Death Certificate
11. Mr A complains the Practice on 2 July 2024 incorrectly completed his father, Mr B’s, death certificate. He says the Practice listed Parkinson’s disease on the death certificate when it should have noted progressive supranuclear palsy (PSP).
12. PSP is a neurodegenerative disorder that progressively damages brain cells, causing problems with balance, eye movement control, speech, swallowing, and thinking, often mimicking Parkinson's disease initially but with key differences like poor response to levodopa (medication for treating Parkinson’s disease symptoms) and fixed gaze.
13. The Practice explained it was of the opinion it had appropriately completed the death certificate based upon the information that was provided to the practice at that time.
14. For context, following Mr B’s death Mr B’s family contacted the Practice on 8 August 2024. The family wished to have PSP noted on the death certificate not Parkinson’s disease. The Practice agreed to help facilitate this.
15. To help us consider this complaint, we have reviewed Mr B’s medical records.
16. On 21 May 2018 Torbay and South Devon NHS Trust sent a letter to Mr B’s GP. The Trust explained Mr B’s symptoms are consistent with Parkinson’s disease. On 24 May it is noted in the Practice records Mr B was diagnosed with Parkinson’s disease. On 31 August a letter from the same Trust to Mr B’s GP further confirms a diagnosis of Parkinson’s disease.
17. On 23 February 2023 PSP is noted in the GP records under active problems. We have not seen this was a diagnosis. On 28 February a letter from North Bristol NHS Trust to the GP states Mr B has probable PSP. On 24 October Torbay and South Devon NHS Trust write to the GP. It says North Bristol NHS Trust felt Mr B had PSP. We have not seen in 2023 a diagnosis of PSP was made.
18. From the evidence we have seen there is no further mention of PSP until after Mr B’s death on 1 July 2024.
19. We have considered the Coroners and Justice Act 2009. It says: ‘20. Medical certificate of cause of death 1 (a) provision requiring a registered medical practitioner who attended the deceased before his or her death (an “attending practitioner”)— (i)to prepare a certificate stating the cause of death to the best of the practitioner's knowledge and belief (an “attending practitioner's certificate”),’
20. The guidance states a practitioner should prepare the certificate to the best of their knowledge. The wording best of their knowledge is not specific and is open to interpretation. We consider it was reasonable by the GP to list the last diagnosis made.
21. We acknowledge Mr A’s upset as he feels the wrong medical condition was listed on his father’s death certificate. The GP made a reasonable choice to list Mr B’s last diagnosis on the death certificate. We cannot say the Practice completed the death certificate incorrectly.
Amended certificate
22. Mr A complains the Practice did not provide the amended copies of the death certificate without cost. Mr A explains the registrar’s office informed him he and his family would be expected to pay for new copies. He says because the issue arose from the Practice’s error it should bear the cost.
23. As noted above, the Practice explained it felt it had completed the death certificate correctly. The Practice said it would not pay for an amended certificate. We have already considered the Practice did not make an error when completing the death certificate.
24. We have reviewed Correcting a death registration on the government website. It says:
25. ‘It costs £83 or £99 to apply to correct a mistake in a death registration. Contact the register office where the death was registered to find out how to send your application, the cost, and how to pay.’
26. It is not the decision of the Practice to charge for amendments to the death certificate. The Practice is not responsible for the cost, and it is unable to waive this cost. We will now review the records to see what information was given to Mr A and his family.
27. On 8 August 2024 the Practice spoke with Mr A’s family. It was not Mr A who it spoke to. The Practice informed the family there would be a fee to change the death certificate. The family explained it would want to pay the fee to have the correct wording on the certificate.
28. On 2 January 2025, the Practice contacted Mr A. It explained it had received the statutory declaration for amending the death certificate. This required to be witnessed. The Practice confirmed it had found a solicitor who would action this. The Practice advised it would cover the cost of the witness.
29. On 24 March Mr A contacted the Practice. He explained he had received copy of the amendments but no an up to date death certificate.
30. We acknowledge Mr A’s frustration as he feels the family should not have to pay for an amended death certificate. We have not seen evidence the Practice informed Mr A it would cover the cost. It is noted the family accepted it would pay the cost on 8 August 2024.
31. We consider the Practice have been reasonable in accepting the family’s request for an amended cause of death. We do not consider the Practice’s agreement to change the cause of death as an acceptance it would pay for new certificates. The registrar’s office is the responsible body for setting the replacement cost. We see no indication of a failing here.
Complaint Handling
32. Mr A complains the Practice did not handle his complaint in line with its own procedure. Mr A says he had to wait over two months for a meaningful update. He says the Practice’s own procedure says it will give a response in 14 days. As this aspect is about complaint handling, the Practice have not made a comment. We have considered the events.
33. On 24 March Mr A submitted his complaint to the Practice. On 26 March the Practice acknowledged Mr A’s complaint. In the letter, the Practice explained the matter will need to be reviewed by a GP who was currently on annual leave. The GP was due to return on 7 April.
34. We have reviewed the Practice’s policy, make a complaint. It says: ‘You can contact our Complaints Team, in writing. Alternatively, please leave your contact telephone number and the Practice Manager or relevant Line Manager will contact you within the next 48 working hours.’
35. We have not seen the Practice says it will provide a full response in 14 days. Mr A does acknowledge the policy he has seen states there will be exceptions in some instances. NHS England, Feedback and complaints about NHS services sets out the following about making a complaint about an NHS service:
36. ‘There’s no set timeframe for responding, and this will depend on the nature of your complaint. If, in the end, the response is delayed for any reason, you should be kept informed.’
37. We have seen the Practice has acknowledged Mr A’s complaint within 48 hours in line with its policy. In its acknowledgement, the Practice set out the GP who will review the complaint will not be able to do so in 14 days due to annual leave. This kept Mr A informed of the process.
38. On 14 April Mr A chased the Practice for a response. The Practice responded on 15 April to confirm the complaint was still being investigated. The Practice said this would take time and to bear with it. Mr A replied to the Practice the same day. He remained unhappy with the time it has taken to investigate the matter.
39. We have seen the Practice have continued to acknowledge Mr A’s complaint correspondence. The complaint was under investigation, and a response would be provided when completed.
40. On 24 April Mr A chased the Practice for a response. He explained the complaint had gone above its own complaints procedure which stated a full reply will be given unless otherwise notified. On 30 May the Practice issued its response to the complaint.
41. We are sorry to hear Mr A felt the Practice had not complied with its own complaint policy. We understand he was frustrated at the time it took to respond to his complaint. We can see local resolution was completed in two months. We do not consider this above and beyond what we see for NHS complaint. In the complaint acknowledgment the Practice had explained there would be a delay in its response due to annual leave. The Practice followed its policy making contact within 48 hours. It informed Mr A a response would not be given in 14 days. It provided a full response within a reasonable timescale. We therefore will not take any further action on the complaint.