From April 2019, the new role of medical examiner will be introduced into the process for investigating the deaths of patients. Dr Ben Lobo, consultant physician, geriatrician and medical examiner, and Dr Ewen Ross, medicolegal consultant at Medical Protection, look at what this means for you

The medical examiner (ME) role is a new one for England and Wales, which will come into non-statutory force in April 2019.^{[1] [2]}The ME will be an independent senior doctor whose role is to enhance the governance and regulatory systems by scrutinising the deaths of patients not under review or inquest by the coroner.

Most MEs appointed to the role will need to draw on a broader clinical experience that meets the standards expected for completing form 5 or part 2 cremation certification, and have been registered to practise for at least five years.

Why do we need medical examiners?

There have been a number of high profile healthcare “horror” stories over the last 30 years, with public inquiries recommending better controls and analysis of deaths; these have gone on to state that if an ME process had been in place, problems would have been detected and stopped at a much earlier stage. Bereaved relatives in these failures wanted and needed an independent process where they could voice their concerns and call for action to be taken. This is reflected in the NHS policy on learning from deaths.^[3]

The bereaved want to know, with a degree of certainty, what their loved one died from. It is especially important for those families who have concerns about genetic disease and their own future risks. Studies have shown death certification to be poor, with one third of scrutinised certificates needing major change, 8% showing a failure to understand the indications for referral to a coroner, and 12% leading to wrong International Classification of Diseases coding.^[4]

 

The MEs have three primary aims:

• to establish the medical cause of death and ensure that this is accurately coded in the medical certification of the cause of death (MCCD)

• to detect significant problems in treatment or care and, where necessary, report to the death to the coroner or to governance systems
• to increase transparency for the bereaved and listen to their concerns, and where necessary, explain the cause of death.

The MEs have secondary aims:

• to educate and/or provide advice to professionals about these clinical and legal processes
• to liaise with agencies such as the coroner, sometimes in special circumstances, eg an urgent release of a body for religious or cultural reasons; or completing an MCCD on the coroner’s instruction, when no qualified practitioner has attended upon the deceased in their last illness
• to provide immediate support to the bereaved through the process.

So what does this mean for doctors?

Under the new system, a cause of death will only be registered after scrutiny by an ME, or by the coroner. The MEs will undertake a ‘proportionate’ scrutiny of medical records, looking at the quality of clinical management and the care provided by medical and other staff. MEs will work in collaboration with the coroner and the system of death certification should see improvements in responsiveness, and allow prompt certification and release of a body.

How does the new ME scrutiny work?

After a patient has died, the clinician responsible for the patient should lead an initial review and discussion with the attending doctor or “Qualified Attending Practitioner (QAP), including offering advice. A decision must then be made whether the death needs to be reported to the coroner, and if not, what medical cause of death should be proposed to the ME. The ME will have scrutinised the records and other information before any interaction with the QAP.

A Medical Examiners Officer (MEO) will often speak to the bereaved to confirm administrative details, and make sensitive inquiries into the deceased’s occupation or other important factors such as recent operations or procedures, and practical, religious and cultural needs. The MEO will be well-placed to listen to any emerging concerns of the bereaved and inform the ME of them.

Following discussion with the ME, the QAP will either propose a cause of death for the MCCD, or ask for advice from the ME to complete this task. The ME may accept the proposed cause of death and sanction the completion and issue of the MCCD, or suggest prior amendments. The ME may seek the consent of the bereaved to speak to them about the death, and explain the MCCD process to listen to any concerns they have. The ME may also stop the issue of a MCCD if they feel the death requires reporting to the coroner, for example if new information has come to light.

Learning and development

The current standard for training and approved resources is hosted online at e-Learning for Healthcare. This includes specific training resources about the process of medical certification of the cause of death and an introduction to the ME. The e-LFH represents the core and additional learning requirements for medical staff to complete if they wish to become an ME, or for others who want to be an MEO.

In conclusion

Healthcare practitioners will need to recognise the role of the ME and engage in the new process for death certification. MEs will scrutinise care provided and, while in the majority of cases positive feedback can be expected, any concerns identified will be acted on. MEs will have the power to stop the certification process, or report a death to the coroner for further investigation.