Dr Emma Davies, Medicolegal Consultant at Medical Protection, looks at how the Medical Examiner system works and key changes taking place in April 2023.
The Medical Examiner (ME) service was set up partly because of a number of high-profile inquiries (such as Shipman and Francis), to provide scrutiny of all deaths that are not directly referred to the coroner. Currently the ME service has been rolled out to all NHS hospital Trusts.
On 11 July all GP practices, integrated care boards and primary care networks should have received a letter outlining what action is needed in preparation for all non-coronial deaths to be referred through the ME service from April 2023.
What are Medical Examiners?
Medical Examiners are senior doctors from a wide variety of specialties who have undertaken specific training in how to scrutinise cases, the role of coroners, the law around death and inquests and communicating with the bereaved.
While the implementation of the service to cover all community deaths will provide some challenges, there are some benefits.
The aims of the service are:
• Provide a proportionate scrutiny of the care by an independent senior clinician, which in turn should be of assurance to the public
• Ensure the accuracy of the Medical Certificate of Cause of Death (MCCD), which in turn will provide more reliable mortality data
• Ensure the right cases are referred to the coroner
• Provide a better service to the bereaved by explaining the MCCD and exploring any concerns they may have.
Having worked as a Medical Examiner for nearly three years and in my experience as a medicolegal consultant for Medical Protection, I have first-hand experience of the benefits of the ME system and its positive impact on staff, patients, organisations and the bereaved.
Benefits to staff
Sometimes the cause of death or requirement for referral to the coroner may not be clear to the clinician. Maybe the deceased had a number of co-existing conditions, and working out which one was the ultimate cause is being challenging. Doctors can also be uncomfortable with the level of uncertainty surrounding a patient’s diagnosis (for example, the patient may have had a suspected cancer but no histological diagnosis at the time of death).
In the NHS Trust setting it is often the most junior doctors who are asked to complete the MCCD and it can be a daunting process for them. The ME can support doctors in coming to a decision about whether or not they can offer a cause of death, and assisting in the correct wording or order of conditions listed on the MCCD.
During the discussion with the bereaved the majority of the feedback we hear is very positive and this is fed back to the staff who cared for the patient; where possible we try to be very specific about what it was that the staff did or said, with the view to improving morale and driving positive reinforcement. Common themes for feedback are that staff showed compassion, care and respect to both the patient and their family; it is often the small gestures that have a large impact on their positive experience.
Benefits to patients
The ME service can identify when there are specific learning points to feed back to the clinical teams to assist in improving quality of care. We may also identify systemic concerns that require feeding back into the governance system, driving better patient experience through change. An example of a common theme for feedback is recognition and management of patients in their last days of life; some wards are more experienced in this and there are examples of good practice and training that can be shared with other specialty wards.
Other examples of feedback have been highlighting to the Trust the impact of long waits in the Emergency Department, such as frail patients developing pressure sores or not receiving medication in a timely manner.
Benefits to the bereaved
Following the scrutiny of a case and the receipt of a completed MCCD the ME service contacts the bereaved to explain the conditions on the death certificate. We ensure the bereaved understand the medical terminology used and can often answer questions regarding the circumstances surrounding the death (such as was their loved one in pain or aware of what was going on). We will answer these questions honestly and to the best of our knowledge. Having an opportunity to ask questions can assist in the grieving process. We can also identify those who may benefit from ongoing bereavement support and refer or signpost them to sources of help.
We explore any concerns the bereaved may have about the care. Some could see this as inciting complaints – it is in fact quite the opposite. In my experience the vast majority of relatives have nothing but positive feedback and praise for the care and compassion afforded to the deceased.
Where there are concerns the ME may be able to address these there and then and, if appropriate, allay the concerns or address any misunderstandings and reduce the likelihood of a formal complaint. Relatives are often very grateful for the opportunity to ask questions and talk through their concerns with an independent senior clinician who has taken time to review the deceased’s care. Sometimes being heard is all they need.
The approach of the ME in these situations where they cannot address the concerns should be professional and collegiate, and to not adjudicate and to acknowledge that they are not able to comment on the actions of others, and to allow the professionals involved in the care the opportunity to address the issues with the family.
Benefits to organisations
Identifying areas of concern and feeding these back into the governance system can result in organisations and practices being more proactive in reducing the number of adverse incidents and can alert institutions to issues around service provision early on. This will help drive compliance with good practice and duty of candour requirements.
The aim is for all deaths not referred to the coroner to be referred through the ME service from April 2023. This service has already proved to be of benefit to the bereaved, staff, patients, the coronial service and the wider public.
Please do reach out to your local Medical Examiner service to talk through how to link into the service and consider what action is needed to ensure your practice is referral ready for April 2023.