‘Business Dilemmas’

A request to certifying the death of a patient from Covid-19 presents a difficulty for this doctor. Dr Sally Old gives her advice 

 

 

 

 

Dilemma 1

Can I sign death form for Covid?

Q I have received a call from the wife of one of my private patients with advanced prostate cancer who tells me that her husband has died at home. 

She said my patient would have wanted me to sign his death certificate, as he trusted me and didn’t have a good relationship with his GP. 

She revealed he had been disappointed with the outcome of a phone consultation with that GP in the week before his death. The patient had tested positive for Covid-19 and was self-isolating but had declined the GP’s advice of an admission to hospital when his condition deteriorated.

I feel that the GP would be better placed to sign the certificate, as I have not seen the patient for many months, but when I called the practice, I was told he was off sick and the receptionist didn’t know when he would return. 

I don’t want to let the family down, so would it be reasonable for me to complete and sign the death certificate in these circumstances?

A Ordinarily, the doctor who attended the deceased during their last illness should complete the medical certificate of cause of death (MCCD). However, death certification rules in England and Wales have been changed temporarily to recognise that this may not be possible during the pandemic. 

Under the Coronavirus Act 2020, the MCCD can be completed by a doctor who has not seen the patient in their last illness if it is not practicable for the attending doctor to do so themselves – for example, if that doctor is unwell or self-isolating. 

It would be reasonable for you to agree to certify the patient’s death, even if you had not attended him in his final illness, provided you are ‘able to state to the best of [your] knowledge and belief the cause of death’. 

Practically speaking, this means having access to relevant medical records and the results of investigations such as the patient’s positive test result.

Updated guidance

The updated temporary guidance for doctors on completing death certificates states that you would need to delete the words ‘last seen by me’ on the MCCD and – if applicable – should include the name of a doctor who saw the patient within the last 28 days. 

In this context, ‘seen’ includes video consultations but not consultation by phone/audio only. So it’s important to check whether any doctor actually saw the patient in the previous 28 days so you can accurately complete the MCCD. 

If you discover that the patient had not been seen by a doctor in the previous 28 days or after death, you need to talk to the coroner and obtain their agreement before you can complete and sign the MCCD and should only go ahead if you are able to state the cause of death to the best of your knowledge and belief.

The guidance states that Covid-19 is an acceptable direct or underlying cause of death for the purposes of completing the MCCD. 

You should also enter any other diseases, injuries, conditions or events that contributed to the death, but were not part of the direct sequence, in part two of the certificate, such as the patient’s advanced prostate cancer. 

The new arrangements also make it easier for the patient’s death to be registered if he was seen by a doctor within the last 28 days. 

Registrars will now accept scanned or photographed copies of the MCCD forwarded from a secure email account, although the original, signed document should be securely retained for delivery to the registrar as soon as circumstances allow. 

Where the patient had not been seen within the last 28 days, relatives should be able to register the death if the coroner agrees to the completion of the MCCD.

Dr Sally Old is a medico-legal adviser at the MDU

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Notes on retirement

What should you do about retaining patient records when retiring from private practice? Dr Sissy Frank explains how to manage things.

 

 

 

 

Dilemma 2

How long should I retain notes?

Q At the beginning of the coronavirus pandemic, I was redeployed to support colleagues in the NHS. While I will continue to do this, I have decided to retire from private practice. 

What are the issues around patient records that I need to consider so that I retire in an ethical, yet timely manner? 

A Patient care must be at the forefront of your decision-making when deciding to retire or close your private practice. Think of your patients in one of three categories: those you have treated in the past but no longer see, those you see regularly and those who are likely to require further treatment. 

It will be important to discuss ongoing care well in advance, as well as preparing treatment plans, particularly for patients that fall in the last two categories.

The GMC in its guidance Delegation and Referral (2013) makes clear that you should explain to the patient that you plan to transfer their care and ensure the patient is informed about who is responsible for their future care and treatment. 

The guidance also states that you should seek the patient’s consent to disclose relevant information about them and to pass their record to their new doctor . 

As a private practitioner, you will be registered as a data controller with the Information Commis­sioner’s Office – a statutory duty – enabling you to collect and hold patient information. Even after stopping independent practice, you might need to respond to a Subject Access Request; that is, a request for access to the notes you hold about a patient. 

The request could be made for a number of different reasons, including complaints or clinical negligence claims. Consequently, it is vital that you securely retain your patients’ records and consider each patient’s record before disposing of it. 

The GMC’s Confidentiality (2017) guidance states: ‘If you are responsible for managing patient records or other patient information, you must make sure the records you are responsible for are made, stored, transferred, protected and disposed of in line with data protection law and other relevant laws.’

Although the previous regulations relating to the retention of private records (schedule 3 of The Private and Voluntary Health Care [England] Regulations 2001) are no longer in force, the GMC also states that you should follow the guidance by the UK health departments, regardless of whether you work in the NHS or not.

Information on appropriate retention time-scales can be found in Records Management Code of Practice for Health and Social Care, which explains that records should be considered on an individual basis and retention schedules vary between different types of records. 

Although it is imperative you check the retention schedule with reference to the types of records you hold, the following are a few examples of the time-scales:

 Adult health records – not specified elsewhere in the schedule: Eight years after conclusion of treatment or death;

 Oncology records: 30 years or eight years after the patient has died;

 Contraception/sexual health: Eight years unless there is an implant or device, in which case ten years – unless it is the record of a child, in which case it should be treated as a child record;

 Records relating to litigation: Ten years after closure of the case.

These should be viewed as a minimum period for record retention, especially if there has been an adverse event or complaint.  

The benefit of retaining a record from a medico-legal standpoint should be balanced against the requirements of data protection law, which states that records should not be kept for longer than necessary.  

When disposing of records, you should ensure that this is done using appropriate means; for example, by crosscut shredding, incineration or by using a commercial company with the necessary accreditations.

Dr Sissy Frank is a medico-legal adviser at the MDU 

• See ‘Patient doesn’t want CPR’