Nick: Hello and welcome to our first podcast about medical examiners.

We’re here today to explore learning from roll out of the medical examiner system in the community. In this podcast, we will look at how GPs and medical examiners can work together and how medical examiners can help GPs and GP practices. We’ll look at some of the challenges and how people have overcome them and how together GPs and medical examiners can support bereaved people better.

I’m Nick Day and I’m NHS England’s programme and policy lead for the National Medical Examiner system. And I’m joined today by Dr Alex Dale, who’s a GP and medical examiner in Surrey; Dr Steph Foulkes who is a GP and medical examiner in Wales. Dr Matthew Neal, who isa GP and medical examiner in Scarborough and North Yorkshire; and Dr Farah Noorani, who’s a GP and a medical examiner in London.

Hello, everybody. Can I kick off by asking how you found the roll out of medical examiners in the community? How’s it going, Alex?

Alex: Yep. I have been a medical examiner now since October 2020, and I’m the lead for my service in Surrey. We’ve had a lot of really productive conversations with bereaved people. Obviously, our days of speaking to the bereaved, for those who’ve died in the community is still relatively in its infancy.

But really the extra sort of layer of reassurance, knowing that an independent person who is a doctor and knows about your loved one’s death but was not themselves involved in their care has gone over it with a critical eye and has been quite reassuring for a lot of bereaved people.

Whilst I don’t think we should be answering questions from the bereaved, which are really about the nitty gritty of clinical decision making, we can sometimes answer general questions about why a particular clinical event did or didn’t happen. So, for example, I remember one. A niece, who was the the bereaved of an elderly gentleman who while everything was going on in the hospital, she’d been very concerned that somebody had mentioned something about genetic testing and he died of cancer and she worried that this was going to leave her at a genetic cancer risk.

And from my review of the notes, I was just able to tell her that actually no, the test that they had been talking about was to do with how likely he was to metabolise a particular line of chemotherapy. And she was so hugely relieved.

Nick: Farah

Farah: As an extension to Alex was saying, I completely agree. I think reassurance is a really massive part of what we do.

Having said that, sometimes the relatives have very useful intel that sometimes gets missed off the clinical notes. And for us it has led to some important learnings both for the clinical teams but also the ward staff and admin staff as well. And this in turn has also led to some level of for the families, just some reassurance that perhaps something won’t happen to somebody else.

So, I think the learnings have also been a major part of our kind of discussions with the families.

Nick:  Steph.

Steph: I think the interaction between GP’s and the ME service can also minimise delays with registration and arranging funerals, cremations, etc. you know, at the office. And the MEs can help ensure that the formulations are registerable. That any complex cases are discussed before an MCDC is written and it avoids predictable rejections.

So, I think the concerns regarding delay can be alleviated because the interaction can certainly help that or, what’s the word I’m looking for, prevent it.

Alex: Yeah. And I think Steph that it’s quite and you know the relationship between a GP and the families may have cultivated this over many decades and actually if we can prevent friction at that difficult time, you know a rejected death certificate might not come to light until a funeral is already arranged. There’s the potential for it to cause serious disruption and delays. So if we’ve been able to filter those out. And you know, we’ve got a really good relationship with our local registrar office in Surrey.

Matthew: Absolutely echoing what Steph, Farah and Alex have said, I think the reality is that we are going to be somewhat of a more accessible echo chamber for general unhappiness about some of the care that’s done in general practice at the moment.

And I think the advantage that we have being GP’s as well is that we understand some of those pressures in a different way to hospital consults consultant ME colleagues. But I think the reality is a lot of what we’re going to be hearing from the bereaved is to do with some of those grievances, a lot of which we know full well that it’s very difficult to do anything about. It isn’t really a failure of that practice. It’s a reflection of a failure of the system. But I think the reality is we’re going to be dealing with a lot of those concerns. But I think even if they are genuinely concerns that need to be dealt with by the practice, there’s still parts of the bereaved person’s journey and I think we need to listen to those because we are going to be that person that’s just that bit more accessible.

Nick: That’s a really helpful observation. I think, and one of the things that I know might cause concern for some GP colleagues might be about how medical examiners will respond when they receive negative feedback. Of course, there can be positive feedback as well as negative feedback, but it’d be helpful to hear about any experiences of passing on information from bereaved people.

Farah: Yeah, I agree. And in my meetings with, with GP’s, which I try and do quite regularly, as an ME team, we tend to try and meet virtually with GPs quite regularly. And I think, we’re all GPs, and Matt mentioned this earlier, we’re hard working. We’ve had to deal with a heck of a lot of change in the last few years and for many GPs it’s felt that this is yet another thing that we have to do. It’s being imposed on us. We don’t have a say over it. Of what benefit is this to us? We understand the pressures that are upon GPs right now and our role is, is actually to help. Yes, writing a referral may take a little bit of extra time in your day, but as you’ve heard, it should hopefully help to kind of streamline the process.

You know, one of our roles is to speak to bereaved relatives, which can take a bit of time. Although I have to say many GPs do like to call their patients and do a bereavement follow up call. But to listen to their experiences of the death, etc. That is our role and that’s something that we can absorb and take away from, you know, from GP time.

And, and as Alex said many times it’s, it’s positive feedback, it’s reinforcing that what you are doing as GPs is excellent, you know, the care, the referrals that you did, the, the early referrals to palliative care, the recognition that this patient was on the end of life pathway, you know, and excellent clinical practice is often reinforced and, and actually for me very rarely have I had to feedback negatively to GPs.

And if that’s the case it’s done with the lets learn from this.

Nick: Thank you Farah, and yes of course, the guidance from the National Medical examiner is very much that feedback needs to be with respect of colleagues professional status and that’s what medical examiners aim for.

When I talked, I asked about positive feedback that is positive because of course medical examiners can give positive feedback. It’s not all about discovering problems. Does anyone have any experience of being able to provide colleagues with positive feedback from bereaved people. Farah.

Farah: So I have had multiple families give positive feedback about the time and care that the GPs have given them. Even if it’s a phone call, you know, or a video consultation from both GPs and maybe the practice nurses as well.

That’s always nice. I think acknowledging interaction with families during what is a pretty difficult time of their lives and the family’s lives is very much appreciated.

Alex: Yes, I remember speaking to a family of a very elderly lady with dementia who suddenly appeared to be sort of to have some new neurology, some new one sided neurology. And it’s very tempting, of course, to say, well, maybe, you know, should she be taken into hospital, the respect documentation was very much that she wanted to be cared for in the nursing home where she’d been a resident for a number of years.

That, of course, you know, when everyone expects that the death will look like a gradual death from Alzheimer’s, and then something comes along that looks like, you know, really clinically, it appeared that she had a stroke and it was very nicely documented in the notes that there’d been a discussion with the family, reviewing the respect decisions and then saying, you know, the worst thing for her would be to come to in the corner of A&E, waiting for a CT scan, which would just tell us what we  probably know already, will absolutely not alter her management.

And when I spoke to the family, they were sort of able to to feel like the right thing had been done as a shared decision making process. And in the end, she died with dignity in her bed. They put her favorite music on. And they said how nicely the nursing home staff had sort of combed her hair and kept her clean and peaceful and everything like that.

So it’s really heartening to be able to hear those kind of stories in detail. And they are many.

Nick: And presumably being able to feed them back to the staff is really important for people to hear that and know that they’ve had such a positive impact at such a difficult time.

Alex: Absolutely. So we use ERS and when we close the case, we tend to say, you know, relatives were really grateful for X, Y and Z. No further action, and you know, Thank you so much. And we do try and feed that back through before we close the case.

Nick: Matthew

Matthew: Yeah, absolutely. I think Alex put it really well. I think given where GP’s have really made it clear to relatives that giving them permission to let that person go, you know, something that they’ve known is coming for a long time and now it’s sort of it’s they’re knocking on the door of that, really just having that discussion early about death and, you know, normalizing death.

And I think that’s really important for families is to really vocalize what they may have only been able to keep to themselves for quite a long period of time. So really allowing that person to let their loved one go and to accept that this might be the time that they don’t pull through and to decide what needs to be put in place, and just really allow them to make that decision because they might not feel they’re able to make that decision on their own.

So I think where that’s been done quite clearly and quite nicely and well in advance is really good care. I think the second thing is continuity and palliative care as well. And I think that’s kind of what Farah and Alex already touched on. The continuity is difficult. We all know that in general practice nowadays. And I think keeping someone on your personal books, as it were, for quite a long period of time. So the end of life phase is weeks and months. That can be a challenge for most GPs. Not all GPs work full time. Trying to keep that continuity. I think you notice when someone’s put in that extra effort to keep that continuity and it really does make a massive difference. I’m always struck by when people describe their doctor as my doctor and I think that’s really powerful when people say that because it really shows how much they value a continuity.

It’s a challenge. Sometimes you might think, how long can I keep visiting this person where they’re relatively stable, but they could deteriorate at any point. I think you’ve just got to work with families to do that, but I think that’s where you really see the people appreciate that and we give positive feedback to our hospital colleagues too. I’m personally grateful for any legible handwriting.

Alex: We hope to be able to be your dons of the death certificate and your mentors in mortality, especially if we can avoid unnecessary traffic.

Nick: Thank you, Alex. In fact, you did mention a case where you were able to guide a GP in something where they thought it might have to be notified to the coroner. And in the end you were able to tell them it wasn’t necessary, which I assume would have saved a lot of time for the GP and, and maybe some admin as well.

Is there anything to say about that.

Alex: Yeah. So this particular case I had in mind was a gentleman in his early seventies with, you know, really advanced COPD and the GP went over on a home visit and found him really very breathless. And this was after a couple of days of antibiotics already. But he had capacity and he was absolutely adamant that he did not want to go into hospital.

But still it wasn’t the right situation where the sort of palliative care we get involved. That’s something he’d declined in the past. And he basically said, I see what you’re saying, doc, but I’m going to take my chances at home. And this gentleman was found peacefully dead in his favourite chair about six days after the GP saw him. And the GP was concerned that they couldn’t name a cause of death in that case and really we were able to sort of talk through them. You know, he’s been seen recently. He had a very clear illness. The risk of death was present and really, to the best of your knowledge and belief in exacerbation of COPD is an appropriate cause of death there.

Matthew: Yeah, just to add on to what Alex said there. I think I correct me if I’m wrong, Alex, but I think what you’re really saying there to GPs is, if you ask yourself the question, am I surprised that they’ve died? If you an instinctive answer is no, then you probably do know a cause of death or can suggest something reasonable.

Nick: Farah

Farah: This is an example of where as an ME, I felt that I assisted a GP, a very worried GP. So very, very briefly. It’s a patient that had been registered at the practice for many years, well known to the GP, who went into hospital, had a series of procedures, complications, tertiary hospital was involved and was discharged from hospital very, very far off their original baseline and unfortunately within a week the patient passed away of Broncho pneumonia.

Now while the GP was able to establish the one as bronchial pneumonia, their biggest concern, it kind of related to what resonated when Matt was speaking, was were they surprised that this patient died and they were, compared to how they were before they went into hospital. So the GP called saying, I can do this death certificate. But my concern is, did anything that happened in-hospital the procedures, the complication, etc lead to this person dying. And that’s the bit that I don’t know.

And here in West London, the MEs scrutinise hospital deaths as well as community deaths. So we cross sort of both boundaries. And what it allowed me to do is actually to look at the admission, actually speak to the consultants that were overseeing the care of that patient and answer some sort of critical questions about the procedures, the care etc. the complication that occurred thereafter.

The case did end up being referred to the coroner, but for that very concerned GP, I think it answered a lot of questions rather than leaving them thinking that they perhaps had, they weren’t able to sort of investigate or scrutinise notes from the hospital in the way that MEs can or have access to.

Nick: Thank you Farah. A question that occurs to me is, can you say anything about your experience of working in medical examiner offices and your interactions with colleagues from other specialties and just give a bit of insight to, you know, GPs who might be wondering how does it work.

Steph: Shall I jump in. Yes, I think it’s been very beneficial to work with our medical examiner officers and medical examiners that have a variety of expertise and specialities. And over a third of the medical examiners in Wales are from a primary care background. But we’ve got surgeons, palliative care docs, acute physicians. So the depth and breadth of experience is great.

As GPs, I think we are used to looking at things in a more holistic approach so we can take a more pragmatic helicopter view of the patient care as compared to some of our secondary care colleagues sometimes who really drill down on the, you know, percentage sodium chloride in the bags that they were actually given. And to be able to share that different scrutiny has been beneficial to us.

Our medical examiners officers also come from a different background or come from different backgrounds. You know, we’ve got police, we’ve got paramedics, registrars. So the wealth of experience from the medical examiner, officers who are the constant within the office is hugely beneficial.

Alex: But it was something that Farah said previously that you mentioned Farah, that you scrutinise both hospital and community deaths.

And certainly that’s the way I believe the medical examiner service is intended to be set up. The idea is as Steph has said previously, that we are supposed to apply proportionate scrutiny and not expert scrutiny. In the event that we have concerns, we could always turn to a colleague or indeed our regional teams who support us for additional help. So things like looking at antenatal notes, maybe having a script for how you kind of introduce yourself to bereaved parents once you start looking at child deaths and also how you interact with the child deaths overview panel so that you’re not treading on anyone’s toes and you really are dovetailing your work with services that already exist.

Farah: So very quickly, look, when a GP calls up a consultant urologist to say, I’ve just scrutinised, you know, the recent death of a patient under your care, it’s natural for you to be met with, well, you know, you’re not a urologist. How on earth can you understand the intricacies of, you know, urological procedures? But actually, what has really helped in in our in our service and this translates also to general practice and helping with the engagement with GP practices is that there was a lot of, there were a lot of kind of communications with the consultants and also with our GPs about the service and like with the hospital ME service where they started with a pilot, the same thing was also done in general practice. So a few practices were kind of chosen to, to kind of pilot with us to, to go through. There was a lot of discussion with the GPs and with the consultants as well, which obviously happened earlier than the GP rollout and this helped this, this kind of open question and answer.

How could we make this more efficient, This much more collaborative approach has made it much easier. So consultant urologists expects to be called by a doctor an ME, who is not from their specialty. And so I’ve actually found it very easy, I must say, when I first started working, it was a little bit kind of, Oh gosh, how am I going to be received as a GP scrutinising hospital deaths?

But I quite agree with Alex and we, you know, we our scrutiny needs to be proportionate. It needs to be. Well, as a senior doctor, can you identify anything that perhaps doesn’t make sense here? And if if it doesn’t make sense, ask the question. I have learned heaps, like Steph, I’ve really, really enjoyed each sort of going through, you know, iareas that I probably wouldn’t have as a as a GP and learning more about what goes on nowadays. And, you know, and keeping up to date. So I’ve definitely enjoyed that side of things. But I think preparation and, and lots of pre rollout meetings has really helped,

Alex: And can I just add to that Farah that we are also a place where doctors can raise concerns. It’s not only the bereaved but other doctors. If they have something that you know maybe they feel like they can’t go to another member of their team or it’s something very general. They’re not quite sure any other concerns. They can raise that with us,

Nick: Has any good examples of how best to share patient records, electronic patient records, because that has been an issue that a lot of people have grappled with. But people are finding solutions and it would be good to talk about that.

Matthew: I think we are making progress. I think the main issues are really just needing to have people on board that are solution focused, that aren’t just head stuck on what the problems are and actually looking for those solutions.

So we’ve managed to set up access with our pilot practices relatively easily. Perhaps some of that is because we share the same clinical record systems. So that’s probably been helpful. I believe all our practices share the same records software at the moment.

So in terms of access, I think we’ve done relatively well. The issues that we’ve got locally are just that nothing talks to each other. So we’re a relatively small trust. Our trust doesn’t talk to anywhere else and hospital and GP records don’t share very well. So once those sort of things are ironed out and it’s better flow of information, it will work a lot better.

Nick: Yes. I mean, it’s unfortunately beyond the scope of the medical examiner programme to resolve all the digital sharing issues that there are, but there are solutions which are overcoming it. People have found local solutions and there is the NHSE referral system, which now provides a mechanism as well for areas where that might not be so straightforward.

Farah did you want to come in on this point?

Farah: Yeah. I mean, I think we are a success story. And it was very much a collaboration of multiple parties, a little bit reflective of the point that I made earlier. So a task group was set up and here we have a North West London ICS task group.

So we had representation from the lead ME from GPs in primary care from across all of the of the London boroughs. IT leads, quality leads, LMC representation. And basically had it out in a big kind of discussion with this group to try and come up and generate options a little bit like what Matt was saying, being solution driven, and the option that was most popular was a single IT solution.

So MEs now have access to, we use System One and EMIS in this part of London and all the MEs including the consultant, MEs etc. now have access to System One, which means that we can communicate with GPs, we can task them, they can task us and iit speeds up a lot of the kind of bureaucracy of, you know, trying to call and get through, blah, blah, blah.

It’s all done on a single system now, which really helps. It happens to be a different system to the system that the consultants use within the hospital, amongst, you know, hospital inpatient admissions. But that’s really helped and that was the most popular option. There were many generated. So I would say if you’re about to embark on this, is to ensure that key stakeholders, I know it sounds obvious, but key stakeholders are really brought together to try and come up with the best solution.

Nick: Thank you Farah, and I think the thing you’ve underlined there is the important role that ICBs can play in unblocking some of those, some of those difficulties. And I just wondered if you’ve got any experience of how medical examiner offices have worked with GP’s, with GP practices, who might have wanted some information for their own staff, for the members of the public, Are there any bits of information you can provide about that, please?

Matthew

Matther: Yeah, certainly. I know our lead ME has gone around several practices and physically gone and talked to them to provide a face, if you like, and I think that’s been really helpful, really to give people very easy, accessible routes, for raising their concerns at an early stage. And I think what we’ve been able to do is, is really kind of address a lot of of those concerns quite quickly and at the end of it, leave people quite positive about the benefits.

Like Farah said earlier, about really showing how it’s going to add not take away from anyone’s experience.

In terms of publicising to the bereaved and to patients. I think the key thing really is very clearly explaining to people that our involvement is not because anybody is suspicious of anything. So I think explaining to people that this will be statutory, it’s going to be for all deaths and really my experience of what’s been really helpful is to kind of explain that we are giving a voice to the bereaved.

I’ve actually had a very positive experience where I said to a bereaved relative, well, actually we’re giving a voice to the deceased as well. It’s not just the bereaved it’s actually a voice for the deceased. And they actually found that really positive and quite comforting. So I think it all comes down to how you explain it, reassure people that the involvement is quite routine and normal, but equally, I think also not trivialise it either.

Nick: Alex.

Alex: Yeah, we’ve developed a leaflet which GPs can give to the bereaved if required. I have done loads of presentations with all of the GP surgeries in Teams meetings or in person for some of the larger practices with kind of, you know, 500 patients in nursing homes. It really is a good investment of medical examiner time and to sort of build those relationships.

We’re currently working with the comms team at our host trust. So whilst it’s important that the medical examiner service remains independent, I do think it’s a good idea if we have visibility in our own section on the hospital website.

Nick: Of course there are some deaths where it’s really important that the body is released rapidly and there have been questions about, well, medical examiners may slow things down because they need to carry out their scrutiny.

Can anyone say anything about how they’ve worked to ensure that medical examiners help with the with the cases where the body does need to be released urgently?

Farah, can I come to you?

Farah: Yes. So we have quite a number of faith deaths in our area and we prioritise them. We do prioritise them. Now, while in normal general practice, a GP may or may do the death certificate, sometimes the family have called multiple times, even turned up at the surgery, and ordinarily the GP would be able to do the death certificate and that would be that.

I would say that of course with an ME involved there may be some delay, but it would still be the same day and we do endeavour to try and do it within hours of receiving the referral. And if the duty ME is just not able to do it, another ME steps in. And it’s just prioritised.

Nick: Okay, we’ve had some really interesting points and discussions today. Just to maybe close things. Can we think a little bit about, you know, for medical examiners and for GPs, you know, what are the top line messages for them to take away in terms of working together?

Alex: My advice would be to take advantage of this period where we are still in a non-statutory situation and to engage with your local medical examiner office slowly.

So it doesn’t have to be a big bang. You don’t have to refer every single death as of a given date. You can start with maybe just one nursing home, one doctor, one day of the week. And also the ME offices should listen to feedback from GP surgeries.

Nick: That’s a really important point to use this time to get things set up as well as we can.

Everyone’s busy so we can use this time to work things out and come up with processes that work for everybody.

Matthew, can I come to you?

Matthew: Yeah, absolutely. I think just to echo earlier points really, that we absolutely can make life easier for lots of GPs, we can provide information that helps prevent unnecessary referrals. I think GPs by and large very good at how they record information, but if they can just continue that theme and really kind of in their notes, explain clearly what they think is going on, why they think someone is dying.

It sounds like a silly question, but in hospital records that’s something we’ve really battled, is not really explaining why someone is dying. But I think GPs are very good at that. So I think clear records, anticipating what’s coming next, and using us for that advice, being able to give that kind of reassurance about when something doesn’t need a referral, going back to right what we said at the start about the standard of proof, that you don’t need to be sure about what’s going on and say, just use us, and that’s what we’re here for.

And bear in mind that lots of us will be back where you are sitting tomorrow. And that’s why we can be very helpful. So yeah.

Nick: Thank you, Matthew.

Farah.

Farah: My top tip, make sure you have the MEO, the medical examiner officer’s number. They are a brilliant resource and can answer many, many questions, logistical questions, that you may have as GPs.

So you don’t necessarily need to speak to the medical examiner. So that’s my top tip. Make sure you have your local MEO’s number.

Nick: That’s a really helpful point. We emphasise there isn’t always a need for a conversation or telephone call between the doctor completing the MCCD and the medical examiner. People don’t always have the time for that, and in straightforward cases, everything can usually be done by email.

Well, thank you, everyone. That’s been really interesting and it’s great to hear about your practical experience on the ground.

I’d like to thank our panellists, Dr Alex Dale, Dr Steph Foulkes, Dr Matthew Neal and Dr Farah Noorani.

If you want to find out more about medical examiners, please search for the National Medical Examiner on the Internet. We’re on NHS England’s website. Thank you again for listening. Goodbye