Dr Alan Fletcher is a consultant in emergency medicine, and the NHS national medical examiner. Dr Fletcher explains the new medical examiner system and how it will be implemented.
NHS England and NHS Improvement launched the new NHS Patient Safety Strategy on 2 July.
This highlights that, despite implementation of the Learning from Deaths programme in acute and community trusts in 2017/18, independent scrutiny of all deaths is still missing. For many years, coroners have fulfilled this role for deaths referred to them. But, in future, medical examiners will fulfil this role for non-coronial deaths to ensure that every death is independently scrutinised, and every bereaved family is given the answers they need.
I started working as a medical examiner in Sheffield in 2008. Our service was the first pilot, working with Department of Health and Social Care (DHSC) in response to Dame Janet Smith’s inquiry into the Harold Shipman case. We have reviewed 29,000 deaths and learned that providing a voice to the bereaved at this most difficult of times is critically important and rewarding. It has allowed us to make significant improvements in what happens after death, including spotting concerns sooner.
Moving to a national view, in June 2018 the DHSC published the government’s response to consultation on the Introduction of Medical Examiners and Reforms to Death Certification in England and Wales. It set out that the medical examiner system will be enshrined in statute, but this will take some time. On 11 July 2018, Lord O’Shaughnessy announced the intention to push ahead with a non-statutory system. NHS England and NHS Improvement are working with DHSC to implement this system for non-coronial deaths in secondary care in 2019/20. The system will be rolled out in 2020/21 to cover all non-coronial deaths, not just those that happen in hospitals.
I see this as a positive opportunity – it means we can work together to implement the system over time, rather than having to meet a statutory deadline from a standing start. I was appointed as the national medical examiner for England and Wales in March 2019, and we have already made significant progress. We have established a small national team, appointed a lead medical examiner for Wales and regional medical examiners, who, from late summer/autumn, will lead on developing local medical examiner offices.
Basing medical examiners in acute trusts will allow straightforward access to patient information; however they must retain their independence.
Medical examiners will be employed by NHS trusts and foundation trusts. They will come from a range of specialties and I expect many will be physicians. Most will be employed by acute trusts, but some specialist providers may also set up medical examiner offices.
Smaller acute trusts may find it helpful to set up offices with neighbouring organisations. Medical examiners will initially review deaths in their own hospital and will incorporate community cases during 2020/21. Basing medical examiners in acute trusts will allow straightforward access to patient information; however they must retain their independence. Medical examiners will normally work in this role part time and will have a separate line of professional accountability to regional medical examiners, who report to me.
To ensure there is independent scrutiny for every death, medical examiners should not scrutinise cases where they or their department provided care.Medical examiners have important links to learning from deaths, highlighting cases for review and ensuring these are flagged to the trust mortality lead and/or to the relevant mortality review programme.
However, medical examiners should neither be involved in mortality reviews of cases they independently scrutinised, nor undertake mortality review work in medical examiner time. The need to preserve independence makes it inappropriate for a medical examiner to be the overall trust mortality lead.
DHSC committed to making the system cost neutral for the NHS, and at time of writing we are drafting information for medical directors of NHS trusts and foundation trusts in England explaining how this will work, with a separate communication for the health system in Wales.
Funding for medical examiners will come from a combination of fees from Cremation Form 5 and funding from DHSC. DHSC have also developed a web-based system to support medical examiner offices. It has passed the first test phase and is ready to expand and develop as systems are set up. There will be a central process to roll out the web system to local medical examiner offices.
We will be working closely with providers as implementation of the medical examiner system continues. To make sure the system is as useful and supportive as possible for the bereaved we will engage with coroners, registration services, funeral directors, faith leaders and other partners, and encourage local offices to take the same approach.
This article appears in the August edition of Commentary.