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A decade after Shipman's arrest1 and 4 years since the Shipman Inquiry report into death certification was published,2 the key proposals have been scarcely debated, let alone any having led to serious action. We believe this failure may be due to the tenor of the inquiry's proposals which saw death as a potentially criminal act to be forensically investigated, rather than an opportunity for proper certification and potential learning.3
The present impasse leaves us worse off than a decade ago, as no one can be satisfied with the current system which is known to be seriously flawed, yet there is clear doubt as to how to proceed. Indeed, locally introduced variations of certification practice, especially regarding cremation, probably abound.
We consider that the Royal College of General Practitioners is best placed to reopen the debate publicly about death certification. The suggestion of ‘pilot schemes during 2008’3 should be actively pursued and College members and others encouraged to participate.
Each death is a significant event and many have lessons for future practice. In our experience these are essential learning opportunities that ought to be part of each doctor's revalidation portfolio.3 For those doctors and teams who are struggling to perform adequately, it is also our experience that a search through the records of the patients who have died can reveal both clinical and systems problems far more quickly than anything else.
‘A retrospective search for avoidable factors in individual deaths is perhaps the most stringent form of self-criticism available to any clinical team.’4