Before the EU referendum in 2016, the Lord Chancellor Michael Gove said that he thinks the British people have had it with experts. I recall thinking he had a point. I suppose you could say the referendum result settled the issue in Michael Gove’s favour.
Doctors tire and make mistakes. They have great days and dreadful days. They are not equally competent
But fast forward to 2020, and one thing the Coronavirus pandemic has shown us is that rather than turn away from experts plenty of people appear to ascribe almost supernatural powers to them.
There are, of course, the epidemiologists, though they may find, even if they did not support it, that the effects of the lockdown do for them what the financial crash did for economists and make hate figures of them.
But there are others, too.
Take the experts who record our deaths: doctors.
If you were to listen to the media on the Covid death toll, you would think that they believed that doctors are infallible – and indeed, that is how they present them. And high support for the lockdown suggests that the public believes that the numbers coming from the medical world are accurate. This week, a YouGov poll found the country is roughly split down the middle on recent changes to relax lockdown rules, but an earlier poll found 93 per cent support for continuing the lockdown.
However, doctors tire and make mistakes. They have great days and dreadful days. They are not equally competent. They are human, just like the rest of us.
All this brings consequences to bear on how well they perform their duties. To mitigate, there are checks and balances to protect them and their patients. But regulations are not a panacea and things still go wrong, including when certifying causes of death. “The ONS itself agrees that in as many as a third of certificates there is significant doubt even in normal times about whether the cause of death is right or not,” said Dr John Lee, a retired professor of pathology who writes for The Spectator.
But these are not normal times.
Almost everyone knows, if only indirectly, about the Coronavirus Act (2020). It gained Royal Assent on March the 25th, 2020 and has kept us cooped up inside, or near, our homes ever since. What fewer people know is it contained two clauses that liberalised the rules for doctors recording deaths and certifying cremations. At the end of March, to reflect the changes, NHS England sent guidelines to doctors, coroners, and undertakers. These are now available to read online here. I had a doctor go through them with me, and what I found left me dumbfounded.
Just when an unknown disease had arrived in town, ministers had increased the chances of mistakes being made. This seemed the wrong way round. Surely they would want to increase scrutiny to find out as much as possible about the disease?
They had placed an ominous cloud of doubt over the veracity of the Covid-19 death toll and risked denying a person his or her right to a duty of care in death – namely, the dignity of having its cause properly recorded. They also appeared to have opened the door to medical malpractice and even murder. “If you wanted to bump someone off, now would be the time to do it,” one experienced doctor said in confidence.
Ministers suspended a safeguard put in place 118 years ago under the Cremation Act (1902) that requires a senior, independent doctor to corroborate cremation applications with a second form
Ministers suspended a safeguard put in place 118 years ago under the Cremation Act (1902) that requires a senior, independent doctor to corroborate cremation applications with a second form.
This led to the eventual capture, in 1998, of doctor-serial killer, Harold Shipman. Linda Reynolds, the GP who corroborated his cremation applications, noticed that a high number of his patients were dying and reported him to the coroner, John Pollard. I tried to contact Mr Pollard to check that I gotten it right, as this seemed almost too crazy to be true. But he had retired and Stockport Coroners Office were unable put me in contact with him. So I contacted the Ministry of Justice instead and, sure enough, I was right:
‘As guidance, the Cremation Act 1902 provides for the Secretary of State to make regulations for “prescribing in what cases and under what conditions the burning of any human remains may take place”. The first such regulations were made in 1903 and there has always been a requirement for 2 medical certificates except where a post-mortem or a coronial inquest took place. The 2 certificates are the medical certificate, and a confirmatory certificate originally referred to as forms B and C respectively. Under the 2008 regulations these were renamed form cremation 4 and form cremation 5. As you correctly note under the Coronavirus Act 2020, the need for a confirmatory medical certificate (cremation form 5) has been temporarily suspended.’
Sarah Fairley, Senior Press Officer, MoJ
Ministers also suspended a safeguard put in place after Shipman’s conviction that allows relatives to inspect medical certificates of cause of death (MCCDs) and cremation applications for incongruous symptoms (Shipman repeatedly lied on form cremation 4 safe in the knowledge both that the doctor completing form cremation 5 would trust him and the victim’s family would be none the wiser).
The bottom line is this: if Shipman were killing under the Coronavirus Act, he might have gotten away with even more murders. And if the safeguards held others back from killing their patients, well, they’re not anymore.
Normally, the attending doctor, that is the one that saw the patient in his or her last illness, completes an MCCD; they must fill this out before releasing a body for burial or applying for a cremation. Now, if the attending doctor is unavailable, any registered doctor can complete an MCCD: even if that doctor never clapped eyes on the patient before their death. This could be a retired doctor who has returned to work, a first-year doctor fresh out of medical school, or even a student who was fast-tracked to the ‘frontline’.
Ministers extended the time in which a doctor should see a patient before a doctor or another registers the patient’s death from 14 to 28 days. And now, if no doctor sees a patient within 28 days before death, any registered doctor (as above) can certify their death, if “they can state the cause of death to the best of their knowledge and belief” and the coroner agrees, an agreement which could be made by a phone call. Normally, if a doctor did not see the patient within the allotted time, they send the deceased to the coroner.
“There are things you can only find out by doing an autopsy and looking at things microscopically and putting it all together,” said Dr Lee. “But now changes to guidance for Covid cases mean that autopsies are less likely, rather than being encouraged. A death can just be deemed to be Covid, even if a doctor hasn’t seen the patient for 4 weeks, or even if they’ve never seen the patient”.
I scanned the news fully expecting to find the story well covered and commentators demanding that ministers immediately reinstate the regulations. I found no such news coverage. This is what I found:
On March 15th, Harry Cole of The Mail on Sunday (now The Sun’s Political Editor) reported that the government planned to relax rules around ‘death management’. But his report only emphasised the relatively minor change (compared to the others anyway), allowing relatives to inspect cremation certificates.
On April 6th, GP Online published an article behind a paywall briefly summarising the guidelines as they apply to GPs.
But besides these all I could find were passing mentions in stories about the Act as a whole. And certainly no ringing alarm bells. (I was made aware at a later date that Off-Guardian had published a piece in March that further substantiates the concerns I have.)
It seemed clear to me, and to the doctor who kindly helped translate the medicalise into plain English, that other reporters, columnists, historians, doctors, politicians, researchers, the public at large, and many others besides should know what the government had done.
Here, once again, is Dr John Lee:
“What’s happening, exceptionally, with Covid is that not only do you not have to be an attending doctor to make a statement that someone has died of Covid, you don’t have to discuss it with anybody else, you don’t even have to be medical, you don’t have to have any test positivity – you can even deem a death to be due to Covid if it’s not mentioned on the death certificate and, say, you’re a care home provider and you think it ought to be mentioned.. and few of these cases are being autopsied. So we’re not building up any sort of knowledge about what this disease actually does to the body, or even whether it was present in the body of somebody who was said to have died of Covid. We actually know less about who’s dying of what now, particularly concerning Covid, than at any time in the past. So it really is a complete mess”.
I am not implying that there is a conspiracy. The government made the changes both to prevent doctors suffering burnout caused by extra paperwork for huge numbers of excess deaths and to ensure they were free to prioritise clinical duties over statutory ones. They also wanted to avoid delays to funerals and the horrifying spectacle of overflowing morgues.
It may not seem entirely rational to all of us, but the fear in ministers’ chests in early March was probably very real to them. Professor Ferguson had been wrong before. But what if this time he was right? The response suggests that they believed he could be and that the only way to put out the fire was to reach for the same extinguisher as China and Italy (i.e., lockdown).
But Professor Ferguson’s models were wrong. The NHS did not, mercifully, need the Nightingales. SARS-Covid-19 did not overwhelm our health service. And doctors now have plenty of time to perform their normal statutory duties.
So may we have sensible legislation reinstated please?
Parliament must review the Coronavirus Act (2020) every six months before renewing it. The first review is due, then, on 25th September. I, for one, will be writing to my MP to voice my concerns, and I hope you will do the same.
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