Launch of New Death Certification System to Prevent Crimes Like Lucy Letby’s Delayed Again
The implementation of a crucial death certification system in England and Wales, aimed at preventing tragedies similar to those caused by Lucy Letby and Harold Shipman, has been postponed until September, marking another delay in its rollout. Initially planned to be operational this month, the new system now faces a five-month setback, by GovWire.
This system mandates that medical examiners thoroughly review causes of death not already referred to the coroner, enhancing the scrutiny of death certifications. This change is part of broader reforms intended to bolster safeguards against criminal activities within the healthcare system and to provide families with greater involvement and transparency during the certification process.
The necessity for this revamped system was first proposed following the horrific findings of a public inquiry into the actions of Dr. Harold Shipman, a general practitioner who became the UK’s most notorious serial killer by claiming the lives of at least 215 patients under his care. The inquiry revealed that Shipman had manipulated the death certification process to avoid detection, often attributing the deaths to natural causes, thus bypassing coroner reviews.
More recently, the system’s urgency was underscored by the case of Lucy Letby, a neonatal nurse convicted of murdering seven infants and attempting to murder seven others. Letby’s heinous acts during her tenure at the Countess of Chester Hospital from 2015 to 2016 have led to calls for a more stringent review process to prevent similar atrocities.
Under the new system, medical examiners will confirm the accuracy of death certificates and ensure proper referrals to coroners when necessary. They will also engage with the deceased’s families or representatives, addressing any concerns or questions they might have.
Health Minister Maria Caulfield emphasized the complexity and sensitivity required to reform the death certification process. “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,” Caulfield stated. She reassured that the measures being introduced would make the system safer by improving protections against potential abuses.
Dr. Suzy Lishman, a senior advisor on medical examiners for the Royal College of Pathologists, welcomed the transition to a statutory system, noting that it would “further strengthen those safeguards, ensuring that all deaths are reviewed and that the voices of all bereaved people are heard.”
Similarly, National Medical Examiner Dr. Alan Fletcher expressed satisfaction with the confirmation of an independent statutory basis for medical examiners, which he believes will support patient safety learning and improvement, including through more accurate coroner referrals.