Certification of Death (Scotland) Bill
The next item of business is a debate on motion S3M-8126, in the name of Shona Robison, on the Certification of Death (Scotland) Bill.
10:32
We are debating a bill that will provide us with a proportionate and robust approach to the scrutiny of death certification. The proposals will lead to a modern Scottish death certification system that is sensitive to bereaved families’ needs.
The bill will introduce a single system of independent scrutiny of medical death certificates that will apply to deaths that do not require a procurator fiscal investigation. The system is based on one of the models that the independent expert burial and cremation review group proposed. The review group was established in 2005 and reported in 2007. Last year, I consulted on all its recommendations. The bill relates to the certification of death aspects.
Most consultation respondents supported our preferred model, which forms the basis of the bill. They included all the respondents who represented patients and consumers, as well as the majority of local authorities and of public bodies and half the medical respondents, including the Royal College of Physicians of Edinburgh, the Royal College of Physicians and Surgeons of Glasgow and the General Medical Council.
The new system will replace the current crematoria medical referee system and the associated forms and will therefore abolish all the cremation fees that families pay to doctors. The bill will remove the historical differences between cremation and burial, which were introduced when medicine was less advanced and when it was believed that more stringent measures were needed for cremations, because the evidence of the body would be destroyed.
In fact, as the independent expert review group concluded, after a body has been embalmed and buried, often little forensic information is available even when the body is exhumed, particularly if it is exhumed after a significant time. This is why we came to the view that the additional checks in cremation cases led to expenses and delays without providing benefits for families or value for money.
No death certification system can guarantee to prevent criminal activity such as that which Harold Shipman carried out, but our proposals are robust and have been designed to deter malpractice and provide public reassurance. It is important that the new death certification system will benefit bereaved families, to whom we owe a duty to ensure that any new system will minimise distress, avoid undue delay to funerals and be affordable.
Nowadays, the majority of families opt for cremation. Once the new system commences, they will no longer have to pay cremation fees, which are currently £147 plus an additional fee for the medical referee. Instead, a universal fee of about £30 will be charged. In addition, individuals will for the first time be empowered to request a review of the information in the certificate if they have concerns.
I stress that, at the heart of the future Scottish system, the emphasis will be on improving the quality of death certification. To that purpose, the independent medical reviewers will undertake 1,000 random comprehensive reviews, as well as additional targeted reviews. Actions following those reviews will be part of a quality improvement programme, and will include direct feedback to the certifying doctors, further investigations of the case, links with clinical governance, and training and educational activities.
The role of the new national statistician will be important. Regular statistical tests will be run on all death data and any unusual results will be identified and reported to the medical reviewers. Furthermore, following concerns expressed in the committee about deterrence and public reassurance, medical reviewers will also randomly scrutinise 25 per cent of all deaths—around 13,500 in all—by way of shorter level 1 reviews. That means that, when those deaths are combined with the number of cases that are reported to the procurator fiscal each year, around 50 per cent of deaths in Scotland will be subject to scrutiny. In other words, a doctor will have a 1 in 2 chance of their certificate being scrutinised.
At stage 2, we introduced amendments in response to concerns raised by the Health and Sport Committee and by stakeholders about where responsibility for checking foreign certificates associated with deaths overseas should lie. I reflected on that matter and listened to stakeholder concerns about the proposals in the bill to give that function to superintendents at local burial grounds and crematoria. The bill was then amended at stage 2 to require the medical reviewers office to carry out that function instead.
The bill’s fee provisions have been amended to allow for fees to be set below cost recovery. That follows a commitment that I made earlier, when I outlined additional reviews that will give rise to increased costs but which are to be paid for by the Scottish Government rather than through fees. The fee therefore will remain at around £30 per case, including costs for collecting the charge. We also amended the bill to clarify that we do not intend to charge a fee for the checking of foreign certificates.
If the bill is approved today, we will consult further on operational matters and the secondary legislation that will be required to implement the system. We acknowledge the need to continue to work with stakeholders, including the general public, on the test sites—which are scheduled for the following year—before the implementation of the new system, which is scheduled to take place during 2013-14. Of course, it is not just a matter of legislation and guidance; good communication and awareness raising will also be key activities in the next phases. I believe that we have a solid base on which to build and I look forward to the work coming to fruition.
I thank the Health and Sport Committee for its sterling work on this bill. As ever, the process has been very constructive. I also thank the committee’s clerks, who worked very hard, and I put on record my thanks to the bill team, who took on a significant piece of work with this bill.
I move,
That the Parliament agrees that the Certification of Death (Scotland) Bill be passed.
10:38
I would like to add to the minister’s thanks by thanking the witnesses who appeared before the committee. They were extremely helpful. In the Scottish Parliament, we go through a particular process with bills. First, there is a review by an expert group—in this case, there was a United Kingdom review of death certification, which led to changes being made in England. The review is followed by a consultation document, and then by a committee’s taking of evidence. It is often during those face-to-face evidence sessions that significant problems become apparent in the bill proposal. We probably need to examine carefully how often that has happened, and to consider what might have been done during the consultation process.
The major flaw with this bill was the level of scrutiny. Originally, the bill arose as a result of the Shipman case. Although the committee and the Government agreed that no system could ever have prevented someone as devious and psychopathic as Shipman from operating, public confidence must be retained. As the bill has gone through its stages, we have reached a point at which 50 per cent of death certificates will be scrutinised. That is a satisfactory move, but we will have to review and examine it in future. In England, a 100 per cent review rate has been adopted, but the costs of that are very much greater. We have a lower-cost system, but it has yet to be demonstrated that it will fully retain the confidence of the public.
The procurator fiscal review—half of cases are to be so reviewed—can be quite cursory, I remember, and I will be interested to hear the views of my colleague Dr McKee on that, if he speaks in the debate. I found that there were occasions on which a death occurred somewhat more suddenly than had been expected, although there were no suspicious circumstances. Nevertheless, because the death had occurred more suddenly, or because we did not have adequate information, since the person was a visitor to our committee—I mean a visitor to our practice area—
Committees have that effect.
Yes. Thank you, Stewart—I have lost my train of thought now.
In the case of a sudden death where we did not know a lot about the patient and we did not have a huge amount of information, our phone call to the procurator fiscal would prompt the question whether we had any real concerns. My response would typically be, “No, I have no real concerns,” so we would then be told, “Thank you very much—go ahead and do the certificate.” That is not a review.
We will need to consider the provisions carefully. We will need to consider the training of procurators fiscal and of doctors so as to ensure that, if we are to rely on half of all reviews being undertaken by the procurator fiscal, an adequate process is followed.
I do not wish to reiterate all the arguments that I advanced in earlier debates on the electronic aspect, but I remain disappointed that, in her opening speech at this final stage of the bill, the Minister for Public Health and Sport yet again did not mention electronic certification. I urge the Government and the minister, even at this very last, dying stage of the present Government—I had to get that in—to commit civil servants to commence consideration of the electronic aspect during the forthcoming interregnum period. We have had two months already; let us have some urgency on the matter. Let us consider what currently exists in the Information Services Division and let us begin now to examine the possibilities for developing a modern system. Although the minister said in her speech that we have a modern system, it is not—it is a revised system, based on an old paper system, with all that system’s flaws.
I still have concerns about the signature on the certificates. Previously, two thirds of them would be reviewed by a second and third doctor. Now, a junior hospital doctor will be able to sign the certificates, and no further review will occur in 50 per cent of cases—although it will vary from individual to individual.
I would like the guidance or the regulations to provide for a system that specifies that no foundation year 1 or foundation year 2 doctor should be able to sign the certificates; only those with specialist training in the hospital—what used to be called registrars—should be able to do that. Alternatively, there should be a counter-signature from the responsible consultant, to make sure. Furthermore, doctors should go through a specific training module.
All of that underlies my concern about retaining public confidence, which is fundamental to the revised system. Two thirds of individuals will welcome the fact that costs will go down from £160 to £30. On the subject of costs, I ask the minister to clarify something that she said earlier when she sums up: that there will not be a charge in relation to overseas deaths. I assume that there will still be a £30 charge—or will there be no charge whatever for people who die abroad? If that is the case, we will perhaps, as with the Eskimos, start to ask our elderly relatives to go to another country, albeit briefly, so as to save some money. That will not happen, of course, but I ask about the possibility of there being no charge. The system for overseas deaths that is now being put in place is a good one, with the central review, which I think will work well.
We have dealt reasonably well with expedited certification for faith burials, particularly for Jewish and Muslim groups. As we come to scrutinise the regulations and guidance, we will have to invite the Subordinate Legislation Committee to examine the matter carefully, with our colleagues in the Jewish and Muslim faith groups, so that the regulations ensure that the post hoc review system will be appropriate.
The bill has been amended appropriately, and I am glad that the Government responded entirely appropriately to the committee’s initial serious concerns. We will now have a modern, proportionate system—except for the fact that it should have been an electronic system from the outset.
10:45
I thank the witnesses, in particular Professor Stewart Fleming and Ishbel Gall, who scrutinised the bill effectively at all stages.
I am pleased that we have reached stage 3, at the tail end of the parliamentary session, but I remain uncertain whether the bill will lead to a system that is more robust than the current arrangements and more likely to identify a potential Harold Shipman or even provide us with more information on cause of death, as Professor Fleming said when he gave evidence and as Richard Simpson said in the debate. Although I remain unconvinced by the bill, I am a non-clinical member of the Health and Sport Committee. I am concerned, however, that the two highly experienced doctors on the committee also have reservations about it.
The bill has changed radically since it was introduced, as a result of the evidence that the committee heard and the minister’s evidence at the end of stage 1. That demonstrates how poorly the measures on certification of death in the bill as introduced reflected 21st century life, and it calls into question the extent to which the minister and the bill team took on board the written evidence that was submitted during the consultation. The committee heard the same concerns expressed in oral evidence at stage 1.
Although up to 1,000 level 2 reviews will be more detailed than is currently the case, level 1 review and certification, which it is alleged will cover up to 25 per cent of deaths, will be significantly less detailed than is currently required. The minister has assured us that the number of level 1 and level 2 reviews can be adjusted up or down and that the matter will be covered in guidance.
However, the bill will be passed in the final days of this session of the Parliament. In May we will have new committees with responsibility for health and subordinate legislation, and, perhaps, a new health minister. The members who agree to the statutory instruments that provide for the guidance will likely be unaware of the serious critical written and oral evidence that has been provided and there is the potential for the number of reviews to be adjusted downwards to the unacceptable levels that were provided for in the bill as introduced.
We have been given assurances on the two pilots that will take place prior to full implementation. However, given discomfort at a review rate of 4 per cent of death certificates—that is up from the 2 per cent in the bill as introduced—will the minister consider having one of the pilots review 4 per cent and the other review a much higher number, for example 10, 20 or perhaps 30 per cent of certificates? Such an approach would enable the new system to be evaluated and might be better than having two pilots—one in an urban area and one in a rural area—in which the rate would be exactly 4 per cent.
Currently, 62 per cent of deaths in Scotland result in cremation. Three doctors check the death certificate in cremation cases, two of whom are not part of the professional practice of the first doctor. After the bill is passed, not three doctors but one doctor will check the death certificate—yet we are told that that is an improvement.
How many of the 25 per cent of deaths that are currently referred to the procurator fiscal are subject to medical examination and review? I understand that the number is likely to be low, and clarity on the issue would be helpful. Will the minister respond in writing on that?
The Scottish Conservatives will support the bill, given that further changes will be made through guidance. We trust that the reservations that have been expressed throughout the bill’s passage will be taken on board by the Government and whatever Administration is tasked with issuing guidance after the election in May.
10:49
The bill was interesting. When it first came before the Health and Sport Committee, there was a sense that it was a relatively simple matter and that it would be disposed of relatively quickly. However, it proved to be rather different once we got into the detail.
As the minister pointed out, the proposal was based on extensive work by a review group and the model that the Government chose was one of those that the group put forward. I am bound to repeat the comment that I made at stage 2, which supports Richard Simpson’s comment, that the review group itself pointed in the direction of using electronic recording. I can see that there are difficulties when, at a rather late stage in the proceedings, members make clever suggestions that are difficult to encapsulate, but electronic recording was part of the review group’s recommendations, so I share the disappointment that attention was not given at an earlier stage to the possibility of, and the benefits that might accrue from, adopting such a system.
The second issue that quickly arose was the level of scrutiny. I do not necessarily share the view that it is possible to find a Shipman. None of the reviews says that it is and nobody seriously suggests that an individual who is determined wilfully to avoid any form of checking will be subjected to such a test under any system. However, as Richard Simpson made clear, there is a need for public confidence. The comparison was between the level of scrutiny that was applied to cremation cases and the level that was applied to burial cases. The evidence was clear and we were left uncomfortable about the level of review.
I am grateful to the Government for increasing its level of scrutiny. I am also grateful to the minister for writing to the convener of the committee setting out a matter that caused me some concern, which was the statistical basis for the ramblings—sorry, I mean the random sampling approach; it is quite difficult to say. The statistical basis for that random sampling, which was conducted by the Information Services Division at NHS National Services Scotland, is set out clearly in the letter and the accompanying one-page note.
Having considered that information, I am greatly encouraged by the combination of preparation for, and review of, the system. However, the minister must be clear that, because of the very different way in which the system will operate, it is imperative that there be clear, open and transparent review and that the results of any such review be published.
I am not sure about the level of doctors’ competence. I do not know whether they have the competence to fill in a death certificate when they qualify or whether they need many years’ experience before they can fill one in. That is a matter about which only medical people can tell me. However, death certification is important and I share Richard Simpson’s view that it is a question of establishing public confidence.
The minister dealt with other matters satisfactorily in her response to the committee’s recommendations. Those concerned not only the medical review, but bringing medical reviewers into the ambit of the check on overseas deaths. She also responded to the evidence about the necessity to expedite procedures to meet the requirements of faith groups. Those responses made substantial improvements to the bill.
The changes that have been introduced radically change the bill, which is much stronger as a result of the committee process. We need to monitor progress carefully in certain areas, but I am satisfied that the bill is worthy of support at decision time.
10:54
There is some belief that the bill is a dull affair and that it is just rather technical. However, information from death certification can have a major effect on future health expenditure. If a series of recordings showed that one condition or another was on the increase, but the recordings were inaccurate and the information incorrect, huge sums of money might be spent on the wrong priority.
It is important that we get things as right as we can, although, short of allowing for 100 per cent post-mortem examinations—and even then—there will always be inaccurate certificates whatever we do. From that perspective, I welcome the bill, as it aims to improve the accuracy of death certification by education and supervision and includes disposal by burial in its remit. There are some points of concern, however, which I raise in the light of my years of experience of the issue.
The bill provides for the appointment of medical reviewers and the minister has informed us that those might be part-time appointments. I think it vital that they are part-time appointments. That will mean that more individuals can be medical reviewers for the same financial outlay, so the geographical spread can be greater, meaning that the reviewer will have more local knowledge. It is important that a medical reviewer keeps up to date with clinical practice, which will be much more difficult, if not impossible, for someone who spends the entire time following up death certificates.
I have a major concern about the number and type of reviews that are implied by the financial memorandum and about which we have been informed by the minister. First, 25 per cent of deaths will be covered by a level 1 review, which seems to be little more than a telephone conversation with the certifying doctor. Although careful questioning might reveal one or two important background factors that can then be included in a certificate, we must bear it in mind that a doctor who has been rather casual in filling in a certificate—let alone one who has been negligent or worse—will have a vested interest in giving answers that back up the original certificate.
The same criticism applies to placing undue reliance on the fact that a procurator fiscal has been informed. Here, I agree entirely with Richard Simpson—I think that we are the only two people in the chamber who have practical experience of these matters—because most interchanges with a procurator fiscal are cursory telephone exchanges, with permission to go ahead with the certificate without much interviewing. There is a risk of a folie à deux in such situations, with neither professional wishing to go too deeply into the issue.
The level 2 investigations are much more comprehensive, but my concern here is about the small proportion intended—about 4 per cent, we are told. I know that the minister has reassured us that the statistics show that that figure is enough to give an accurate estimate of the total number of identifiably inaccurate certificates overall. As Ross Finnie said, that is true, but the present system for cremation, where in effect all disposals are subject to something very similar to a level 2-type procedure, identifies not only inaccurate certificates, but the deaths to which they relate. That allows the inaccuracies to be corrected, which will not be the case for at least the 50 per cent or more of certificates that are to be allowed through totally unchecked under present plans—and probably not for many of the rest.
Store is set by the two proposed pilots, but in a small pilot the number of level 2 investigations will be very small and I doubt that the evidence will be robust enough to draw accurate inferences about the reliability of the results. I agree to an extent with Mary Scanlon that it would be more informative to have two pilots, one of which reviewed 4 per cent of death certificates at level 2 while the other reviewed an increased proportion—for a small pilot, that could be 100 per cent—so that we could see the differences in results, if there were any.
We have been told that the reforms have their origin in the Shipman scandal but that no system could guarantee to prevent another such scandal. That is undoubtedly true, but that is no reason to replace the existing system of death certification with one that is less effective, simply to be able to charge smaller fees. I support the bill and will vote for it, as none of what I perceive to be defects are in the bill. If we truly wish death certificates to be more, rather than less, accurate in future, however, I am convinced that the proportion of level 2 assessments will have to be considerably increased.
10:59
I am very pleased that we have reached stage 3 of the bill and that its consideration is coming to an end. I tend to disagree with Ian McKee, in that I think that the bill is very technical, but I agree that it is incredibly important.
As was said at stage 2 and again today, the Shipman inquiry led to the bill and our work on it to see how it would affect the issues raised. It was acknowledged early in the process that it would be impossible to stop another Shipman, but the bill might act as a deterrent. I hope that it will also lead to better recording of the reasons for death.
I have a number of points on the pilots and implementation, and I make no apology for repeating much of what I said in the stage 1 debate. When I raised issues to do with the collection of fees by registrars and asked what would happen if a death were registered by a police officer or a neighbour, the minister said that she hoped that she could send out a reassuring message on that but, rather than reassurance, we need a clear solution. I ask her to bring forward such a solution, which should be available not only to people such as police officers, who might be asked to register a death, but to the likes of neighbours and friends of the deceased, who might wish to help a bereaved family in that way.
I welcomed the minister’s assurance in the stage 1 debate that non-payment of the fee would not delay certification, but clear guidance must be provided so that registrars know what to do in the process.
Another issue that I raised in the stage 1 debate was that of the delay that might be caused by a death being reviewed, which could be extremely distressing for cultural and religious reasons. The minister said that she would look at having test sites to see how the policy would work, and she suggested Glasgow as a possible test site for dealing with issues regarding faith groups. I welcome that commitment, but I ask that another of the test sites be in one of our island authority areas, where the local culture is that the body would normally remain at home prior to the funeral. That would enable us to look into how the operational issues could be dealt with in those areas.
Given the timing of the bill and of the setting up of the pilots, it might not be possible to test the proposed system in the winter months, so I ask the minister to ensure that the people who work in the test site areas look at the implications of poor weather and possible transport disruption. Last weekend, I had an interesting experience travelling to Shetland, which took quite a while longer than I expected and included an overnight stay in Kirkwall in Orkney, as well as a visit to Aberdeen. That is frustrating enough for people who have plans, but it could be extremely distressing for a bereaved family that was waiting for a medical examiner to pitch up, as it could delay the making of funeral arrangements.
The possibility of such delays might lead to a requirement for refrigerated mortuaries on our islands and in our remote communities, and that would come with an additional cost. Winter conditions are challenging for obvious reasons, but ferries and planes can also be affected during the summer months, when it can be difficult to get on and off islands because of tourist travel. In that period, it is often difficult to book a ferry or a plane ticket.
We must ensure that the policy works in practice, otherwise it will lead to distress and possibly to additional costs for authorities that attempt to implement the bill. We must also ensure that our remote, rural and island communities receive a service and safeguards that are equivalent to those that more urban areas receive. A process needs to be put in place that will deal with all those issues and deliver the same protection for all our communities.
The bill is technical, but it is important nonetheless, and we need to ensure that the system that it puts in place is right so that we can protect the people whom we seek to serve.
11:03
I have a few observations to make, some of which pick up points that others have made and some of which are new. Dr Ian McKee talked about the importance of death certification feeding into health care planning. That is correct, but we must not fail to take account of the need for death certification to feed into immediate response to possible epidemics. Professor Stewart Fleming did not make reference to that in his definition of the three aims of the certification process.
Ian McKee also talked—absolutely correctly—about folie à deux. It is worth saying that in aviation some 20 years ago we had precisely that situation in the cockpit, when a very senior captain would often not be told by a very junior but recently trained and high-quality first officer that they were getting it wrong. In designing the relationship between different players in the system, we must be aware of the influence that respect for experience and seniority has and must ensure that a junior person can point out freely and frankly to a more senior person that they are not up to the standard that is required. Folie à deux was killing people in aviation 20 years ago, but training has changed and it is not killing people now.
Last week, I had the very great pleasure to be in Giffnock synagogue to launch a Jewish education project on the internet. On that occasion, I received representations on the particular issues surrounding Jewish burial practice, which are equally applicable to people of the Muslim faith. It is important that we take account of the fact that those faiths use burial rather than cremation and make sure that we acknowledge that and preserve those traditions.
Rhoda Grant talked about testing. It is worth observing that testing has more limitations than one might imagine. About 30 years ago, IBM produced a computer that turned out to incorrectly multiply 10 by 10,000,008. Every other calculation appeared to be correct, but it was established that to use testing to see whether they were correct would require every model of that computer that had ever been produced to run through exhaustive tests for more than 1,000 years. It is important to get the design of the system correct.
We have heard some discussions about computers and I want to make some observations, of which members might or might not be aware, that indicate the need for some caution. For the registration of births, Registers of Scotland provides 200 characters for forenames and 50 characters for surnames. Approximately 19 per cent of current registrations are for people who have three or more forenames, so that issue is not insignificant because people have more complex names than they once had. Until a few months ago, I was refusing to take my parliamentary payslip—I was still taking the pay, of course—because my name was not right on the payslip. I am James Alexander Stewart Stevenson and the system provided for only two initials, thus omitting the initial that I use.
Joining computer systems together is often complex when we look at the metadata, to use the technical term, that are associated with information. I say that in the context of my genealogical researches on my great-grandfather who was a coal miner in Bannockburn. He first appears in the record in the 1841 census. The difficulty is that he is one of 328 Stevensons who were working in coal mining in Bannockburn in that year. Having the ability to distinguish names is very important indeed.
Equally, even if we impose rigorous standards for data collection and entry, there might be difficulties. When I worked in the Bank of Scotland, financial services legislation was introduced that required that we collect people’s dates of birth. Our tellers found themselves inhibited in asking ladies of a certain age what their date of birth was, but they had to put in a date so they just chose a random date. We ended up with something like 9 per cent of dates being 1 January. A further 2 per cent turned out to be the teller’s own birthday and, for a further small proportion, the teller simply entered that day’s date and discounted the number of years. Computer systems are not just mechanical systems; they have to interact with the human effects that often surround the collection of data.
If time permits, Presiding Officer—no; I see that you are signalling to me to wind up.
That would be a sensible idea.
In that case, I will close. Clive James’s autobiography contains the wonderful phrase,
“Don’t take life seriously; you won’t get out of it alive anyway.”
Today, we take death seriously and we are entirely correct to do so.
11:09
As I am not a member of the Health and Sport Committee, I come to the bill and the debate as a comparative layman. However, I am struck by a central theme that we have heard a lot about this morning, which is what Dr Simpson referred to as whether the next of kin are content with the death certificate. Public confidence depends on whether people are content with the stated reason for death.
I go back a few years to a case that exemplifies the question of doubt. It started on the day in 1997 when the body of Kevin McLeod was pulled out of Wick harbour. Despite meetings with the police and other authorities, including the procurator fiscal, the doubt about and lack of confidence in the death certificate remains. Kevin McLeod’s death predated by two years my election as an MSP. However, like every other Highland member, I was aware of the case. Questions were raised on the matter in the chamber, but we still do not know whether Kevin McLeod accidentally fell to his death or whether he was murdered. That lack of confidence is exactly what this debate is about. I am aware that I have used an extreme example, but the failure to ascertain the facts means that Kevin McLeod’s family and friends and many people in the north of Scotland remain unhappy with the system. What we see in the bill goes a long way towards addressing the issue.
Dr Simpson mentioned training for medical professionals and procurators fiscal. I argue that such training should be extended slightly more widely than that, perhaps to include our police services. I do not wish to denigrate anyone, but doubt will remain until we can demonstrate to the public that things are being done to the highest possible standards and that our systems are watertight. We must get rid of that doubt. That is what the bill is mostly about.
Does the member accept that it is not possible to eliminate all doubt from death? I say that having been close to a suicide. To this day, more than a decade later, we do not know the cause. The medical record shows the correct reason for death, but the underlying cause is still not known. There will always be a small percentage of cases in which certainty simply cannot be given.
I accept that, but the point of raising Kevin McLeod’s death was to highlight a case in which the element of doubt is unacceptably high. In a proper democracy, that should be totally unacceptable.
I turn to the policy memorandum and two issues in particular to which my attention has been drawn. First, people rightly welcome the reduction in the cost of cremation but, as the policy memorandum points out, we must remember that in island, Highland and other remote areas the prevalence of burial is statistically higher than is the case in the rest of Scotland. We must guard against any possible increase in the cost of burial. I am not saying that that will necessarily happen, but we must be careful. Secondly, people have concerns about delay between death and the funeral and burial or cremation. Other members touched on that. As is the case in many other countries, the feeling in Scotland is that the dead being unburied is completely and utterly unacceptable. As other members rightly said, we must minimise distress to families. This is an important issue. I do not for one instance want to suggest that the bill may lead to delay, but we must guard against that.
Once we have agreed the bill at decision time—which I am sure that we shall—it will be for a future Government and the civil service to ensure that the driving principles behind the bill are met. Those principles are making things more efficient and increasing public confidence. We also want to avoid another Harold Shipman, although I accept that we can never rule that out entirely. We must increase public confidence at all times. That is the great goal that is to be attained.
I cannot wave a magic wand to find out the truth about Kevin McLeod’s death, but as long as such doubts remain, they should act as a spur to members. We must minimise doubt. It may or may not be up to my successor to take up the issue in a future session of the Parliament. I support the bill.
11:13
Despite Stewart Stevenson’s incredible experience in business, innovation and enterprise throughout Scotland, he seems to think that modern technology is incapable of overcoming all the obstacles and difficulties that he raised. That is the challenge for technology. Someone having more than two or three Christian names—indeed, someone having 11 Christian names, having been named after a football team—should not be used as a reason not to utilise and embrace technology.
We need only consider telehealth and e-health, including the advent of clinical portals and electronic bed management, to see the advantages to the NHS of having such instant information and communication. Long-term self-management of many conditions also brings benefit to the NHS and the taxpayer, particularly in these difficult times. There is also the benefit to patients. We have to overcome these difficulties; obstacles cannot be put in the way.
I agree with every word that Mary Scanlon has said; I merely sound a note of caution that it is sometimes more difficult than people imagine to achieve that desired outcome. In particular, we must have systems that allow unstructured data to be entered in a way that enables them subsequently to be analysed, as we are unlikely to identify every bit of data that we want to collect at the outset. That is difficult to do, but it needs to be done.
I appreciate that, but I am sure that people around Scotland like Stewart Stevenson, working in an advisory capacity, can keep everyone right.
My second point relates to the phone call to the doctor that is referred to on the first page of the supplementary financial memorandum to the bill, which states:
“The MR will discuss any concerns with the certifying doctor (or another doctor in the team) by phone and any disagreements will be covered by the same procedure as currently set out in the Bill.”
Had a medical reviewer phoned Harold Shipman, he might have said, “Well, she was getting old. She was over 80 and had been failing for a wee while,” and the medical reviewer might just have said, “That’s fine. Cheerio.” Is a phone call to the doctor who writes the certificate, with no further checks, enough? Having heard two doctors speak in the debate today, I still feel uncomfortable about that.
As a list MSP for the Highlands and Islands, I listened with interest to what Jamie Stone said about Kevin McLeod and the devastating impact of his death on his family. I have tried to help in that case and I appreciate what Jamie Stone said. We should all be aware of specific examples that lead to problems with death certification.
That takes me on to my next point, which I raised earlier. Sixty-two per cent of people in Scotland are cremated after their death; yet, in the future, only one doctor rather than three will check the death certificates and the evidence will be gone forever. In recent times, bodies have been exhumed and DNA samples have been taken for use in murder cases, et cetera. That is why I still have a level of discomfort about the proposal. I hope that the minister will raise the issue, as I am looking for assurances on the matter. I have been an MSP for 11 years, in which time many people have told me that their mother died of a hospital infection—that she did not die of whatever the certificate said. I welcome the fact that, under the bill, individuals and families will be able to request a review of their mother’s death or whatever. That is a step forward, as that is not possible at the moment. My concern is to ensure that hospital-acquired infections and things that contribute to someone’s death, although they may not be the actual cause of death, are taken into account.
I thank Ian McKee for his point about increasing the number of reviews. I also support Rhoda Grant’s proposal that there should be piloting on the islands, where the culture around death is very different.
11:18
The bill began rather like the Patient Rights (Scotland) Bill, looking rather flawed and weary, but it has been resurrected through the useful process that we have gone through. Nevertheless, doubts are still being expressed about whether the bill will introduce a fully robust system that will retain public confidence. The debate has been useful in suggesting that the pilot should be conducted almost as a research exercise, with not only 25 per cent of deaths being reviewed by medical reviewers, as is required by the act, and approximately 25 per cent of deaths being reviewed by procurators fiscal—accounting for 50 per cent of deaths—but 100 per cent of deaths being reviewed on a post hoc basis to determine whether the system that we are putting in place is error strewn.
If we are concerned about errors, we need look no further than two quotes from Professor Stewart Fleming. He told the committee that,
“in cases in which a post mortem was performed after a death certificate had been completed, the inaccuracy rate was about 20 to 30 per cent.”
He also said that, every year, around 30
“unnatural causes of death are picked up only at the confirmatory medical certificate on the cremation form.”—[Official Report, Health and Sport Committee, 1 December 2010; c 3756 and 3746.]
Some of those deaths might be due to road traffic accidents rather than something more serious but, nevertheless, they are missed.
Those are a few of the issues that we need to examine, apart from the general issues raised by the Harold Shipman case, which are almost a distraction. However, I should say that the care home deaths in England gave rise to considerable public concern. Therefore, an analysis on a geographic basis, which the bill provides for, is important. If there is a higher than normal proportion of deaths in one care home, that might lead to much more detailed scrutiny, which would be welcome.
I suggest to the minister that the details of the pilot should be brought before Parliament so that we have the opportunity to see precisely what is proposed. The Subordinate Legislation Committee or the committee that is responsible for health should have the opportunity to scrutinise them and make helpful comments to the minister and the team that is running the system.
Rhoda Grant raised the situation in remote and island communities. Clearly, those concerns are important. In her evidence to the committee, Ishbel Gall, from Aberdeen, gave us some classic illustrations of the practical difficulties that will need to be explored in the new system. A pilot, perhaps involving Aberdeen, that might address the issues around the island communities would be useful because a lot of people from the island communities die in hospitals on the mainland. The majority of such certifications take place in hospitals—hopefully we can change that, but it is not happening so far.
Rhoda Grant also referred to the problem of fee collection, and I will be interested to hear the minister’s comment on that when she sums up.
Ian McKee stressed the importance of accurate data. In that regard, I conclude by repeating what I said at the start of stage 1, which is that—Stewart Stevenson’s concerns notwithstanding—electronic data are the way forward, because drop-down menus allow people to be interrogated in a much more detailed way when completing the certificate and, far from adding time, can save time.
With regard to the ISD checks, which I presume will still occur, will the minister ensure that the regulations make it compulsory for there to be a response to an inquiry? In other words, if Colin Fishbacher or his successor has a query about the certificate, the doctor should be required to respond; it should not be voluntary. With regard to public confidence, it will be interesting to see whether the number of queries drops from the current level of 2,000 to a much lower level. If, under the new system of ISD checks, the number of those queries drops as a result of the accuracy of the data, it is possible that the system will have the public confidence that we all desire.
Wind up, please.
We have a better bill now, although it still needs to be reviewed and we will examine the pilots as they go through. I support the passing of the bill.
11:23
The debate has shown that, although there are still differences of opinion on some matters, the Parliament has engaged positively with the bill and has raised some important issues, which is encouraging. I have listened with great interest to the many and varied points that have been made about the proposals and I will try to respond to as many of them as possible.
Richard Simpson has, with some justification, doggedly pursued the issue of electronic medical certificates of cause of death. I envisage that work will start very soon on scoping the feasibility study on electronic MCCDs, and in the spirit of consensus I say to Richard Simpson that some of his pointers on where the starting point should be—instead of starting from scratch—are very helpful. He also asked a specific question about the charge for overseas deaths, and I can confirm that the £30 fee will apply in those circumstances.
It is worth putting on record my response to Richard Simpson’s point about the CHI number, which he raised in debating the amendments. I confirm that the General Register Office for Scotland already plans to add that to the MCCD, which I hope the member will welcome.
Mary Scanlon made a number of points in her opening and closing remarks, and I will pick up on one in particular: health care associated infection. We should bear in mind that the MCCD is a record of the cause of death and as such should not list all the conditions that the patient had at the time of death.
Mary Scanlon will be aware that an inquiry is currently examining the outbreak of Clostridium difficile in the Vale of Leven hospital. The inquiry’s terms of reference require an investigation into the recording of deaths associated with C diff in the NHS for the purposes of death certification. It might be premature to pre-empt the outcome, but I am sure that Mary Scanlon and many others will consider the specific issue and any recommendations that emerge.
I am trying to clarify two things. We all know that the cause of death is listed, but I have seen death certificates on which the major contributory factor is noted. That was the point that I was trying to make.
There is a difference between that and a list of every condition, as I am sure we agree.
Ross Finnie made a number of points and I am pleased that he found the letter on the statistical basis of the findings helpful. He raised the need for scrutiny to be open and transparent. I point out to him that the senior medical reviewer must provide an annual review of medical reviewers’ activities, which, I hope, will aid the transparency of the process.
I acknowledge Ian McKee’s interest in these issues, which he has pursued rigorously through the bill’s various stages. I know that he is yet to be persuaded on some matters, and I hope that the test site process will offer him and the other members who have raised concerns some reassurance on those issues. Rhoda Grant suggested that one of the test sites should be in an island authority, and we can certainly consider that, although as yet no decisions have been made about definite locations. We will take on board and reflect on her point about the implications of poor weather and transport disruption.
Stewart Stevenson highlighted the importance of being responsive to faith group issues. I think that that has been the case throughout the bill process, and our reassurances have been well received by the faith communities, which is to be welcomed.
Yet again, the bill process has in many ways demonstrated the work of the Parliament at its best. It has worked very effectively in taking through the bill, hearing the evidence and coming up with a series of recommendations that I have no doubt have improved the bill. I do not see that as a negative at all: it is very positive that the Parliament has had—as in so many cases—a positive impact on a piece of legislation by improving it.
We have an opportunity to reform and modernise death certification, and I invite the Parliament to agree the Certification of Death (Scotland) Bill, which I believe will achieve that.