Background to medical examiner implementation
Death certification reform has been called for over 100 years, but it was the third of Dame Janet Smith’s reports following the Shipman Inquiry in 2003 that recommended an independent system of medical practitioners to work with coroners to review all deaths in England and Wales. Medical examiners (MEs) scrutinise deaths to ensure the cause of death is accurate, that cases are referred to the coroner appropriately and to identify any clinical governance concerns. They do this by proportionate review of the patient record and discussion with the attending doctor and next of kin. MEs work closely with medical examiner officers (MEOs), who come from a range of clinical and non-clinical backgrounds.
Long-standing College involvement
Former president Professor Peter Furness was the first chair of the Medical Examiners Committee (MEC) and was instrumental in establishing the lead role of the College in ME implementation. The MEC continues to oversee the introduction of the ME system and the training of MEs and MEOs, with representatives from other relevant College committees, medical royal colleges, the Department of Health and Social Care (DHSC), Welsh Government and the Coroners' Society of England & Wales. Dr Alan Fletcher, the National Medical Examiner, and a lay representative also attend. The College has also published several important documents to support ME services, including the Cause of Death List and the National Medical Examiner’s Good Practice Series, which covers topics including urgent release of a body, organ donation, learning disability and dementia.
Legislation takes time
Introducing a new national system requires legislation – both new laws and changes to existing ones. The primary legislation putting MEs on a statutory footing was passed in the Coroners and Justice Act 2009 but secondary legislation is required before full implementation. This is because death review does not occur in isolation; there will need to be changes to the legislation governing how deaths are registered and how cremations are authorised, for example. The pandemic, Brexit, general elections and ministerial changes have all slowed down the progress of statutory implementation.
Changes to the 2009 legislation were made in the Health and Care Act 2022, which moved the responsibility for employing MEs from local authorities to the NHS. A huge amount of work is being done behind the scenes to prepare for full implementation. In April 2023, the government announced plans to implement a statutory ME system from April 2024, with the relevant provisions of the Coroners and Justice Act 2009 and Health and Care Act 2022 being commenced by autumn 2023, with publication of draft regulation by the autumn. This is very welcome progress.
Engaging with stakeholders
The ME system interacts with many stakeholders and it is vital that they are closely involved in implementation. The College has been represented on the DHSC Death Certification Reform Programme Board since it was established in 2016, working closely with several government departments and other stakeholders. The MEC also includes a wide range of representation from within the Collegeand external organisations.
Attracting and training the workforce
Introducing an entirely new medical specialty is a huge challenge and there have been concerns that there would not be enough people interested in working as MEs and MEOs. Once these individuals have been identified, they all need to be trained and appointed to posts.
There is now a full training programme in place for MEs and MEOs. 26 core e-learning modules were developed with e-Learning for Health in 2011, updated in 2018 and currently under review for the introduction of the statutory system. All MEs and MEOs must complete these modules, which cover the basics of death review such as when a death must be referred to the coroner, the role of the registrar and how to complete a medical certificate of the cause of death. There are a further 35 optional modules that MEs can complete if relevant to their practice, such as those on organ donation and different faiths.
The College also provides a mandatory 1-day training course for all MEs. Initially held in person at venues in England and Wales, the course moved online during the pandemic and is now offered in both formats. Since the training day was introduced, almost 2,000 MEs have attended. Over 600 people have attended similar training days for MEOs.
The programmes include short talks from the coroner, faith communities and patients, discussions about the vital role of the MEO, conversations with bereaved families and the role of the ME system in primary care. The majority of the day is spent with delegates discussing challenging scenarios in small groups, led by an experienced facilitator. The team of facilitators, from ME, MEO and coroner backgrounds, has made the training a great success, with many delegates saying it’s the best educational event they’ve ever attended.
Individuals who complete the training become eligible to join the College; there are now around 1,000 ME and MEO members. As well as providing training for MEs and MEOs, the College worked closely with the Judicial College in 2022 to deliver 5 online training days for established MEs and coroners, ensuring mutual understanding of each other’s roles and encouraging good communication. The College also holds an annual ME conference, which gives an opportunity to share policy updates, progress with legislation and talks on hot topics.
Review of community deaths
In England, the non-statutory ME service was first introduced in acute trusts and many of the MEs appointed were hospital consultants. MEs shared facilities with bereavement care teams and were able to feed into existing governance pathways, such as structured judgement reviews, morbidity and mortality meetings and serious incident investigations; they direct families with concerns to the Patient Advice and Liaison Service.
Almost all deaths in acute trusts are now reviewed by MEs and the service has been rolled out to cover deaths in the community over the last year or so. Some ME offices review 100% of community deaths; others are at an earlier stage. With the well-recognised pressures on primary care, the nature of the GP contract and the absence of corresponding governance pathways, there have understandably been concerns about the perceived burden on primary care. This has been one of the biggest challenges the ME service has faced.
However, several hundred GPs have now completed ME training and have been appointed to ME roles. Hundreds of GP practices have engaged with ME services and are benefitting from advice about coroner referrals and causes of death, and valuing the support provided to both certifying doctors and bereaved families.
IT
MEs need access to appropriate IT systems to document their work, access GP records and communicate with others. A digital case management system has been in development for several years but is not yet available for routine use. In the meantime, ME services have successfully developed their own way of recording ME scrutiny and providing detailed quarterly returns to NHS England (NHSE).
NHSE has worked with the national Confidentiality Advisory Group to ensure that MEs have the legal right to access patient records for the purpose of death review. ME services have been encouraged to find local solutions to the challenge of accessing community records. Many can access records via SystmOne, others via e-RS and, if no direct access, 3 months’ records can usually be downloaded easily and attached to an email for ME review.
Impact on families
There was initially concern that recently bereaved families would not wish to be contacted shortly after a loved one’s death to discuss the quality of care and cause of death. However, feedback from families has been overwhelmingly positive, with almost everyone welcoming the opportunity to talk to someone about their loved one’s final illness and death. The independence of MEs is valued, as is the opportunity to ask questions, understand what is written on the death certificate and raise concerns. Much positive feedback is also received and shared with staff.
The future
The ME system in England and Wales will move to a statutory footing from April 2024. When that happens, every death in England and Wales that is not referred directly to the coroner will be scrutinised by an ME and it will not be possible to register a non-coronial death without ME involvement. It has taken many years and a lot of hard work to get to this point. The College has played a vital role, particularly in the training of MEs and MEOs and the publication of guidance for ME services. I’m sure there will be further challenges ahead but the College is well equipped to meet them.
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