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. 1999 Mar 20;318(7186):811. doi: 10.1136/bmj.318.7186.811a

Crisis in cremation

Poor form filling makes medical referees essential

Clare Hawley 1
PMCID: PMC1115237  PMID: 10082726

Editor—I was one of the medical referees who received and completed Horner’s questionnaire on cremation forms as part of the BMA survey in June 1997.1 I was interested to learn that only 21% of cremation certificates presented to Horner were complete, and this prompted me to survey the forms presented to me in Chesterfield.

From September 1997 I looked at 1000 consecutive sets of papers presented to me for authorisation of cremation. At the same time as starting the survey I produced a handout giving guidance on how to complete certificates B (completed by the attending doctor) and C (confirmatory certificate from independent doctor of 5 years’ standing), which was distributed to all junior doctors at Chesterfield and North Derbyshire Royal Hospital. The table shows the papers received and numbers requiring intervention. Ninety seven forms had incomplete or incorrect details of name, address, or age; 64 had incomplete or incorrect details of pacemakers or radioactive implants; 39 required investigation of medical details; in 29 the patient had not been seen within 14 days of death; 24 had discrepancies in date, time, or place of death; 22 did not state whether the coroner was informed of the death; and 14 did not give the date the patient was last seen alive.

Interestingly, on three occasions the body had not been seen after death; six forms were unsigned; three doctors signing part C were discovered to be ineligible; five doctors completing form B had never attended the patient; and on two occasions forms B and C recorded different causes of death. Two hundred and seventeen forms had one error; 36 forms had two errors, and seven forms had three or more.

Although my figures are better than Horner’s, over a quarter of cremation papers were unsatisfactorily completed. The problems vary from simple administrative matters, which could be handled by a clerk, to more complex medical queries requiring lengthy investigation. Families have to pay £76 for the two certificates, so a considerable amount of money is being paid for a service that is often performed poorly. While this situation remains, every effort should be made to protect the position of the medical referee.

Table.

Proportion of cremation forms requiring interventions

Source of form Total No No (%) requiring intervention
Coroner’s office 260  29 (11%)
General practitioners 324 104 (32%)
Hospital doctors 416 127 (31%)
All forms 1000 260 (26%)
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References

BMJ. 1999 Mar 20;318(7186):811.

Cremation form should be abolished

M C Bateson 1

Editor—Homer’s leader emphasises a problem which has arisen because of the overwhelming popularity of cremation as a means of disposing of bodies.1-1

The regulations which govern the three part cremation form, completed by three different doctors, originated when this alternative to burial was uncommon. Then there was a real fear that cremation might be used to dispose of the evidence of crime. However, the system is clumsy, ineffective, and completely obsolete.

Both the medical certificate of cause of death and the cremation form are legal documents, not medical evidence. If we really wanted more information about diagnoses and cause of death then almost everyone should have a necropsy, which is the opposite of standard practice.

If there is serious concern about a death the medical certificate of cause of death allows this to be recorded, and coroners and their officers are available to resolve issues.

Why not abolish the cremation form altogether and amend the medical certificate of cause of death to include two further questions: “Have you any reason to suppose there is suspicion about the cause of death, or that it may have been caused by wrongdoing, or that a cremation should not be performed?” and “Is the patient currently fitted with a cardiac pacemaker?” This would reduce the paperwork and remove a non-clinical chore from doctors. It would do no credit to the profession to try to maintain the old way purely because of the fees involved.

References

BMJ. 1999 Mar 20;318(7186):811.

May have been created to increase fees

R N Arber 1

Editor—The crisis situation described by Horner’s editorial on cremation is not one that I recognise nor would any of my colleagues in other national cremation organisations.2-1 A picture of medical referees as “trapped in a system from which there was no escape—required to attend virtually every day, for a fee which does not even pay their travelling costs” makes emotive reading. However, Horner seems to have overlooked the fact that there are recommended travelling fees for medical referees which are quite generous.

Interestingly, the author instigated the sending of a questionnaire to medical referees in June 1997. The letter accompanying the questionnaire made reference to the “derisory level of fees paid to medical referees,” and the survey was explicitly intended to assist negotiations in a review of the fees paid to them. It is hardly surprising if the answer to questions as to whether fees should be doubled or trebled received a positive response. This was hardly a piece of objective research.

If there are to be any changes to the death certification procedure they should include the implementation of the recommendations made in the Brodrick committee’s report2-2 and the prompt elimination of the medical confirmation certificate form C. This form must be signed by a second doctor who certifies the fact and cause of death.

Medical fees incurred by families who require cremation services are already a burden and are the object of a great deal of criticism from within the funeral industry. Those of us involved in the national cremation movement are best placed to see the signs of any impending crisis. In this respect, the author seems to be somewhat of a lone voice as the cremation movement, the Home Office, and the funeral directing profession do not have any experience of the crisis to which he refers.

The illusion of a crisis may be being created to justify increases in fees. This may not be the case but I am sure that that is how many people will perceive the content of the editorial; this perception does not augur well for the reputation of the medical profession.

The claims of a crisis and delays in cremation services are misleading, alarmist, and give a false impression of the present situation. Such claims will do little to comfort the bereaved at a difficult time.

References

  • 2-1.Horner S. Crisis in cremation. BMJ. 1998;317:485–486. doi: 10.1136/bmj.317.7157.485. . (22 August.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2-2.Home Office. Report of the committee on death certification and coroners. London: HMSO; 1971. (Cmnd 4810.) [Google Scholar]

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