Information for non-acute NHS trusts on extending medical examiner scrutiny to non-coronial deaths in the community
This webpage summarises information for non-acute NHS trusts on the extension of medical examiner scrutiny to non-coronial deaths in the community. The information may also be of interest to those working in other community healthcare settings.
Once the new death certification process comes into force on 9 September 2024, all deaths in England and Wales will be independently reviewed, without exception, either by a medical examiner or a coroner.
We also have a separate webpage providing specific information for primary care.
Introduction
Medical examiners are senior doctors who provide independent scrutiny of deaths not taken at the outset for coroner investigation. By giving families and next of kin an opportunity to ask questions and raise concerns, they put the bereaved at the centre of processes after the death of a patient. Medical examiners carry out a proportionate review of medical records, and speak with doctors completing the Medical Certificate of Cause of Death.
Medical examiner offices have been established at all acute trusts in England, creating a national network to provide independent scrutiny of non-coronial deaths occurring in acute hospitals. The role of these offices is now being extended to also cover deaths occurring in the community, including at NHS mental health and community trusts.
The complexity of extending the medical examiner system to all non-coronial deaths is recognised, and implementation should proceed carefully and through an agreed incremental process made possible by the non-statutory period.
- Medical examiners can support doctors completing medical certificates of cause of death (MCCDs) with complex cases, administrative elements of notifications to coroners where agreed, and help reduce administration.
- Implementing medical examiners does not introduce any new requirement for doctors completing MCCDs to view the body.
- There is usually no need for a verbal discussion between the doctor completing the MCCD and the medical examiner. In most cases medical examiners only need access to relevant parts of the record (or a summary) and last entry.
- The National Medical Examiner encourages medical examiners to adopt a constructive and developmental approach, respectful of the professional status of clinical colleagues.
What medical examiners do
Medical examiners’ conclusions can inform learning to improve care for future patients, or, in a smaller number of cases, may be referred to others for further review. Their involvement also provides reassurance to the bereaved.
Medical examiners seek to answer three questions:
- What caused the death of the deceased?
- Does the coroner need to be notified of the death?
- Was the care before death appropriate?
Medical examiners answer these by providing independent scrutiny, with three elements:
- A proportionate review of relevant medical records
- Interaction with the doctor completing the Medical Certificate of Cause of Death
- Interaction with the bereaved, providing an opportunity to ask questions and to raise concerns
Medical examiners are encouraged to adopt a constructive and developmental approach, respectful of the professional status of clinical colleagues who provided care to deceased patients in their final illness.
How medical examiner scrutiny is being extended to community settings
We recognise there is not be a “one-size fits all” approach to implementing medical examiners. Through a negotiated process, medical examiner offices and healthcare providers can discuss appropriate geographical clusters, to enable each provider to link to a medical examiner office. A key consideration will be how these arrangements can be optimised for the benefit of bereaved families and relatives.
Such arrangements may require time to test and improve processes before the statutory system comes into force on 9 September 2024.
An incremental approach is being encouraged which allows local systems to identify suitable first steps, and to build on these. Geography, existing partnerships and links between health providers and Integrated Care Systems are just some of the factors that will influence planning. An incremental approach will also allow the medical examiner office and its local healthcare partners time to recruit and develop staff, to develop and embed agreed processes, and to grow capacity in step with the widening scope and remit of the medical examiner office.
How medical examiners can benefit non-acute trusts
Medical examiners are already delivering benefits outlined in the National Medical Examiner’s 2020 report, including fewer rejected MCCDs, improved referrals to coroners, improvements to patient care, and positive feedback from certifying doctors and bereaved people. Potential benefits for non-acute trusts include:
- Supporting bereaved people: this can reduce workload by taking care of enquiries and follow-ups. This does not replace staff speaking with families or next of kin, and providing the support they wish to give.
- Support with MCCD completion: specialist training and understanding of the MCCD and death certification processes means medical examiners can reduce the burden associated with coroner notifications.
- Supporting work with coroners’ offices: medical examiners are a source of medical advice for coroners, which should reduce requests from coroners to discuss cases or to advise on wording.
- Timely completion of scrutiny: medical examiners complete their scrutiny in a timely manner to facilitate registration within five days.
- Complex cases:Medical examiners will support the doctor completing the MCCD, drawing on their extensive knowledge gained through training and regular exposure to more complex scenarios to support and advise. This will assist doctors to complete MCCDs accurately in more complex cases.
- Urgent release of the body: medical examiners will develop positive relationships with contacts in faith communities, and will be able to support requests for urgent issue of the MCCD.
- Clinical governance: where issues are detected, medical examiners will offer non-judgmental feedback. Their aim is not to find fault or review in unnecessary detail.
- Insight and learning: a key objective for the medical examiner system is to identify constructive learning to improve care for patients.
Medical examiners from non-acute specialties
Experienced doctors from all specialties make a valuable contribution as medical examiners.
We expect representation from a broad range of medical specialties in the medical examiner workforce to increase with the extension of scrutiny to all non-coronial deaths. All medical examiners are trained to review cases whatever their origin or clinical specialty. Most medical examiners work in this role part time, carrying out medical examiner duties alongside clinical duties. A portfolio career approach to working appears attractive to the large majority of the 1,300 senior doctors that have completed medical examiner training, and who represent a broad range of specialities.
Training for medical examiners is provided by the Royal College of Pathologists, and is open to senior doctors from all specialties. The National Medical Examiner has made it clear that having medical examiners from a range of specialties will provide a useful range of perspectives, and strengthen the ability of each medical examiner office to scrutinise the spectrum of non-coronial deaths which occur.
The statutory medical examiner system
From 9 September 2024 all deaths in any health setting that are not investigated by a coroner will be reviewed by NHS medical examiners. The changes, which form part the DHSC’s Death Certification Reforms, were announced by the government on Monday 15 April 2024.