Death certification system designed to prevent another Lucy Letby scandal delayed again

The roll-out of a new death certification system designed to prevent another Lucy Letby or Harold Shipman scandal has been pushed back until September.

Last year, the Government announced that medical examiners would investigate causes of death in England and Wales which have not been referred to the coroner.

The move, designed to help strengthen safeguards and prevent criminal activity, was supposed to come into force this month but has now been delayed until 9 September following repeated delays.

Medical examiners will have to confirm the proposed cause of death and overall accuracy of the death certificate under the reforms, as well as support any appropriate referrals to the coroner. They will also consult with families or representatives of the dead to give them the chance to ask questions or raise any concerns.

Ministers said the changes demonstrate the Government’s commitment to providing greater transparency and will ensure the right deaths are referred to coroners for further investigation.

A national system to cross-check all deaths was first recommended two decades ago following a public inquiry into Dr Harold Shipman’s crimes, which found he had killed at least 215 of his patients while working as a a GP in Hyde, Greater Manchester.

Shipman, the UK’s most prolific serial killer, was able to escape detection by certifying that patients he murdered had died from natural causes, avoiding scrutiny by a coroner.

Since 2019, NHS trusts have appointed medical examiners to scrutinise most deaths in acute healthcare settings and some community settings on a non-statutory basis, but critics say the changes should have been made sooner.

Letby, 33, was convicted of murdering seven newborn babies and the attempted murder of seven others during her time as a neonatal nurse at the Countess of Chester hospital between 2015 and 2016. A bid to appeal her convictions will be heard in court this month.

Both scandals “highlighted the need for an extra layer of scrutiny”, the Government said.

Health minister Maria Caulfield said: “Reforming death certification is a highly complex and sensitive process, so it was important for us to make sure we got these changes right. At such a difficult time, it’s vital that bereaved families have full faith in how the death of their loved one is certified and have their voices heard if they are concerned in any way.

“The measures I’m introducing today will ensure all deaths are reviewed and the bereaved are fully informed, making the system safer by improving protections against rare abuses.”

Welcoming the announcement Dr Suzy Lishman, senior advisor on medical examiners for the Royal College of Pathologists, said: “Medical examiners are already scrutinising the majority of deaths in England and Wales, identifying concerns, improving care for patients and supporting bereaved people. The move to a statutory system in September will further strengthen those safeguards, ensuring that all deaths are reviewed and that the voices of all bereaved people are heard.”

National medical examiner Dr Alan Fletcher said: “I am delighted that the statutory basis for independent medical examiners is confirmed. This will ensure all bereaved people have a voice, supporting patient safety learning and improvement, including through accurate coroner referrals.”