Late Nineteenth and Early Twentieth Centuries
By 1910, less than 1% of deaths were uncertified in the large Scottish towns. But the situation was very different in some of the country areas, particularly in the Highlands and Islands, where up to 50% of all deaths remained uncertified, due to the scattered population and lack of medical assistance.
Apart from the general problem of access to a doctor, there were other difficulties with medical certification of death. The first was that the doctor's certificate of cause of death was not confidential, but was handed to the relatives or friends of the deceased, who were then expected to deliver it to the registrar. The register entry then became a public document. This created problems for the doctor when the cause of death was potentially upsetting to relatives, as in cases of venereal disease, alcoholism, or suicide. Doctors were known to be 'economical with the truth' in such cases. They might attempt to substitute a less offensive cause of death to spare the feelings of relatives, or use a form of shorthand to try to disguise the cause, as in 'C2H6Q' for cirrhosis of the liver caused by alcoholism. Registrars objected to this because it would affect the national statistics, and private attempts were sometimes made to get deaths re-certified without the relatives' knowledge when it was suspected that the doctor had disguised the true cause of death. In the days when surgical operations were carried out in small cottage hospitals, or even in family homes, doctors were also wary of recording deaths under anaesthetic, in case it led to litigation.
Another serious problem was that it was quite legal for doctors to issue a death certificate without having seen the corpse. In pre-NHS days, doctors were paid a fee for their services, and paying them to inspect every deceased person was not something that the government would contemplate. Doctors were already grumbling about having to issue death certificates for former patients without being paid a fee, and they would have resisted any attempt to make them provide certificates for people whom they had not visited in life.
There were also the usual logistical problems in the remoter areas, where doctors were few, and great delays might occur before burial if relatives had to wait for a doctor's visit. The system even seemed to offer opportunities for criminal activity. Murder might not be detected if a doctor did not see the body before burial. Insurance fraud was also easier if a doctor was willing to simply take a relative's word that a person had died. This was possible where a patient lived in a remote area or the doctor knew that he was suffering from a serious illness, and was therefore willing to certify that illness as the cause of death, without viewing the body.
One particularly elaborate case of fraud involved a Glasgow woman who between 1912 and 1917 took out burial insurance on 24 children, both real and fictitious, then pretended to the insurance companies that all these children had died, and claimed the insurance money. Doctors were willing to certify the deaths because the woman had previously visited them when one of her (real) children was ill. Claims for burial insurance for a child who was still living were also detected.
Cremation was becoming more common by the early twentieth century, but was regarded as an eccentric (and expensive) practice, mainly for the wealthier classes. There were much stricter rules on death registration before cremation, since two doctors had to write death certificates before a body could be handed over for a process after which no further post-mortem examination would be possible.
There were also fears over premature burial if a doctor did not have to see the body to check whether the patient was dead. The newspapers revelled in several ghoulish tales of near-misses which were only betrayed by the gentle knocking of a supposed corpse inside the coffin.
Meetings of the medical profession frequently deplored the lack of consistency and accuracy in death certificates. Medical students received a little training in this area, but the subject was a touchy one that threatened a doctor's relations with the relatives of his or her deceased patient. The problem was partly resolved by the expansion of medical services. By the middle of the twentieth century, most people died in hospital rather than their own homes, and death certificates were formally issued by the hospital staff. Nevertheless, as late as 1960, J.D. Havard, a leading member of the British Medical Association, was complaining about the inaccuracy of many death certificates. He pointed out that, even in hospital, and in apparently uncontentious cases, the doctor's original assessment of the cause of death was often overturned after a post-mortem.