The Role of the Medical Examiner

From a Reader’s Lecture held on 14 November 2022

My unique experience is as a histopathologist, a coroner’s post-mortem pathologist, a medical examiner and a crematorium medical referee. Medical examiners are senior doctors from any hospital specialty or general practice. An ideal medical examiner service includes doctors from a range of disciplines. All medical examiners are employed by acute trusts in England, and NHS Wales Shared Services Partnership (NHSWSSP) in Wales. Medical examiners review all deaths in hospital and are currently extending their service to cover deaths in the community. One of the important principles is that any medical examiner can review any death, wherever it took place. The aim is that ultimately every death that is not referred to the coroner will be scrutinised by a medical examiner in England and Wales when the system becomes statutory.

Medical examiners seek to answer three questions. Firstly, what did the person die from? This is about making sure that death certificates are accurate. The second question is does the coroner need to be notified of the death? Although the initial intention was that medical examiners would only review deaths that were not referred to the coroner, in practice most deaths are reviewed to ensure that deaths are referred to the coroner in line with the Notification of Deaths Act 2019. The third question is about whether there any clinical governance concerns, which the medical examiner can escalate appropriately.

Medical examiners answer these questions through three key steps. They review the medical record, speak to the attending doctor, and most importantly, speak to the bereaved family. Until medical examiners were introduced, it was entirely possible for patients to die and the family never to hear again from the hospital or from a doctor to explain what happened. We phone the family and tell them what will be written on the death certificate so that they don’t get any surprises when they go to register the death. We explain what the terminology means so that they understand it and we relate it to what they saw happening to their loved one in their final illness. We ask if they have any questions about the certificate, about the care and the deceased person’s last illness and whether they have any concerns.

So, why do we need it? You would think, with all the other safeguards and checks when somebody dies, that we really don’t need medical examiners. The short answer is Harold Shipman. Dame Janet Smith recommended the introduction of medical examiners in her report to the Shipman inquiry. The introduction of medical examiners has also been a recommendation in several inquiry reports since then.

Death certification reform is not new, or at least calls for it are not new. Death certificates were first introduced in 1836. Since then, there have been numerous reviews, and every single one, including a parliamentary Select Committee in 1893, recommended an overhaul. We’re just about getting there now. So, it’s taken a while.

About 10 to 15 years ago, the Department of Health funded pilot sites to trial the medical examiner system to see how it worked, and they looked at seven different areas, including rural and urban sites and locations with a high proportion of faith communities. The biggest of these was Sheffield – over ten years, they reviewed 25,000 deaths. They found possible harm in 10 per cent of cases, but family concerns in only 2.3 per cent. Interestingly they weren’t always the same cases, so medical examiners were identifying concerns that wouldn’t otherwise have been picked up. In eighty-three per cent of cases the wording of the cause of death on the death certificate was changed. About a third required a major change, such as a completely different cause of death.

One consequence of the pilot scheme was no rejection of certificates by the Registrar. When the family take the certificate to register the death, previously about 2 per cent were rejected because there was something wrong with the certificate or further investigation was required. Medical examiners completely removed that, ensuring that the cause of death was correctly formulated, and cases were referred to the coroner if required before the point of registration. This reduces delays and further distress for families. There was a concern that relatives would not want to talk to a new doctor asking them questions around the time of bereavement. But actually, relatives were usually grateful to have that opportunity to ask questions and to speak to someone independent.

The Coroners and Justice Act 2009 put medical examiners in the primary legislation to be employed by local authorities. Medical examiners are still not on a statutory footing. It’s still completely voluntary for trusts. One of the things that held up implementation was the question of who was going to pay for it.

Newspapers talked about ‘death tax’ and ‘tombstone tax’ because the original plan for funding was that cremation forms would be scrapped, and families would pay around £100 for a medical examiner certificate for all deaths, whether burial or cremation. This was not popular, particularly with faith communities where burial was the norm, as it would be a new charge.

There were other reasons for delays, including general elections and Brexit, which reduced the parliamentary time available to pass the legislation required to move to a statutory footing. Some of the pilot sites continued the offer a medical examiner service, as they had seen the benefits that it brings, and some other sites introduced their own medical examiner service.

Professor Peter Furness, the first Interim National Medical Examiner, was instrumental in developing the early medical examiner service and was Lead Medical Examiner for an early adopter site in Leicester. He funded the service by having medical examiners complete cremation form 5 (the second, confirmatory form), using the income from that to fund the medical examiner service. Before the pandemic, this funding model was rolled out nationally and all trusts were encouraged to develop their own medical examiner services from April 2019. It’s not statutory and took about two years for all trusts to establish a medical examiner office, but we now have 100 per cent coverage, with an office in every acute trust in England. Wales have a slightly different delivery model, with medical examiners sitting outside health boards and a single country-wide service.

In 2019, the first substantive National Medical Examiner was appointed, Dr Alan Fletcher. He was the lead medical examiner for the Sheffield pilot scheme, the most experienced medical examiner in the country as he’d been working on it for ten years. The National Medical Examiner sits within the National Patient Safety Team at NHS England, and his job is to provide professional strategic leadership. The Royal College of Pathologists, the lead college for medical examiners, provides the training for medical examiners and officers. Dr Fletcher is very collaborative and is working with all stakeholders to standardise the way the system is rolled out in the current non-statutory phase.

I mentioned that services were largely funded from the income from cremation form 5 but this form was removed in the easements of the Coronavirus Act 2020. So, all the funding disappeared just when medical examiners were needed most. Thankfully services moved to being centrally funded during the pandemic. It was said that the long-term funding would be revisited in the future. Earlier this year, the Department of Health and Social Care announced that the government would continue to fund the service, which was very welcome news.

The training of medical examiners has two parts. Firstly, we have developed e-learning modules with elearning for healthcare, which is an online e-learning platform. There are 26 core modules looking at the key areas that we feel every medical examiner must know, such as how to write a death certificate, when to refer to the coroner, how to deal with faith deaths, child deaths, organ donation and so on. After completing the e-learning, doctors attend a one-day training course, either in person or online, during which they discuss challenging scenarios that medical examiners may encounter and hear from key speakers including faith and patient representatives, a coroner and a medical examiner officer. Once a doctor has completed both parts of the training, they can join the Royal College of Pathologists as medical examiner members. There is a similar training programme for medical examiner officers, who work closely with medical examiners.

It is important that medical examiners are independent of the clinical team that looks after the patient. So, if any medical examiner has had any involvement whatsoever in the care of a patient, they wouldn’t review the case.

The medical examiner system is very collaborative. We work closely with attending doctors, nurses, midwives, safeguarding teams, tissue viability nurses, and with palliative care teams. And we give a lot of feedback, the majority of which is positive. We collect data about cases reviewed and submit it centrally every quarter, but also review it locally, looking for any trends or themes that we can learn from.

In terms of legislation, the Coronavirus Act ended in March this year, and most of the easements it included came to an end. The Health and Care Act 2022 received royal assent on April 28, and that changed the primary legislation that said medical examiners have to be employed by local authorities and put them into the NHS. Now we can build on that.

The secondary legislation to make all the other changes required for full implementation, such as changes to death registration and the role of the coroner, remains a work in progress. We still haven’t got a date for statutory implementation, but the plan is that everything that’s required for the statutory scheme will be in place before it becomes statutory.

A very important thing that we’re starting to think about is quality assurance of the system. How do we know medical examiners are doing what they’re meant to be doing? What impact are they having? I think this will be an important focus in future years. The big concern is that no action is taken, so we need that feedback loop. It’s all very well us feeding our concerns into existing governance structures, but if we’re just shouting into a black hole, then that’s pointless. We need to be making sure that change is happening as a result of the intelligence that we’re feeding in.

Concerns have been raised about the independence of medical examiners, now that they are employed in the NHS. You could understand that families might say: “Well, you say you’re independent, but you work in the same hospital, and they pay your wages so how independent is that?” But there’s no practical way of getting doctors to work at hospitals that are hours away from the one that they’re based at or their GP practice, and employing doctors outside the NHS is fraught with difficulties. Medical examiners are independent of treating doctors and have an independent line of accountability to Regional Medical Examiners and the National Medical Examiner.

In summary, this has been a long time coming but we are nearly there. I’ve been working on this for over 10 years and others been working on it for longer than that. It’s currently non-statutory, but it’s working remarkably well already. We’ve got a national leadership team and medical examiner offices in all acute trusts now. We’re waiting for the secondary legislation, which we expect to be introduced at some point from April next year.

I’m just going to finish with some feedback from families:

“If the medical examiner hadn’t phoned, I don’t know who else I’d have spoken to.”

“It was brilliant to speak to someone kind, who listen to my concerns and was understanding.”

“It’s like a voice for the person who’s died.”

For the full video recording:


Dr Suzy Lishman CBE

Consultant Histopathologist and Medical Examiner in Peterborough and a past President of the Royal College of Pathologists

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