Death Under Scrutiny
How a new national system of medical examiners can support patient safety
As of April 2019, the UK has implemented rollout of a national system of medical examiners to increase patient safety and support bereaved families – a step forward that I believe will provide increased accountability, sensitivity, and credibility to the processes surrounding a death.
What is a medical examiner? These doctors are senior physicians from a range of disciplines including pathology, primary care, acute medicine, and many other specialties. They act as independent doctors in the review of deaths. Why has the UK’s National Health Service (NHS) decided to employ medical examiners? Three independent inquiries into NHS failings – the Shipman Inquiry, the Mid-Staffordshire NHS Foundation Trust Public Inquiry, and the Report of the Morecambe Bay Investigation – recommended that certificates for cause of death should be scrutinized by an independent doctor.
I was a medical examiner in the pilot scheme at the Royal London Hospital and saw firsthand how valuable the role was, not only as support for those certifying deaths, but also – and most importantly – for loved ones and families. I heard details, occasionally worrisome, but far more often deeply gratifying, about the services we gave to patients during their treatment and at the end of their lives. I fed back to the teams involved and was happy to see that either things improved as a result, or the staff were appropriately congratulated. I helped junior colleagues learn more about death certification and to feel supported in the learning process. Evidence from pilot sites showed that bereaved families valued the opportunity to ask questions and discuss concerns about the death of their loved one with an independent doctor.
Medical examiners are a key part of the drive to improve patient safety. When issues with care are identified by families, or by the examiner during scrutiny of the records, they can be fed into governance systems in the organization providing care or escalated to a Coroner. Positive feedback for staff and organizations is also part of the process! Learning from the examiner system is key to a culture of continuing safety improvement, and will link to other programs aimed at learning from deaths and to established systems, such as structured judgment reviews.
The other broader aspect of the examiner’s role is to help ensure high-quality data on causes of death through accurate certification. Such data helps in monitoring the “health” of the population, and feeds into local health planning and national public health. We cannot plan future health services without accurate data on what is causing death in our population!
As lead medical royal college for medical examiners, the Royal College of Pathologists is firmly committed to the patient safety and public health benefits this program will bring. We are providing support for doctors who wish to take on this important new role by delivering training and ensuring medical examiners have a collective voice through our medical examiner committee. We have also created resources for organizations that are planning to set up a medical examiner system.
The system will be rolling out across acute and community services, starting in the acute setting; although some services are already operational in primary and community care. The range and number of these “full-service” systems will increase, and we will continue to encourage this spread to ensure that everyone can benefit from the new system of medical examiners – and perhaps, one day, other countries will be able to learn from this example.
Jo Martin is President of the Royal College of Pathologists, Professor of Pathology at Queen Mary University of London, and Director of Academic Health Sciences at Barts Health NHS Trust.