Audit to evaluate delays in filling out Medical certificates of cause of death
Abstract
Introduction
A doctor's duty of care continues after a patient's death until the body leaves the hospital. Following a patient's death, doctors involved in their care receive reminder emails until a proposed Medical Certificate of Cause of Death (MCCD) is submitted. The case is then reviewed by a Medical Examiner (ME), who determines whether the cause of death is acceptable, requires amendment, or should be referred to the Coroner. Delays in completing this process can cause significant distress to bereaved families by delaying funeral arrangements and final rites.
Method
The Bereavement Team at Medway Maritime Hospital maintains a database of inpatient deaths, including dates of reminder emails, proposed cause of death, Coroner referrals and final MCCD completion. We analysed the number of working days between the date of death and proposed MCCD, ME acceptance and final MCCD completion, Coroner referral, and CN1A to final MCCD. Cases requiring an inquest or post-mortem were excluded due to unavailable data. Following the first audit cycle, an electronic MCCD system was introduced, allowing approved proposed MCCDs to populate the final certificate. Teaching sessions and awareness posters were also implemented between audit cycles.
Results
Across all specialties, implementation of the electronic MCCD system and targeted educational interventions was associated with improved timeliness of death certification. A greater proportion of proposed and final MCCDs were completed within 0–1 working days, with corresponding reductions in delays of 2–4 and 5–7 working days. Timeliness of Coroner referrals also improved across the trust, with referrals completed within 0–1 working days increasing from 51.7% to 73.0%, while referrals taking 5–7 working days reduced from 13.3% to 4.8%. Analysis then focused on patients under Frailty, where completion of proposed MCCDs within 0–1 working days improved from 58.3% to 76.9%, while completion of final MCCDs within 0–1 working days following Medical Examiner approval increased from 70.8% to 91.7%. Delays exceeding four working days were eliminated in the second audit cycle.
Conclusion
Introduction of an electronic MCCD system, supported by targeted education and awareness initiatives, was associated with improved timeliness of MCCD completion and Coroner referrals. Streamlining the certification process can minimise avoidable delays, reduce distress for bereaved families, and facilitate timely funeral arrangements.
Comments
electronic MCCD
This is a very interesting audit. We have recently implemented electronic MCCD in Ty Olwen, Morriston Hospital and I also feel that, since going online, completing MCCD has never been more streamlined. Most resident doctors are now able to complete the digital MCCD within a day or two. When before, it usually would take a lot more days as they would have had to make time to go to the care after death office and fill out the handwritten form which would usually require having to find time in a busy day on the ward or people might have to fill it out after finishing a long run of on-call nights. Thus, I agree that providing an electronic MCCD has also likely improved our timelines as well, so it would be interesting to do an internal audit to see if our data would objectively prove that as well.
Separating the electronic system from the teaching
Thank you for sharing this. Death certification stays invisible until it goes wrong for a family, and it is good to see it audited as a dignity issue rather than an administrative one. One thought on the measure. You have used working days throughout, which makes operational sense, but the wait a family experiences is in calendar days. A death late on a Friday certified on Monday counts as within one working day while the family has waited three, and that falls hardest on families whose faith expects burial within a day or two. Would it be possible to report calendar days alongside working days? It might also show that the delay that remains sits in the weekend and out of hours pathway. A second thought on attribution. The electronic system does something mechanically different from the teaching and posters, in that approved proposals populate the final certificate. The rise in final MCCDs within 0 to 1 days of ME approval, from 70.8% to 91.7%, may largely be that automation. The step still depending on a clinician is death to proposed MCCD, 58.3% to 76.9%. Since your conclusion is that the onus sits with the medical team, that second figure may be the one that shows whether the education worked. Congratulations for this important work!