Information for primary care on extending medical examiner scrutiny to non-coronial deaths in the community

This webpage summarises information for primary care on the extension of medical examiner scrutiny to non-coronial deaths in the community. The information is primarily for GPs and practice managers, but may also be of interest to those working in other areas of primary care.

Introduction

Medical examiner offices at acute trusts now provide independent scrutiny of almost all non-coronial deaths occurring in acute hospitals. 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. Medical examiners provide an important safeguard, as highlighted after the Lucy Letby verdict.

Medical examiner offices are led by medical examiners, senior doctors from a range of specialties including general practice, who provide independent scrutiny of deaths not taken at the outset for coroner investigation. They put the bereaved at the centre of processes after the death of a patient, by giving families and next of kin an opportunity to ask questions and raise concerns. Medical examiners carry out a proportionate review of medical records, and liaise with doctors completing the Medical Certificate of Cause of Death (MCCD). DHSC has published draft regulations and an overview of the statutory medical examiner system. After the changes, there will be a new Medical Certificate of Cause of Death, which can be completed by a doctor who attended the deceased at any time.

The National Medical Examiner has released a podcast explaining the new process.

  • The National Medical Examiner recognises the complexity of extending the medical examiner system to primary care, and previously advised that implementation should proceed carefully and through an agreed incremental process made possible by the non-statutory period
  • Medical examiners can offer GPs support with complex cases, administrative elements of notifications to coroners where agreed, and reduced administration
  • Implementing medical examiners does not introduce any new requirement to view the body
  • There is no need for a verbal discussion between GPs 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.

How medical examiners can benefit primary care

Medical examiners are already delivering benefits outlined in the National Medical Examiner reports, including fewer rejected MCCDs, improved referrals to coroners, improvements to patient care, and positive feedback from certifying doctors and bereaved people. Potential benefits for GPs include:

  • Supporting the bereaved:For GPs, this can reduce workload by taking care of enquiries and follow-ups. This does not replace GPs 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 from GP practices.
  • Supporting work with coroners’ offices:medical examiners are a source of medical advice for coroners, which should reduce requests from coroners for GPs to discuss cases or to advise on wording.
  • Reduce administration:if agreed locally, medical examiner officers can carry out administrative tasks relating to death certification.
  • Timely completion of scrutiny:medical examiners complete their scrutiny in a timely manner to facilitate registration within five days.
  • Examination of the deceased:the Coronavirus Act introduced easements to the process of certifying deaths. There is no new mandatory requirement for examination of the deceased by GPs in the medical examiner system.
  • 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 GPs in completing 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 GPs if there are 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.
  • Concerns and learning;a key objective for the medical examiner system is to identify constructive learning to improve care for patients.

GPs and medical examiners working together

In this podcast GPs and medical examiners from England and Wales discuss their experience of extending medical examiner scrutiny to deaths in community settings. It explains how partnership working between GPs and medical examiners improves the experience of bereaved people and explores advantages for GPs of starting work with medical examiners now, before medical examiners become a required part of the new statutory death certification process from April 2024.

Interaction with medical examiners

The interaction between the GP completing the MCCD and the medical examiner can usually take place through correspondence (without the need for a verbal discussion) and the usual entries in the patient record. In most cases a short ‘last entry’ in the records will normally suffice for interaction between GPs and medical examiners, but a discussion is welcome if the GP would find it helpful. Medical examiner officers provide continuity in the office and are available through the working week, similar to coroners’ officers.

What do GPs need to do?

GP practices should set up processes to start referring deaths to medical examiner offices if they have not already done so. This will help mitigate disruption and distress for bereaved people when the regulations become statutory.

Sharing records of deceased patients with medical examiners

When the statutory medical examiner system commences, the Access to Health Records Act 1990 will give medical examiners the statutory right to access the medical records of deceased patients from the holders of those records, including GP practices.

For the period before the statutory medical examiner system commences, following an application by NHS England and on the advice of the Confidentiality Advisory Group (CAG – an independent body which provides expert advice on the use of confidential patient information), the Secretary of State for Health and Social Care has approved the use of confidential patient information for the purposes of the non-statutory medical examiner system, under section 251 of the National Health Service Act 2006 and Regulation 5 of the Health Service (Control of Patient Information) Regulations 2002 (‘section 251 support’). This section 251 support is in place until 31 March 2024 and enables healthcare providers, including GP practices, to share the medical records of deceased patients with medical examiners. The approved application can be found on the Health Research Authority’s website (ref: 21/CAG/0032).

Medical records of deceased patients are outside the scope of UK GDPR, however healthcare providers may share (and medical examiner offices may process) contact details of deceased patients’ next of kin in accordance with Article 6.1(e) UK GDPR (processing that is necessary for the exercise of a public task). Medical examiner offices are based in NHS trusts/foundation trusts which process personal data in accordance with all applicable legal and NHS requirements including UK GDPR.