Inspired by the recent death of Queen Elizabeth II and publication of her death certificate, a discussion of the procedures which follow death, an overview of the ways in which cause of death can be determined and the implications of such determinations on inquest findings (here, considering neglect) and other legal claims.
By Beth Caunce, Pupil Barrister at 9 St. John Street Chambers
At 7pm on 8th September 2022 the UK was stopped with news of the death of Queen Elizabeth II. Some weeks later the death certificate, dated 29th September 2022, was made public. This listed cause of death as I(a) Old Age.
Post-Death Procedure
After death, the doctor who attended the deceased during their last illness must complete a medical certificate of cause of death which is then delivered to the relevant registrar. Doctors and registrars have a legal obligation to report certain categories of death to the coroner under the Notification of Deaths Regulations 2019 and the Registration of Births and Deaths Regulations 1987 respectively. Such instances include:
- Deaths which appear to have been unnatural or violent
- Deaths which occur while the deceased was undergoing a medical procedure
- ‘Natural’ deaths where concerns about neglect or standards of care are present
- Deaths for which the cause is not known
The law requires that where a doctor can issue a Medical Certificate of Cause of Death they should do so, even if the death has been reported to the coroner. This can differ in practice, as coroners may request that a doctor does not complete the certificate if a post-mortem has been ordered or if an inquest is to be conducted. The coroner can legally certify the cause of death if this has been investigated through an autopsy or inquest.
Medical Certificate of Cause of Death (“MCCD”)
Doctors are provided with guidance for completing medical certificates.[1] The cause of death statement is divided into Parts I and II. Part I is used to show the immediate cause of death and any underlying causes. The certificate will record the disease or condition that led directly to death on the first line (I(a)), and work back in time through the antecedents of this condition until the underlying cause of death is reached. Where there is only one condition which led directly to death with no antecedents, only line I(a) would be completed.
Part II is used for any significant condition or disease that contributed to death, but which is not part of the sequence leading directly to death. Where possible, the approximate interval between the onset of the contributing conditions and the death can be included.
Old Age/Senility
The guidance states that old age or senility should be given as the sole cause of death in only very limited circumstances, where the doctor:
- Has personally cared for the deceased over a long period (years, or many months)
- Has observed a gradual decline in your patient’s general health and functioning
- Is not aware of any identifiable disease or injury that contributed to death
- Is certain that there is no reason that the death should be reported to the coroner
Instead, old age or frailty is more typically included as a contributory cause, particularly if the condition which directly caused death would not ordinarily be fatal. For instance, if the immediate cause of death was Covid-19 and the deceased was particularly vulnerable due to old age, it may be appropriate to include old age as a contributing factor.
The Queen’s death was registered by medical practitioner Douglas James Allan Glass, an apothecary to the Queen and her personal doctor in Scotland. It would be rare for ordinary members of the public to have personal care from the same practitioner for the requisite period. There are further issues around the age limit for old age to be considered adequate as a cause of death. There is no statutory age limit. The ONS Death Certification Advisory Group has recommended that deaths certified as due to old age or senility alone should be referred to the coroner unless the deceased was aged 80 or older. Consequently, a death certified as due to old age or senility alone will usually be referred to the coroner, unless the deceased was over 80 and the conditions above are satisfied.
Inquest Conclusions
Section 10 of the Coroners and Justice Act 2009 requires the coroner (or jury) to make a determination of the matters to be ascertained by the investigation and make findings for registration purposes. The questions are who the deceased was and when, where and how they came by their death, addressed by way of a 3-stage process:[2]
- Stage 1: Make findings of fact based upon the evidence
- Stage 2: Distil from the findings ‘how’ the deceased came by their death
- Stage 3: Record the conclusion, either a short-form conclusion or a narrative conclusion, or a combination of both, which must be consistent with (1) and (2) above
A list of short-form conclusions is produced in the Schedule to the 2013 rules and includes natural causes, misadventure and suicide, among others. Narrative conclusions are directed to the issues which are central to the cause of death, without needing to state a conclusion on every issue raised.
One conclusion which might be drawn is neglect. Neglect can form part of a short-form or narrative conclusion at the close of an inquest. Neglect has a restricted meaning in inquests which is narrower than the duty of care in the law of negligence. There must be a sufficient level of fault to justify the finding, where there has been a gross failure to provide basic medical attention to someone in a dependant position.[3] Generally this will be limited to failures to make the most basic of checks, rather than every twist and turn of the patient’s treatment.[4]
Conduct amounting to neglect is insufficient for the finding to be made. The critical factor is whether there was a direct causal connection between the conduct and the cause of death. The conduct must have more than minimally, negligibly or trivially contributed to the death and “the opportunity of rendering care…would have prevented death”.[5] Only if, on the balance of probabilities, care should have been rendered and this would have saved or prolonged life, will a conclusion of neglect be drawn.
Implications
The implications of findings as to causes of death are wide-ranging. These provide a level of closure for families. They inform public mortality statistics. Where an inquest addresses adequacy of care specifically, the investigations and conclusions can be material on other legal processes, such as claims in negligence brought in relation to poor medical, nursing or residential care. Where neglect is investigated and found, this can have a critical bearing on the conduct and outcome of such future claims. Even absent such a conclusion, the investigations and considerations of neglect can inform such processes.
Old age was appropriate for the Queen in the circumstances of her death, but it will rarely be appropriate for the general public. Instead, the primary cause of death and underlying conditions will be addressed. These investigations allow a coroner to draw conclusions as to how an individual has died. Conclusions such as neglect can have a critical bearing on future actions. Nonetheless, inquests serve a particular purpose, and the scope of an inquest will necessarily limit the investigations and findings which may later become appropriate in other claims. The ways in which care and neglect cause death, rather than the conduct itself, remain at the fore.
Beth Caunce, Pupil Barrister at 9 St. John Street Chambers
[1] https://www.gov.uk/government/publications/guidance-notes-for-completing-a-medical-certificate-of-cause-of-death/guidance-for-doctors-completing-medical-certificates-of-cause-of-death-in-england-and-wales-accessible-version
[2] https://www.judiciary.uk/guidance-and-resources/chief-coroners-guidance-no-17-conclusions-short-form-and-narrative/
[3] R (Khan) v HM Coroner for West Hertfordshire [2002] EWHC 302 (Admin) at [44].
[4] R (Nicholls) v HM Coroner for City of Liverpool [2001] EWHC Admin 922 at [45]-[58].
[5] R v HM Coroner for Coventry ex parte Chief Constable of Staffordshire (2000) 164 JP 665.