Welcome

Following this month’s written ministerial statement, we expect all relevant deaths to be scrutinised by medical examiners by April 2024. I am sorry it has taken so long for this to be clarified.

The additional preparation time may be welcome for many, to embed processes with other providers, and to implement options for sharing patient information, as set out in this bulletin. It is helpful to have more certainty in advance of our annual conference on 17 May. I look forward to seeing many of you at this virtual event, and I am very grateful to the Royal College of Pathologists for all their work to make this happen.

There continues to be good news about community rollout. I am extremely grateful to Malini Bhular, the lead medical examiner at West Hertfordshire Teaching Hospitals NHS Trust, and to her team. They kindly invited me to visit and celebrate achieving scrutiny of deaths with all GP practices in their area.

Increasing numbers of bereaved people whose loved ones died in the community are being supported by medical examiners. Of course there are challenges, but the overall trend is extremely encouraging.

Medical examiners in England are now reviewing around 22% of estimated deaths in the community (up from 16% in the previous quarter). Medical examiners and officers in Wales have been working closely with GP practices, you can read more in this bulletin.

We are also taking the opportunity to highlight the achievements of the East Dorset office, which adopted an innovative approach including a helpline for all GP practices. I understand several other medical examiner offices in England are working with all or nearly all GP practices, including Harrogate, Wolverhampton, East Kent and the Isle of Wight. In some areas, such as Greater Manchester, ICBs have also been providing invaluable support.

I offer my congratulations and thanks to the medical examiners and medical examiner officers for the progress they are making in all areas in England and Wales.

Dr Alan Fletcher, National Medical Examiner.

What’s included in this update

• Supporting roll out in the community
• Easier sharing of GP patient records in England
• Good Practice Series – homelessness paper
• Implementation in Wales
• Chief Coroner‘s guidance on stillbirth
• Quarterly reporting in England
• UK Fatal Anaphylaxis Registry
• Healthcare inequalities publications
• Training and events
• Contact details
• Further information

Supporting rollout in the community

We are taking the opportunity to highlight the East Dorset Medical Examiner Service. They were supported by the Integrated Care Board (ICB) and the Local Medical Committee (LMC) which undoubtedly smoothed the implementation process for everyone involved.

Getting GP practices on board was made easier by establishing a helpline available to all GP practices, before they were formally linked to the medical examiner office. By March 2023, 34 of the 54 GP practices in the area had linked to the medical examiner office, with over 1,000 deaths in the community already scrutinised. The support and guidance offered built confidence and trust, and we would encourage all medical examiner offices to consider replicating this offer. For example, it can help GPs with more complex cases, such as deciding whether notification to coroner is required, advising on the legislation around death certification, or identifying the most appropriate doctor to complete the MCCD.

East Dorset uses the e-referral process, and GPs send patient record summaries from their electronic patient system, providing one solution to sharing records electronically. Dorset ICB were able to add a Medical Examiner e-referral to the existing templates.

Simple IT processes, and incremental rollout at an appropriate pace, have provided the basis for successful introduction of the service. The East Dorset medical examiner office have received overwhelmingly positive feedback from local GPs about the help and guidance during a time of significant NHS activity, and the ease of accessing support.

The following item sets out other recent developments that support extending medical examiner scrutiny to GP practices in the non-statutory phase, relating particularly to England.

Easier sharing of GP patient records in England

The Confidentiality Advisory Group recently confirmed they have extended section 251 support for the non-statutory medical examiner system in England until March 2024. This approval provides the legal basis for all healthcare providers to share deceased patients’ records with medical examiners while the system remains non-statutory. After the statutory system commences, medical examiners will have a statutory right of access to patient records.

The NHS e-Referral Service (e-RS) has been updated to provide a straightforward method for GPs in England to share summaries of patient records with medical examiners. Local medical examiner offices will need to decide whether to use this system, and work with e-RS leads in their trust to switch on local functionality.

e-RS is a national electronic referral system which GPs use to request advice and assistance from secondary care, or make clinical referrals for more specialised care. Support for medical examiners has now been enabled in e-RS. Some medical examiner offices already use other systems, but e-RS may be of assistance in areas which have not yet identified workable methods for sharing access to electronic patient records. It will allow GP practices to alert their medical examiner offices of deaths and to send patient summaries; it provides case management functions for both GP practices and medical examiner offices; and it will facilitate further communication in the minority of cases where this is required.

In the previous bulletin, we described details that should be included in summaries of records to facilitate scrutiny by medical examiners. Summaries should include entries for at least 3 months, including previous medical or medicines history, and any hospital correspondence. Any other information the GP practice staff believe relevant can also be included. If medical examiners require further information to complete scrutiny, they can often obtain this from hospital records. In the minority of cases where more information is needed to complete scrutiny, medical examiners will liaise with GP practices for further details.

Good Practice Series – homelessness

We are pleased to announce that the Royal College of Pathologists has published the latest of the National Medical Examiner’s good practice series. This latest paper includes information and recommendations for medical examiners regarding homelessness.

Implementation in Wales

The Medical Examiner Service for Wales is now recruiting to the last tranche of posts to bring the service up to full establishment in readiness for the legislative requirement later this year. The all-Wales nature of the service means that our medical examiners are now working fully peripatetically, supported by medical examiner officers who are based in one of our four hub sites, but utilising agile working arrangements where practicable. This helps maintain the independence of the service, but also efficiency as demand and capacity can be better matched on an ongoing basis across the whole of the country. This was very evident over the Christmas and new year period when the number of cases presented for scrutiny was particularly high, and our thanks go to all staff who went above and beyond to ensure that all three elements of the scrutiny process were completed in a timely manner.

We are conscious that our planned build-up of cases from non-acute settings coincides with huge pressures on GP Practices at the moment, and so we are working with the General Practitioner Committee of the BMA in Wales to ensure that the demand that we place on practice staff is kept to the absolute minimum, and also that our outputs are able to form part of a wider, single, and coherent, clinical quality and patient safety assurance system.

We will also continue to refine our reporting arrangements over the coming months so that we are able to analyse and present themes and trends at multiple levels as part of the all-Wales assurance and concerns management system.

Chief Coroner’s guidance on stillbirth

The Chief Coroner recently published an excellent summary of the law relating to stillbirths and live birth following termination of pregnancy (see Guidance number 45). This is a complex area and one that often generates questions, so this guidance is timely and welcome. The Chief Coroner’s guidance papers offer a range of valuable information and are a recommended resource for medical examiner offices.

Quarterly reporting in England

Future submission windows for quarterly reporting via the online portal are as follows: 

Please contact reporting.nme@nhs.net if you have any queries. 

Healthcare inequalities publications

NHS England’s Healthcare Inequalities Improvement Team are pleased to draw medical examiners’ attention to several recent publications which highlight the ways healthcare inequalities can cause or contribute to patient safety issues and can lead to adverse patient outcomes. Medical examiners are asked to consider the healthcare inequalities during scrutiny of deaths.

Action on patient safety can reduce health inequalities, published by the BMJ, notes that the risk of harm may be experienced unequally in different population groups. The National Confidential Enquiry into Patient Outcome and Death report highlights where inequalities have been revealed and how data can help identify healthcare inequalities. Healthcare Inequalities: Access to NHS prescribing and exemption schemes in England, published January 2023, provides initial insights into the uptake of NHS exemption schemes and prescribing of medications associated with Chronic Obstructive Pulmonary Disease, Hypertension and Severe Mental Illness in deprived populations in England. For further information about the work of the Healthcare Inequalities Improvement Team, please visit the Equality and Health Inequalities Network.

UK Fatal Anaphylaxis Registry

The UK Fatal Anaphylaxis Registry (UKFAR), held at Manchester University NHS Foundation Trust (MFT), was setup in 1993 and is supported by the British Society for Allergy and Clinical Immunology (BSACI) and patient support groups including Anaphylaxis Campaign and Allergy UK. UKFAR analyses suspected cases of fatal anaphylaxis from any cause. There are currently 20-50 such cases reported each year which is likely to be an underestimate. The registry data helps develop better understanding of the risks and causes of fatal anaphylaxis. This will ultimately provide knowledge to reduce the risk of future deaths from anaphylactic reactions. UKFAR has ethics permission (05/Q1405) and Section 251, confidential advisory group permissions (8-03(PR2)/2013) to acquire and retain identifiable information.  

UKFAR encourages the submission of suspected cases and can provide advice on the investigation and assist Coroner’s investigations. Early involvement of UKFAR in the assessment of suspected fatal anaphylactic events is beneficial in the identification of contributing factors and to guide or focus post-mortem assessment.

Contact them on mft.fatal.anaphylaxis@nhs.net

Training and events

The total number of medical examiners trained is 1,946, and over 500 staff have completed the medical examiner officer training. Future sessions are arranged.

The Royal College of Pathologists will host the third Medical Examiner Annual Conference on Wednesday 17 May 2023. This will be an online event, and registration is now open on the College website.

Contact details

We encourage you to continue to raise queries with us and share your thoughts on the introduction of medical examiners, through the contacts list.

The page contains contact details for the national medical examiner’s office, the medical examiner team in Wales, and regional medical examiner contacts in England.

Further information

Further information about the programme, including previous editions of this bulletin, can be found on the national medical examiner webpage.

NHS Wales Shared Services Partnership also has a web page for the medical examiner system in Wales.