NHS England » National Medical Examiner update

Welcome

I am extremely pleased to be writing to you at the end of what has proved the most significant year for the medical examiner system. In April ministers announced that the statutory system would commence from April 2024, and that primary legislation would be commenced and draft regulations published in the autumn this year. Although a little later than first anticipated, this has now happened.

The draft regulations will help smooth the way for the new death certification process from April 2024, to help improve the experience of bereaved people. There is also good news for front-line staff. The changes include: no requirement for the attending doctor to have seen the deceased 28 days before death, allowing a wider pool of doctors to be able to complete MCCDs; recognising that seeing the body after a death is not practical; introducing more straightforward processes between medical examiners, register offices and coroners; and notably, reducing delay and distress to bereaved people by avoiding unnecessary interactions between coroners, doctors and register offices where the cause of death is known and natural.

I expect like me, many of you would have preferred the draft regulations to be published sooner. However, I reflect that after many years of preparation, and the complex choreography required, we can recognise the challenges and celebrate the legislative requirements all being in place. The plain language document published alongside the draft regulations is also extremely helpful in making requirements clear for everyone involved in the death certification process.

My appeal now is that we focus on delivering benefits quickly for the people who are the primary consideration in these reforms, namely bereaved people. The draft regulations provide a platform for national and local outreach. There are more details in this update about materials to help medical examiner offices agree processes with all local partners.

I recognise that winter pressures will cause additional challenges in getting the message out. However, GP practices using the time ahead of April 2024 to work with medical examiners, even on just one or two referrals, will help staff to understand the process and stand them in good stead when the new regulations come into force. Medical examiner offices should continue to do all they can to support GP practices, particularly around challenges in complex cases. This programme has always depended on local partnerships and will continue to do so.

I would like to extend my thanks and best wishes to Margaret Butler, who recently retired as Regional Medical Examiner Officer in the North West, and welcome two new starters. Danielle Wall is the Regional Medical Examiner Officer for East of England and the Midlands, and Helen Rose joins the national team as Senior Project Manager.

Finally, thank you for all you are doing to move things forward. My visits (thank you to colleagues at Homerton, Royal Berkshire, Colchester and Liverpool for your warm welcomes) reinforce my appreciation of the continued hard work and progress on the ground. Your Quarter 2 returns indicate that medical examiners provide independent scrutiny of a third of deaths in non-acute settings, and more than two thirds of all deaths. Great progress, we are now in the final straight.

Dr Alan Fletcher, National Medical Examiner

What’s included in this update

Draft medical examiner regulations published

The Department for Health and Social Care (DHSC) has published details of the death certification reforms planned from April 2024. DHSC and Welsh Government have also published draft regulations for England and Wales. Primary legislation was commenced on 1 October 2023, and changes from April 2024 will affect all healthcare providers. Once the new death certification process comes into force, all deaths in England and Wales will be independently reviewed, without exception, either by a medical examiner or a coroner. The introduction of Medical examiners provide an important safeguard, as highlighted after the Lucy Letby verdict. DHSC’s document notes that:

NHS trusts hosting a medical examiner office should provide adequate support and ensure the independence of medical examiners is respected.
All other healthcare providers including GP practices should set up processes to start referring deaths to medical examiner offices if they have not already done so. This will allow procedures to bed in and avoid disruption and distress for bereaved people when the regulations come into force. A podcast is available exploring how medical examiners can support GPs and their work with bereaved people.
Integrated Care Boards (ICBs) in England should ask all healthcare providers in their area to establish processes to refer relevant deaths to medical examiner offices for independent scrutiny as soon as possible.

Other changes are being introduced, including a new Medical Certificate of Cause of Death, which can be completed by a doctor who attended the deceased at any time – at present MCCDs can only be completed if the doctor saw the patient within 28 days before death or after death.

In addition to the new MCCD, the Coroners and Justice Act 2009 also allows for a new Medical Examiner Medical Certificate of Cause of Death (ME MCCD), but only where no attending practitioner is available within a reasonable time, and the cause of death is known and natural. There are additional requirements – a doctor (not the medical examiner) is expected to refer the case to the senior coroner. If the senior coroner decides not to investigate, they need to refer the case to a medical examiner. There is no other route for the ME MCCD to be completed.

If all these exceptional circumstances apply and all the requirements are met, the new ME MCCD can be completed. It will minimise delays and reduce additional distress for bereaved people, and allows the death to be registered without unnecessary post-mortems and uncertified deaths. While medical examiners completing a ME MCCD will not have an interaction with an attending practitioner, all other elements of medical examiner scrutiny remain in place. Medical examiners, supported by medical examiner officers, will continue to offer bereaved people the opportunity to ask questions and raise concerns. They will carry out a proportionate review of medical records. If the medical examiner is unable to establish the cause of death, the case can be referred back to the senior coroner.

The National Medical Examiner has released a podcast explaining the new process. The Royal College of Pathologists will also be holding an information-sharing event on 17 January.

New good practice paper – major incidents

The Royal College of Pathologists have published the National Medical Examiner’s latest good practice paper exploring medical examiners’ role in relation to major incidents.

Implementation in Wales

The number of deaths scrutinised by the service continues to grow in line with our aim of being able to scrutinise 100% of deaths not investigated by a coroner from April 2024, including an increasing proportion of deaths from community settings. We are regularly being invited to scrutinise deaths directly referred to coroners which may be certified with the benefit of medical examiner scrutiny.

The desire to continue to build and refine our systems and processes, both workflow and reporting, means that we are continually looking to improve outcomes and performance. This can be seen in several areas. Firstly, we have sought to improve our recruitment process through a greater emphasis on practical application of skills in real time, using a selection centre type of approach, rather than reliance on more traditional interviews alone. Secondly, we have adapted our continuous professional development (CPD) programme to ensure that it addresses areas that are identified though our performance monitoring framework including the use of journal-based learning based on the Good Practice Series publications and the use of quiz-style exercises based on core principles and concepts identified through internal incident reporting. The framework has also recently been reviewed, with amendments made to ensure that it reflects the key outcomes and drivers of performance from both internal and external perspectives as well as being owned by the service as much as possible.

The use of local stakeholder groups, based around our Hub Offices, is also ensuring that the scrutiny process is embedded in a wider system context, and that there is a free flow of reflections and ideas that can be used to further enhance service delivery and perceptions, inside and outside the Service.

In line with the National Medical Examiner’s good practice paper on escalating thematic issues and maximising the impact of medical examiner scrutiny, the first formal reports have been submitted to Medical Directors and Assistants in Mortality Review/Learning from Death. Further work is now being undertaken to refine the Welsh medical examiner case management system to add further detailed information for future reporting. The medical examiner service is fully engaged with the Welsh Mortality Review network as part of further efforts to standardise the approach to learning from death.

There continues to be regular engagement with Welsh coroners and the medical profession to maximise the understanding of how the legislation will impact on their functions.

Digital Medical Certificate of Cause of Death

The NHS Business Services Authority and the Department of Health and Social Care are developing a digitised Medical Certificate of Cause of Death (MCCD) for England and Wales.

If your role involves completing or handling MCCDs in any capacity, you can take part in the research and be involved in shaping the design of the future digital MCCD. As many people as possible are needed to take part to build an effective and inclusive digital service.

The research sessions will be at times convenient to users and NHSBSA will make sure they fit around colleagues’ availability. If you would like to participate, please complete the survey and provide your contact details. If you would like more information please contact UserResearch.DCR@nhsbsa.nhs.uk.

Weekend and bank holiday cover

We are encouraging all medical examiner offices to consider how to ensure they provide appropriate levels of cover for weekends and bank holidays. There is no expectation that all medical examiner offices will open every day, but proportionate arrangements to reflect local circumstances are necessary. The good practice paper sets out key factors to consider, including facilitating organ and tissue donation, and responding to the needs of faith communities. We are grateful for proposals that many offices have submitted, and ask those in England that are still working on arrangements to liaise with their Regional Medical Examiner before the year end.

Changes to NHS e-RS referral system in England

We have been informed the user authentication system used by the e-RS referral system changed at the end of November. This national system is used by some medical examiner offices in England to manage referrals from GP practices and to provide GP practices with a straightforward and secure way of sharing summaries of electronic patient records. The system itself is not changing, it is simply a new web address. Users need to change the browser address (URL) they use to access e-RS. Online guidance is available to help teams implement the simple change to e-RS.

Training and events

To date, 2,153 medical examiners have been trained and over 711 staff have completed the medical examiner officer training.

As mentioned earlier, the Royal College of Pathologists will host an information-sharing event on the death certification reforms on 17 January 2024.

Quarterly reporting and finance

We recently completed verifying data for quarter 2 and would like to thank medical examiner offices for providing this helpful information. A number have not provided finance reconciliation data yet, please do send this to funding.nme@nhs.net to support planning for 2024/25.

Welsh Government are working with DHSC to finalise their funding allocation for 2023/24 and to agree planning assumptions for 2024/25. The National Medical Examiner office is also discussing details for 2024/25 with NHS England’s strategic finance team and will provide details as soon as we can.

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.

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