Billy Horner
Well-known member
I believe that the situation within care homes has been nothing short of a scandal. They have not been prioritised for the supply of PPE to their staff, have been almost totally excluded from the testing regime and their staff, who are amongst the lowest paid and most overworked in the country, have basically been left to muddle through as best they can. In many ways it has put into sharp focus how our social care system is very much the Cinderella service when it comes to health care in this country.
However, the one area where I do have some sympathy with the Government is on the timely reporting of deaths within a care home setting. It is incredibly difficult to see how an accurate and robust system could be introduced that would enable such deaths to be included within the figures published daily by the Department of Health and Social Care (DHSC).
The figures currently published daily are a count of those who have tested positive for Covid-19, who have then subsequently died within hospital. As a result, we know for certain that all of those individuals actually had Covid-19, we know that they were suffering severe symptoms as a result (because our testing regime only tests individuals who meet that criteria) and we know that they then, unfortunately, went on to die whilst in hospital. Therefore, we can have a high degree of confidence in the accuracy of these statistics.
In addition, NHS Trusts are large organisations with teams of staff who are suitably qualified and experienced in collating, validating and submitting data on a daily basis. They have the reporting systems in place and people who are used to operating them in an accurate and timely manner.
The system in care homes is completely different. Firstly, there is no 'chain' to follow, whereby an individual displays severe symptoms, tests positive for the virus, receives medical intervention within a hospital and then, ulimately, dies from the disease. There will, of course, be significant evidence regarding the symptoms suffered by individuals in care homes, but they will be contained within their personal medical records and care plans, which are not routinely reported anywhere (for obvious reasons).
Therefore, we are entirely reliant on the attending doctor who has certified the death. I have absolute confidence in their clinical judgement, which will be based on the individual's recent and underlying medical history, displayed symptoms and progression of disease. Even if we had doubts about the accuracy of the above, the law is clear that a doctor can only certify a death if they have clear clinical evidence of cause of death, and any cases which do not meet that criteria must be reported to the coroner.
It can take several days for a doctor to complete and submit the Medical Certificate of Cause of Death (MCCD). Following receipt of the MCCD, the notifying person (usually the next of kin) has a further nine days to register the death with the Registrar of Births, Deaths and Marriages. This is the reason why the ONS statistics on registered deaths are published two weeks in arrears. Any deaths which have been reported to the coroner cannot be registered until the coroner has concluded their enquiries, which leads to further delays.
The only way in which the system could be speeded up would be, in my opinion, to enable reporting once the MCCD has been issued, rather than waiting for registration of the death to have occured. However, this would require either the attending doctor to submit the information to the DHSC or, alternatively, for the care home themselves to do so.
Both of those systems would have significant problems. If we ask attending doctors (usually GPs) to do it, we would be placing an additional administrative burden on them, at a time when they are already struggling to deliver community based health services and are attending and certifying significantly more deaths than is usual. The data would also require a secondary validation in order to collate place of death in a meaningful, statistical manner which would be an additional burden on GP practices. I am not sure this should be our priority for GPs at this time.
If however, we ask care homes to do it, then this would introduce a whole series of issues. Firstly, do attending doctors routinely share information regarding cause of death with the care home? They may do so informally at times, but can a formal system be introduced which would provide an audit trail for reporting purposes? If such a system is introduced, how would that fit with the doctor's duty to report to the coroner and/or police if they believe that neglect or other action by care home staff may have contributed to the death?
What is the capacity for the care home staff to collate, validate and submit data accurately to the DHSC on a daily basis? How would they deal with the anomalies which invariably occur between one reporting period and the next? As this would be an entirely new administrative system which would require reporting in a uniform manner, what training could be provided duirng a period of social distancing that would enable care home staff to undertake this role in a competent manner? Again, at this point in time, should this be a priority for overstretched care home staff?
In any event, given the usual delay between point of death and the issuing of an MCCD, there would still be a delay of nearly a week (possibly longer if some form a secondary statistical validation is required) before these deaths could be included in the daily figures published by DHSC. My personal view would be that we should wait the additional week and continue to use the ONS publication on registered deaths to capture this information, as this utilises a system which is accurate, well established and well resourced.
However, the one area where I do have some sympathy with the Government is on the timely reporting of deaths within a care home setting. It is incredibly difficult to see how an accurate and robust system could be introduced that would enable such deaths to be included within the figures published daily by the Department of Health and Social Care (DHSC).
The figures currently published daily are a count of those who have tested positive for Covid-19, who have then subsequently died within hospital. As a result, we know for certain that all of those individuals actually had Covid-19, we know that they were suffering severe symptoms as a result (because our testing regime only tests individuals who meet that criteria) and we know that they then, unfortunately, went on to die whilst in hospital. Therefore, we can have a high degree of confidence in the accuracy of these statistics.
In addition, NHS Trusts are large organisations with teams of staff who are suitably qualified and experienced in collating, validating and submitting data on a daily basis. They have the reporting systems in place and people who are used to operating them in an accurate and timely manner.
The system in care homes is completely different. Firstly, there is no 'chain' to follow, whereby an individual displays severe symptoms, tests positive for the virus, receives medical intervention within a hospital and then, ulimately, dies from the disease. There will, of course, be significant evidence regarding the symptoms suffered by individuals in care homes, but they will be contained within their personal medical records and care plans, which are not routinely reported anywhere (for obvious reasons).
Therefore, we are entirely reliant on the attending doctor who has certified the death. I have absolute confidence in their clinical judgement, which will be based on the individual's recent and underlying medical history, displayed symptoms and progression of disease. Even if we had doubts about the accuracy of the above, the law is clear that a doctor can only certify a death if they have clear clinical evidence of cause of death, and any cases which do not meet that criteria must be reported to the coroner.
It can take several days for a doctor to complete and submit the Medical Certificate of Cause of Death (MCCD). Following receipt of the MCCD, the notifying person (usually the next of kin) has a further nine days to register the death with the Registrar of Births, Deaths and Marriages. This is the reason why the ONS statistics on registered deaths are published two weeks in arrears. Any deaths which have been reported to the coroner cannot be registered until the coroner has concluded their enquiries, which leads to further delays.
The only way in which the system could be speeded up would be, in my opinion, to enable reporting once the MCCD has been issued, rather than waiting for registration of the death to have occured. However, this would require either the attending doctor to submit the information to the DHSC or, alternatively, for the care home themselves to do so.
Both of those systems would have significant problems. If we ask attending doctors (usually GPs) to do it, we would be placing an additional administrative burden on them, at a time when they are already struggling to deliver community based health services and are attending and certifying significantly more deaths than is usual. The data would also require a secondary validation in order to collate place of death in a meaningful, statistical manner which would be an additional burden on GP practices. I am not sure this should be our priority for GPs at this time.
If however, we ask care homes to do it, then this would introduce a whole series of issues. Firstly, do attending doctors routinely share information regarding cause of death with the care home? They may do so informally at times, but can a formal system be introduced which would provide an audit trail for reporting purposes? If such a system is introduced, how would that fit with the doctor's duty to report to the coroner and/or police if they believe that neglect or other action by care home staff may have contributed to the death?
What is the capacity for the care home staff to collate, validate and submit data accurately to the DHSC on a daily basis? How would they deal with the anomalies which invariably occur between one reporting period and the next? As this would be an entirely new administrative system which would require reporting in a uniform manner, what training could be provided duirng a period of social distancing that would enable care home staff to undertake this role in a competent manner? Again, at this point in time, should this be a priority for overstretched care home staff?
In any event, given the usual delay between point of death and the issuing of an MCCD, there would still be a delay of nearly a week (possibly longer if some form a secondary statistical validation is required) before these deaths could be included in the daily figures published by DHSC. My personal view would be that we should wait the additional week and continue to use the ONS publication on registered deaths to capture this information, as this utilises a system which is accurate, well established and well resourced.