How medical examiners support bereaved people and help improve patient safety

As this year’s World Patient Safety Day celebrates the theme ‘Engaging patients for patient safety’, I felt it was a good opportunity to explain the connection between medical examiners and patient safety, and particularly the support we provide for bereaved people, whose insights and experiences can be crucial in supporting the NHS to learn and improve.

We started implementing a new medical examiner system in England in 2019. Of course the pandemic created additional challenges, but the government now plans to commence the new statutory death certification process from April 2024. After this, every single death in England and Wales will be reviewed by someone independent – a “second pair of eyes.” This will  either be a coroner conducting an investigation (where the death is unexpected or there are other specific circumstances), or in all other cases, a medical examiner.

Medical examiner is a new role performed by dedicated senior doctors in England and Wales, who in the period before a death is registered, provide independent scrutiny of deaths not taken for investigation by a coroner. They come from all specialties, including hospital doctors and GPs, and are trained in the legal and clinical elements of the death certification processes. To ensure they (and the officers working with them) are independent, medical examiners have not been involved in providing care for those whose deaths they review.

Medical examiner scrutiny is provided in three principal ways. First, they offer bereaved people the opportunity to ask questions and raise concerns. Secondly, there is contact with the doctor completing the Medical Certificate of Cause of Death (MCCD).  And finally, medical examiners carry out a proportionate review of medical records. If they detect issues or concerns, medical examiners refer cases for further review through established clinical governance processes.

We are now in the final stages of the rollout of this service, and are already gathering significant information about the support medical examiners and their teams offer to bereaved people, particularly through the regular feedback medical examiner offices receive. I took the opportunity to briefly review feedback from the past six months, and the examples shared here are characteristic of the positive comments made by bereaved families.

One family commented that speaking to someone not involved in care empowered them to say what they really felt. Another family said the medical examiner office kept them informed about an unfamiliar process – which the act of death certification so often is for bereaved people – providing much appreciated support at this difficult time. Another medical examiner office arranged a meeting for the family with the clinical team to address their concerns in greater detail.

It is important to note that this support is provided to bereaved families at the most sensitive of times and can be crucial in helping them to start a healthy grieving process.

The benefits also flow over into providers of healthcare.  Discussions with bereaved people happen very soon after death.  In the rare but still sad instances where medical examiners detect concerns, medical examiner officers reported that a number of families did not feel the need to make formal complaints because the case weas being referred for clinical governance review.

I am delighted that medical examiners in England are already having a positive impact on improving patient safety. Recent examples reported by medical examiners show that the new system is already making a difference and informing learning to improve care.

The chief way that medical examiners contribute to patient safety is by providing early insight where care before death was not as it should have been. These findings are often very local and specific to a provider or even a ward or specialty, and can be used quickly to improve care for future patients.  In general, medical examiner offices in England report that they refer around 10% of deaths for further clinical governance review. Medical examiners have now scrutinised 600,000 deaths, each one is a potential opportunity to improve care.

It is important to note that medical examiners also pass on positive feedback from bereaved people. Affirming positive examples of good care, and letting front line staff know that their efforts are appreciated – even where the outcome is the death of a patient – is really important when health systems are under so much pressure.

In the minority of cases where there is a concern, medical examiners provide opportunities to improve things for future patients. Often the findings can be quite minor and simply passed on to the attending doctor or team for action. In other cases the issues are more significant.

Medical examiner offices in a number of NHS trusts have identified improvements that could be made to discharge arrangements, which can improve patient safety and provide better end of life care where this is appropriate. Medicines management is another area that is frequently highlighted for improvement.

In conclusion, medical examiners make a very positive contribution to supporting bereaved people and improving patient safety. I recently released guidance for medical examiners, published by the Royal College of Pathologists, to ensure their significant findings are shared across healthcare systems and with healthcare providers. Medical examiners provide a real opportunity, and it is important this chance to improve care is seized.

You can find out more about the introduction of medical examiners on our National Medical Examiner webpage.

Dr Alan Fletcher is the National Medical Examiner for England and Wales, appointed in March 2019. He was Lead Medical Examiner in Sheffield before this. He pioneered the medical examiner role since 2008 as part of the Department of Health reforms of death certification; personally reviewing over 22,000 deaths. He has overseen the introduction of the medical examiner system in England and Wales. Dr Fletcher maintains his clinical practice as Consultant in Emergency Medicine and General Medicine at Sheffield Teaching Hospitals.