It is over 15 years since Dame Janet Smith's third report in the Shipman Inquiry recommended reforms to the coronial service that ultimately led to the setting up of the national medical examiner system in England and Wales. Although progress has been slow to date, there is much to appreciate about the new system as it enters its initial, non-statutory, implementation phase (The Coroners and Justice Act 2009, section 19, provides the statutory basis for a national medical examiners service, but is not yet in force).
Although currently limited to acute NHS trust hospitals in England and Health Boards in Wales over the next year medical examiner offices will work towards expanding the geographical scope of their scrutiny beyond the hospital where they are based. Leadership for the new service is provided by the National Medical Examiner, Dr Alan Fletcher. This is a statutory role, established under section 21 of the Coroners and Justice Act 2009.
In order to describe some of the key features of the medical examiner service we have used a question-and-answer approach. It is important to bear in mind that when the service is fully implemented on a statutory basis there may be some changes, although it is not anticipated these will be significant.
The Coronavirus Act 2020 has implications for death certification and the signing of cremation forms, details of which can be found here, and medical examiners will continue to offer advice to clinical teams during the pandemic.
Who are medical examiners?
Medical examiners must be doctors and, specifically, have been registered with the GMC for the previous five years (or if retired they must have been registered within the previous five years). Although not required by statute, the National Medical Examiner recommends that medical examiners are consultants, or senior doctors of equivalent experience, or senior GPs.
What qualifications do medical examiners need?
There is no specific qualification necessary (apart from the need to be a registered medical practitioner), but all medical examiners will need to undergo a mixture of online e-learning modules and face-to-face training.
Like clinical roles, a medical examiner will also need to include this aspect of their professional practice in their annual appraisals and undertake suitable and sufficient CPD to support it. This will be in part facilitated by an increasingly-developed regional and national network of educational and training events.
What do medical examiners do?
The principal role of the medical examiner is to scrutinise all deaths occurring in their geographical area of responsibility. Initially, and during the early roll-out of medical examiners in trusts and health boards, it will not be possible to scrutinise all deaths and there will be an incremental implementation with review of a suitable number of cases. The incremental period is not intended to be lengthy - it should be three-to-six months only.
In practice, the scrutiny of deaths should answer three questions.
- What did the patient die from, and is the medical certificate of the cause of death (MCCD) accurate? This will require reviewing clinical records, speaking to the clinician responsible for the deceased's care (qualified attending practitioner) and, importantly, speaking to the relatives to establish whether they have questions about the cause of death or concerns about the care leading up to it.
- Does the death need to be reported to the coroner?
- Does the death raise any clinical governance concerns?
This final question will require a detailed working knowledge of clinical governance arrangements in the locality, so that appropriate notification for further action can be made. There may be circumstances where medical examiners are not satisfied that the concerns they have identified have been adequately addressed. It is intended that regional medical examiners can be involved in such circumstances to help ensure appropriate learning and remedial action is implemented in the trust.
The principal role of the medical examiner is to scrutinise all deaths occurring in their geographical area of responsibility.
It sounds like a lot of work - how will medical examiners be supported?
Medical examiner officers (MEOs) will be one of the keys to a successful service. As there are likely to be several part-time medical examiners in a particular locality, there needs to be one person who can oversee all of the activity and ensure the process runs smoothly.
With suitable training, it's also envisaged the MEO will be able to carry out a preliminary review of the clinical records as well as speaking to clinical staff to obtain further information, helping to put together a case file.
If the medical examiner is a practising doctor, could there be conflicts of interest?
Independence in the role of medical examiner is important and vital that this is seen to be the case. It will be necessary, for example, to make sure they do not scrutinise the deaths of patients under their care. Given that there will usually be more than one medical examiner locally, it should be straightforward to ensure that scrutiny is carried out by someone else.
The National Medical Examiner in his guidance has made clear that medical examiners should demonstrate the highest professional standards at all times, in order to ensure the service is seen as both credible and independent.
Is the medical examiner service a part of the coroner's function?
No, it is independent - but there is every expectation medical examiners will work closely with coroners, in partnership. It is also important to recognise there are now statutory obligations for doctors to report certain deaths to the coroner, and this applies to medical examiners too, which they will achieve primarily by discussion with the qualified attending practitioner.
The process for death certification sounds complex with the involvement of medical examiners - are there resources available to help?
The National Medical Examiner's good practice guidelines helpfully has produced a flow diagram, which makes it easy to see how the various processes and professionals interlink. Keep in mind that the medical examiner will want to help, and therefore there may be local education and training events that will explain more - and also they are available for advice where necessary.