fiscal 3 (1%) 4 (2.1%) Reason Administration, Compassionate or both 249 (89.5%) 167 (88%) Religion or faith 29 (10.4%) 22 (11.9%) Review level Level (57.5%) 119 (61.9%) Level (42.4%) 70 (38%) Total Data source: Death Certification Review Service case management system (Sugar) The Death Certification Review Service operates 24 hours a day, 7 days a week. Core business hours are Monday Friday 8.30am to 5.30pm. The service provides an out-of- hours on-call medical reviewer service, primarily to deal with advance registration applications. The service continues to receive fewer out-of-hours contacts than expected. Registrar referrals Section 2 of the Certification of Death (Scotland) Act 2011 states that A district registrar for a registration district may refer for review under Section 8(1) of that Act a certificate of cause of death where the district registrar considers it appropriate to do so. MCCDs referred by the registrar are reviewed at Level 2. The service received 21 registrar referrals in year two; of which 90% were found to be not in order. The service received a similar number of registrar referral cases its first year (27) with 77% found to be not in order. 19

20 Deaths outwith Scotland The service is responsible for checking relevant paperwork and authorising burial or cremation of people who have died outside the UK and have been repatriated (returned) to Scotland, often in tragic and particularly upsetting circumstances. For some deaths that occur outside the UK, the paperwork provided by the country where the person died may not contain information on the cause of death. If, following reasonable enquiries, the cause of death is still not clear, the family may be able to apply to the service for assistance (including financial assistance) to arrange a post-mortem examination. This may help to establish the cause of death. This is not an investigation of a suspicious death and is not designed to provide a second opinion, as there are other local and national processes available for this purpose. The service received 174 repatriation applications during year two; 30% of which were approved for burial, 70% of which were approved for cremation. The service received 2 post-mortem examination requests in the reporting period: 1 request was approved and 1 request was declined as a post-mortem examination had already been carried out in the country of origin, and a cause of death was or was likely to be available. 20

21 Breached cases The service aims to complete reviews within the timescales below (Table 7). Table 7: Service level agreement timescales Type Level 1 Level 2 Advance registration decision Senior Medical Reviewer escalation Interested person Repatriation Service level agreement timescale Within 1 working day Within 3 working days Within 2 hours Within 1 working day 3 to 14 days Within 5 working days Of all the cases the service reviewed, 161 (2.8%) cases breached the service level agreement timescales during year two. A breakdown of breach reasons are detailed in (Table 8). Table 8: Breakdown of breach category Category No Reason Count of cases 1 Case reported to the Procurator Fiscal 92 2 Difficulty contacting certifying doctor or member of team 47 3 Delay in obtaining required documents 13 4 Delay in receiving new MCCD/amendment 2 5 Delay with the post mortem examination 2 6 Foreign Commonwealth Office 2 7 Other 3 Total 161 Data source: Death Certification Review Service case management system (Sugar) The service provides NHS boards with any breach data during their 6-monthly review meetings. 21

22 Training and information function The Death Certification Review Service supports doctors, healthcare professionals, funeral directors, registrars and members of the public through the case selection and review process to minimise impact on the bereaved, and support continuous system and service improvement. In year two the service hosted 12 district registrars for shadowing experience and 1,081 telephone advice enquiries were received. It has become apparent the advice function is being considered a valuable resource in respect to cases not selected for review, deaths in the community, doctors referred to the service by the Scottish Fatalities Investigation Unit and members of the public. The service also continues to meet with NHS boards every 6 months to feedback performance statistics and discuss their educational support requirements. Engagement from NHS boards in terms of educational support has been variable across Scotland and uptake continues to be lower than expected. The Senior Medical Reviewer and medical reviewers delivered 21 educational sessions to NHS boards. Service evaluation The service conducted a Survey Monkey questionnaire from 1 November 2016 to 31 January 2017 to evaluate participant experience. The results demonstrate a high degree of respondent satisfaction and medical reviewer compliance. The service reflected on free text comments provided by respondents and will work together with staff to ensure: all participants are made aware of the survey end date we are consistent in terms of inviting participants, and we are consistent in terms of communicating the importance of getting the MCCD right during educational discussions. Complaints, concerns, comments, compliments The service received 4 complaints during year two: 3 related to service provision and 1 related to policy/communication. All complaints received were processed within the NHS complaints timescale. 3 complaints were upheld. DCRS complaints are formally reported in the Healthcare Improvement Scotland Complaints and Feedback Annual Report. The service also received 2 concerns in relation to cases outwith the service's remit and 11 comments. No formal compliments were recorded. As a result of this feedback a number of improvements were made to service provision. 22

23 Stakeholder reflections Despite some initial worries prior to the new death certification procedures coming into effect, it has been a great pleasure for registrars and National Records of Scotland to see the system go live with few difficulties, very little in the way of out-of-hours problems and most importantly a minimal impact on families registering a death. This would not have been possible without an excellent working relationship between the Death Certification Review Service, National Records of Scotland and registrars, and this will be the basis for successful operation of the service in the future. Rod Burns: Deputy Registrar General The Crown Office and Procurator Fiscal Service involvement in deaths investigation intersects with that of DCRS where the death is from natural causes. In such cases, we continue to work closely with DCRS to reduce the numbers of unnecessary post-mortem examinations. It is of great benefit to us to be able to refer doctors to DCRS for advice and support where they are unsure if they can provide a certificate. This has been particularly valuable at times of peak activity such as the Christmas and New Year periods. We have participated in joint training initiatives and very much appreciated the training on the role of the Medical Reviewers. David Green: Deputy Head of Specialist Casework, Head of the Scottish Fatalities Investigation Unit 23

24 Moving into the third year, the system is really working well. Reviews are being completed timeously and the use of the electronic signature pads is saving return appointments to the registration office for informants. Any issues are resolved quickly with the various stakeholders. Cathy Dunlop: East Ayrshire District Registrar As a certifying doctor in a hospice, I only had positive experiences in dealing with the Death Certification Review Service. I always found the medical reviewers to be helpful and the discussions productive. I liked the systematic approach of the reviews and was delighted when the opportunity arose to be a medical reviewer. Now, when I speak to certifying doctors I am able to draw on my previous experience and offer practical advice and support, to help ensure that the system works for everyone. Anne Marie Brandon: Healthcare Improvement Scotland, Medical Reviewer 24

25 Adverse events and lessons learned The service has reflected on interesting cases and adverse events which have led to changes in existing standard operating procedures and the creation of new standard operating procedures. Where appropriate, the service shared lessons learned with NHS boards and partner organisations. The service conducted a national pilot Emergency Care Summary (ECS) access for Level 1 case reviews during year two. The pilot demonstrated clear benefits in terms of: supporting case reviews improving the quality of case review, and negating the need for medical records requests in some cases. A recommendation was made to the Death Certification Review Service Management Board in July 2017 to incorporate ECS access for Level 1 reviews. 25

26 Annex A Membership of Death Certification Review Service Management Board Healthcare Improvement Scotland Dr Brian Robson Dr George Fernie Rachel Wyse Angela Hay Tim Norwood Scottish Government Cheryl Paris NHS 24 David Wright NHS National Services Scotland, IT Neil Dustan Scottish Fatalities Investigation Unit David Green Medical Director/Chair Senior Medical Reviewer Operations Team Manager Service Manager Data & Measurement Advisor Burial and Cremation Legislation Team Head of Integrated Service Development Head of Information Technology Programmes Head of the Scottish Fatalities Investigation Unit Public Partners Michael Macmillan Howard McNulty Association of Registrars Scotland Cathy Dunlop NHS Education for Scotland Janice Turner Senior Registrar Principal Educator, Medical Education NHS National Services Scotland, Information Services Division Helen Storkey Information Consultant National Records of Scotland Rod Burns Jim Clark Deputy Registrar General Systems Development Manager 26

27 You can read and download this document from our website. We are happy to consider requests for other languages or formats. Please contact our Equality and Diversity Advisor on or For more information about Healthcare Improvement Scotland s Death Certification Review Service, visit or telephone

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