Foreword
It has been a significant year. Medical examiners have reviewed more deaths in 2023, a total of 311,249 in England and Wales, than in any previous year. Importantly, by bringing to the fore the feedback they have gathered from bereaved people they are providing invaluable learning for improved patient safety. That is at the heart of what we strive for, giving a voice to relatives and friends of the deceased.
The introduction of the Death Certification Reforms on Monday 9 September 2024 means independent scrutiny by a medical examiner will become a statutory requirement prior to the registration of all deaths in England and Wales that are not investigated by a coroner. The regulations were laid in Parliament and the Senedd on 15 April 2024 and announced by the Department of Health and Social Care and Welsh Government.
This statutory footing is extremely good news for the medical examiner system I am grateful for the hard work of all medical examiners and officers leading up to this important milestone. Medical examiners are already supporting patient safety, learning and improvement, along with more consistent and appropriate coroner referrals. The weeks before the Death Certification Reforms come into force will allow time to cement excellent working processes and to ensure we make the most of the insights medical examiners can bring. I am sure, like me, they are delighted to now be planning with certainty.
Listening to our podcasts, GPs and medical examiners working together and changes to the death certification process and introduction of the statutory medical examiner system can answer questions about some of the changes from 9 September 2024, as can listening to the recordings of two timely information events The Royal College of Pathologists hosted about the statutory system on 17 January 2024 and 11 June 2024.
Dr Alan Fletcher, National Medical Examiner
Introduction
Implementation of medical examiners began in England and Wales in 2019 with the appointment of the National Medical Examiner and recruitment of national and regional teams.
This report summarises the progress during 2023.
The Death Certification Reforms come into force on 9 September 2024 and from this date independent scrutiny by a medical examiner becomes a statutory requirement for registration of all deaths in England and Wales not investigated by a coroner.
Medical examiners are senior doctors employed by NHS bodies in England and Wales.
In England, they are supported by medical examiner officers and are based in 126 medical examiner offices in NHS trusts.
In Wales, the service is being provided by NHS Wales Shared Services Partnership (NWSSP), an independent mutual organisation, owned and directed by NHS Wales. The four hub sites cover all health board areas with substantial growth throughout 2023 in scrutinising deaths in non-acute healthcare settings.
The purpose of the medical examiner system is to:
- provide greater safeguards for the public by ensuring independent scrutiny of all non-coronial deaths
- ensure the appropriate direction of deaths to the coroner
- provide a better service for bereaved people and an opportunity for them to raise any concerns to a doctor not involved in the care of the deceased
- improve the quality of death certification
- improve the quality of mortality data
The medical examiner office is professional, efficient and upholds the highest standards of compliance and integrity in the work that it produces and the way the staff operate.
Coroner’s office
When medical examiners started working, they began to identify issues with care and it quickly became apparent that the existing clinical and quality governance arrangements were not adequate.
As a result, the NHS provider completely refreshed its governance processes to ensure they were fit for purpose and enabled the provider to improve care and safety for patients.
Medical examiner office
Medical examiners put the bereaved at the centre of processes after the death of a person, by giving families and next of kin an opportunity to ask questions and raise concerns. They carry out a proportionate review of medical records and speak with doctors completing the Medical Certificate of Cause of Death (MCCDs). If medical examiners detect concerns or issues with care, they pass these on for further investigation for learning and to improve care.
Medical examiners are usually contracted for 1 or 2 sessions a week to provide independent scrutiny of the causes of death, outside their usual clinical duties. They are trained in the legal and clinical elements of death certification processes.
Medical examiner officers manage cases from initial notification through to completion and communication with the registrar. They provide a constant presence in the office and come from a range of specialties. A medical examiner officer may or may not have a clinical background.
Medical examiner officers are well-placed to identify patterns and trends, and to act as a source of expert guidance to all users of the system. They obtain and carry out a preliminary review of all relevant medical records (and additional details where required) to develop a case file setting out the circumstances of each death for the medical examiner.
A voice for bereaved people
One of the most important roles of a medical examiner is providing bereaved people with information about the cause of death and offering families and next of kin an opportunity to ask questions and raise any concerns they may have about the care and treatment the deceased person received.
Medical examiners and officers ensure concerns about care are identified promptly and referred for further investigation where required, to improve services and care for all patients.
“The medical examiner gave a clear, concise, and reasoned explanation of why and how she had reached her decision on the cause of death. She also gave me the opportunity to ask any questions…. Before, I was told just to collect the certificate”.
A bereaved family member
“The medical examiner service has been instrumental in securing additional palliative care beds in the acute trust and the recruitment of a dedicated palliative care nurse in the emergency department. This came about through medical examiner feedback to the palliative care team and support from the medical examiner team writing the business case”.
Medical examiner office
Reporting and progress
The issues identified by medical examiners inform improvements in care and health systems.
The National Medical Examiner’s team began collating quarterly submissions of activity and outcomes from medical examiners in England in October 2020. In addition, NWSSP collates reports from Wales and feeds these back to the National Medical Examiner. In both nations, feedback from bereaved people and stakeholders is also collated.
In a typical year in England and Wales, there are about 550,000 deaths and approximately 60,000 of these deaths are notified directly to a coroner without medical examiner scrutiny.
England
There has been a steady progression in England for both acute and community deaths scrutinised. In 2022, medical examiner offices in England reported independent scrutiny of 240,562 deaths.
The total number of deaths reported as independently scrutinised by medical examiners in England in 2023 increased to 295,487 (acute setting: 222,502, non-acute (community): 72,985), with breakdown by quarter as follows:
- January to March: 70,515
- April to June: 75,146
- July to September: 69,104
- October to December: 80,722
- Year total: 295,487
Source: Medical Examiner Offices Quarterly Reporting for England
Of these, 8.1% (23,934) were notified to a coroner after medical examiner scrutiny, and 8.8% (26,003) were referred for case record review or other clinical governance review.
Of the deaths referred for case record review, 2,740 were deaths of people with a learning disability or severe mental illness.
Medical examiners in England reported they had identified 2,242 patient safety incidents.
Medical examiner offices in England reported that when urgent release of the body was requested, this was achieved 89.3% of the time.
Progress continued to be made for non-acute (community) deaths in England, increasing steadily from July 2022 to latest data available (March 2024) as shown in Figure 1.
Figure 1: Non-acute deaths scrutinised by medical examiners from July 2022 to March 2024
Source: Medical Examiner Offices Quarterly Reporting for England
Wales
The total number of deaths reported as independently scrutinised by medical examiners in Wales in 2023 was 15,762 (acute setting: 13,869 community: 1,893), this has risen from 12,218 (acute setting:11,199, community: 1019) in 2022. Figure 2 shows the monthly breakdown by setting.
Figure 2: Report of death settings by month reported by medical examiners in Wales in 2023
Source: Medical Examiner Reporting in Wales
Training and events
The third annual Medical Examiners Conference took place on 17 May 2023 and was hosted by The Royal College of Pathologists.
At the end of December 2023, 2,167 medical examiners had been trained and 711 staff had undertaken the training to be a medical examiner officer. Details of the training can be found on The Royal College of Pathologist’s website.
The e-learning modules for prospective medical examiners and medical examiner officers have been updated to reflect the changes to the medical examiner system once the Death Certification Reforms come into force on 9 September 2024. We will only expect medical examiners who have already completed their training to complete 4 refreshed e-learning modules explaining the legislative changes.
Medical examiner office raised concerns following resuscitation of an elderly patient with a Respect Form stating that they did not want resuscitation in hospital. Following an investigation, learning points were shared with staff about providing patients with dignity and comfort at the end of their life.
Lessons were learnt regarding rejecting referrals, and it was highlighted that requests for same day visits should be prioritised.
Medical examiner office
The medical examiner office staff are most helpful in dealing with faith deaths in the community and with requests for urgent releases for burial. They have all been processed immediately by very experienced officers with great compassion.
Faith group representative
Feedback and stakeholder engagement
Feedback
Feedback from bereaved families and stakeholders in England and Wales has been positive during 2023 as illustrated in the examples throughout this report.
Medical examiners offer bereaved people a voice and the opportunity to ask questions or raise concerns. Relatives appreciate the independence and expertise of medical examiner teams and the time they take to discuss concerns with them.
Doctors completing MCCDs often benefit from medical examiners’ support to ensure causes of death are recorded accurately, particularly where cases are complex.
Stakeholder engagement
By listening to the bereaved and acting on their concerns quickly and carefully, medical examiners can prevent formal complaints.
Coroners and registrars find the involvement of medical examiners improves the accuracy of notifications and MCCDs. By helping to ensure causes of death are recorded accurately, medical examiners can help reduce delays for bereaved people, for example when registrars reject MCCDs. More accurate MCCDs also support healthcare research that relies on causes of death recorded in death certificates.
The National Medical Examiner and his team work closely with the Department of Health and Social Care (DHSC) and the Welsh Government. DHSC continues to lead on all work around the new MCCD, including the distribution of paper copies, as well as updating the MCCD guidance for doctors.
Medical examiner offices’ engagement with GP practices and other healthcare providers grew steadily throughout the year, with a surge after the government’s announcement of the draft regulations on 14 December 2023.
Resources and guidance
Weekend and public holiday cover
During 2023, the National Medical Examiner asked medical examiner offices to develop plans to provide appropriate arrangements for cover at weekends and on public holidays. Demand for such cover varies by location but is important to facilitate urgent release of bodies where required, for example to enable organ donation or to facilitate burial by some faith communities in line with their religious requirements. Funding was identified to facilitate developments in England and Wales, and the National Medical Examiner’s office will continue to monitor demand and delivery of these important arrangements.
National Medical Examiner’s good practice series
In partnership with subject matter experts and key stakeholders, the National Medical Examiner has continued to provide good practice papers for medical examiners on topical matters, designed to be easily digested by busy frontline staff, with links to further reading, guidance and support. The following papers were published by The Royal College of Pathologists in 2023:
- Medical examiners and homelessness (February 2023)
- Medical examiners and dementia (May 2023)
- Escalating thematic issues and maximising the impact of medical examiner scrutiny (July 2023)
- Major incidents (October 2023)
Papers on palliative and end of life care, maternal deaths and deaths after delays in care and treatment were published in March, May and August 2024 respectively.
Good practice guidance
The National Medical Examiner’s good practice guidelines, published in January 2020, should be followed up to 8 September 2024.
New guidance has been published in readiness for the introduction of the Death Certification Reforms from 9 September 2024, but should not be followed before this date. This is the core document setting out requirements for medical examiners and medical examiner officers.
The medical examiner office continues to build relationships, understanding and improvements between themselves and the coroner’s office. We are grateful that communication is always helpful, honest and open.
Coroner’s office
National Medical Examiner’s webpage and bulletins
The National Medical Examiner’s webpage on the NHS England website hosts lots of information about the service. NHS Wales Shared Services Partnership also has a webpage for the medical examiner system in Wales.
Regular bulletins providing information and news for medical examiners and stakeholders continued through 2023. Fortnightly update emails were also sent to lead medical examiners in England and Wales from August 2023. Information was also shared more widely with healthcare providers in England though regular NHS England bulletins, including the Primary Care Bulletin, NHS Leaders’ Update, and Medical Directors’ Digest and in Wales via letters from the Deputy Chief Medical Officer, Welsh Government.
Podcasts
In July 2023, NHS England released our first podcast in which GPs and medical examiners from England and Wales discuss their experience of extending medical examiner scrutiny to deaths in community settings. They explain how their partnership working is improving the experience of bereaved people and explore the advantages for GPs of starting work with medical examiners now, before medical examiners become a required part of the new statutory death certification process.
In December 2023, we produced a second podcast in which Dr Alan Fletcher, National Medical Examiner, and Dr Suzy Lishman, Senior Advisor on Medical Examiners at The Royal College of Pathologists, discuss what the changes introduced by the Death Certification Reforms will mean for medical examiners, medical examiner officers and others involved in death certification.
Looking to the future
The National Medical Examiner and his team continue to work with medical examiners and their officers towards the implementation of the Death Certification Reforms from 9 September 2024, when all deaths in any health setting in England and Wales that are not investigated by a coroner will be reviewed, without exception, by NHS medical examiners.
The changes are an opportunity to improve processes around death certification and they will require some adjustments from everyone involved, particularly in the first few months.
The reforms will provide a system to support bereaved people and allow reflection and reporting on patient care and treatment to improve services across the NHS. The medical examiner system is an important function in NHS England’s Patient Safety directorate and is an important patient safety and quality workstream within Welsh Government.
There will be opportunities for surveillance and review of the effect of the statutory system on coroners, cause of death statistics, time to registration, and urgent release requirements.
The medical examiner alerted the medicines optimisation team to a series of potentially avoidable deaths due to intracerebral bleeds after wrong doses or inadequate monitoring of anticoagulants.
Following this, clinician monitoring guidance was published as well as patient information, such as anticoagulation alert cards for patients.
Medical examiner office
Potential safeguarding issues were identified during scrutiny, including injuries that may not have been accidental. The medical examiner provided a route for consultants to share concerns, and the case was notified to the coroner and the police.
Medical examiner office
It is a positive time for medical examiners with the arrival of the new death certification process, and key objectives will focus on addressing concerns and identifying constructive learning to improve care for patients as well as giving the bereaved a voice.
Appendix 1: statutory regulations
The 2024 Death Certification Reforms
Regulations were laid in Parliament and in the Senedd on 15 April 2024 concerning medical examiners in England and Wales, medical certificates of cause of death and the role of the National Medical Examiner, with the changes coming into force from 9 September 2024.
Throughout 2023 medical examiners have worked to extend independent scrutiny to non-coronial deaths in all healthcare settings and continued to prepare for the Death Certification Reforms in 2024. However, the coming into force date was not announced until regulations were laid in Parliament and the Senedd.
Documentation relating to the introduction of medical examiners and reforms to death certification can be found on gov.uk: An overview of the death certification reforms
A full version of the statutory regulations can be found on legislation.gov.uk: The Medical Examiners (England) Regulations 2024 and The Medical Examiners (Wales) Regulations 2024 | GOV.WALES.
Further information
- NHS England. The national medical examiner system
- NHS England. Contact details for medical examiner offices in England and Wales
- NHS England. National Medical Examiner good practice guidelines
- NHS England. National Medical Examiner’s guidance for England and Wales
- The Royal College of Pathologists. National Medical Examiner’s Good Practice Series
- The Royal College of Pathologists. The role of medical examiners and medical examiner officers
- The Royal College of Pathologists. Background to medical examiners
- The Royal College of Pathologists. Train to become a medical examiner
- elearning for healthcare. Medical examiner e-learning resource
- HM Passport Office. Guidance for doctors completing medical certificates of cause of death in England and Wales (accessible version)
Publication reference: PRN01085