Practically, only three methods have been used from the earliest times: burial, embalming and cremation. Burial is perhaps the earliest and most primitive method. It was customary to bury the bodies of the dead in consecrated ground around churches up until the earlier half of the 19th century, when the utterly insanitary state of churchyards led to legislation for their better control. Burials in Britain take place usually upon production of a certiﬁcate from a registrar of deaths, to whom notice of the death, accompanied by a medical certiﬁcate, must be given without delay by the nearest relatives.
When a death occurs at sea, the captain of the ship has authority to permit burial at sea. If, however, there are any doubts about cause of death, the captain may decide to preserve the body and refer the case to the relevant authorities at the next port of call.
Embalming is still used occasionally. The process consists in removing the internal organs through small openings, and ﬁlling the body cavities with various aromatics of antiseptic power – the skin being swathed in bandages or otherwise protected from the action of the air. Bodies are also preserved by injecting the blood vessels with strong antiseptics such as perchloride of mercury.
Cremation or incineration of the body is now the commonest method of disposal of the dead in the UK, where land for burials is increasingly scarce; today it accounts for around 75 per cent of disposals. The process of incineration takes 1–2 hours. Something in the range of 2·3 to 3·2 kg (5–7 lbs) of ash result from the combustion of the body, and there is no admixture with that from the fuel.
Cremation of a body means that it is almost impossible to conduct any meaningful forensic tests should any subsequent doubts be raised about the cause of death. So, before cremation can take place, two doctors have to sign the cremation forms. The ﬁrst is usually the doctor who was caring for the patient at the time of death – an important exception being cases of sudden death, when the coroner holds an inquest into the cause and authorises the necessary approval for cremation. In 1999, fewer than 3,500 deaths were certiﬁed following a post-mortem, out of a total number of deaths in England and Wales of more than 556,000. When the coroner is not involved, the second doctor must have been qualiﬁed for ﬁve years; he or she must be unconnected with the patient’s care and not linked professionally with the ﬁrst doctor. (For example, if the ﬁrst doctor is a general practitioner – as in the majority of cases they are – the second doctor should be from another practice.) Before signing the cremation certiﬁcate the second doctor must conduct an external examination of the dead person and discuss the circumstances of death with the ﬁrst doctor.
The two cremation forms are then inspected by crematorium medical referees who must be satisﬁed that the cause of death has deﬁnitely been ascertained. The present death and cremation certiﬁcation system has been in place in the UK for many years – the legislative framework for cremation was set up in 1902 – and death certiﬁcation procedures were last reviewed by the government-appointed Brodrick committee in 1971, with no fundamental changes proposed. The case of Harold Shipman, a general practitioner convicted of murdering more than 15 patients, and suspected of murdering many more, has revealed serious weaknesses in the certiﬁcation system. A comprehensive review of the present procedures was in place at the time of writing (2004).