Printed on: November 21st, 2024

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The Medical Examiner System

The Medical Examiner System

On 9 September 2024, the process for certification of death changed. All deaths now need to be discussed with either the coroner service or the medical examiner service locally. This has raised uncertainty for some clinicians around the remit of new medical examiner role, and concern about how the process will work.

I am a GP and a medical examiner.

For GPs, the idea of an external clinician reviewing the cause of a patient’s death can feel intimidating. The language used in the legislation referring to ‘scrutiny’ of the death feels as if it could be critical of our care (although, in this context, it simply means careful and complete examination). As GPs, we are used to having great freedom in how we consult. We may have developed an ongoing relationship with patients over many years, and we are adept at tailoring our interaction with each patient. The idea that an external clinician might judge our consultations without that insight, and in hindsight, provokes understandable concern!

As a medical examiner, however, my role is not to assess or judge the decisions taken by individual clinicians. When examining notes, I am very aware that I already know how this person’s story ends! It would be inappropriate for me to judge decisions taken by medical colleagues who didn't have all the information I now have at my disposal. My focus when I am undertaking a “proportionate review of the notes“ is to establish what the likely cause of death is, and to ensure that the cause of death proposed by the individual completing the MCCD (death certificate) matches with the clinical history and investigations which I have access to. It might also allow me to identify any issues within the system or processes that may have had an impact on this death, and to what extent they may have impacted. In this article, we look at the medical examiner service in more detail and address some of these concerns.

This article is based on:

• Government guidance for death certification reform published in December 2023 (applicable to England and Wales).
• Ministry of Justice - guidance for registered medical practitioners on the Notification of Deaths Regulations, published September 2024.
• Professor Jason Payne-James’s study published in Medicine, Science and the Law in 2022 (Med Sci Law. 2023; 63(1): 6).

As of 9 September 2024, all deaths in acute hospitals, community hospitals and primary care that don't need referral to the coroner service (HMC) are now reviewed by the Medical Examiner System (MES). The MES is a process that was introduced in England and Wales from April 2019 to improve the medicolegal monitoring of deaths. It aims to improve transparency and governance in recording and monitoring deaths, in part as a response to several reports and enquiries, including the Shipman enquiry and the public enquiries into Mid Staffordshire Foundation Trust and Morecambe Bay Foundation Trust.

There are five key purposes of the MES:

• To ensure that there is proper scrutiny of deaths, and that appropriate referral is made to the coroner service (HMC), where applicable.
• To identify any patient safety issues, and to ensure that appropriate public safeguarding measures are in place.
• To provide a route for relatives, qualified attending practitioners (QAPs: the doctor who has completed the death certificate) and whistle blowers to have their concerns listened to and appropriately escalated.
• To improve the quality of death certification (medical certificate of cause of death (MCCD)), and to support and educate QAPs in appropriate completion and escalation.
• To improve the quality of data around deaths in England and Wales.

The national Medical Examiner System is delivered in each area by a local medical examiner service.

As of 9 September 2024, all deaths need referral, either to the coroner service or to the medical examiner service.

The criteria for referral to the coroner service (HMC) have not changed, and include:

The death was due to:

• Poisoning, including by an otherwise benign substance.
• Exposure to, or contact with, a toxic substance.
• The use of a medical product, controlled drug or psychoactive substance.
• Violence, trauma or injury.
• Self-harm.
• Neglect, including self-neglect.
• A person undergoing any treatment or procedure of a medical or similar nature.
• An injury or disease attributable to any employment held by the person during the person’s lifetime.

Or if:

• The death is unnatural, but doesn’t fall under any of the above circumstances.
• The cause of the death is unknown.
• The registered medical practitioner suspects the person died while in custody or otherwise in state detention.
• There is no attending practitioner, or an attending practitioner is not available within a reasonable time to sign an MCCD in relation to the deceased.
• The identity of the deceased is unknown.

Referrals to the coroner are made via the ‘coroner portal’ by those authorised to use this (GP, hospital and the registrar of births, deaths and marriages). Those wishing to refer a death to the coroner who aren't preauthorised to do so will need to contact their local service via telephone or email.

All other deaths will need referral to the local medical examiner service, usually via an electronic referral form.

Different areas will have developed slightly different approaches.

The good news is that the approach should involve a referral form that will self-populate from clinical systems, and the amount of work we end up doing as clinicians should be very little.

There will usually be three questions we need to answer before a referral can be made:

• What is the proposed cause of death?
• Why do I think that this is the cause of death? (this is a quick overview – think cremation form summary and no more!)
• Are the next-of-kin details correct?

We can either complete the medical certificate of cause of death (MCCD) at that point and send it along with the referral form via email, or, if we’re not sure or expect that the medical examiner service may have some queries, we might wait for their review and then complete the MCCD later, once agreed.

Prior to 9 September 2024, to complete an MCCD, we needed to:

• Be a doctor registered with the General Medical Council.
• Have attended the patient in their last illness AND
• To have seen them within 28 days of death or after death.

Under the new system, doctors will be able to complete an MCCD if they have attended the deceased ‘in their lifetime’ and if they can propose a cause of death to the ‘best of our knowledge and belief’.

When a death is referred to the medical examiner service, the process is as follows.

It will be ‘pre-reviewed’ by a medical examiner officer (MEO), who will also bring together all the information and records needed by the medical examiner to complete their fuller ‘scrutiny’. (An MEO is a trained, independent and experienced health professional who can be from a variety of medical backgrounds. They will usually work solely for the medical examiner service and are the day-to-day face of the service.)

The case is then passed to a medical examiner, who is a trained, independent senior doctor, increasingly from primary as well as secondary care. Medical examiners are usually part-time and undertake this role in addition to their usual clinical practice.

The medical examiner will set out to answer three key questions:

• What did this person die of?
• Does the death need to be referred to the coroner service (HMC)?
• Are there clinical governance concerns?

To do this for community deaths, they will first undertake a ‘proportionate review’ of primary care notes and investigations over the 3 months before death. This is known as ‘scrutiny’, and the aim is to ensure that the proposed cause of death matches with the clinical picture; that a referral to the coroner service (HMC) isn’t needed instead of the medical examiner service; and to identify any clinical governance issues, e.g. understaffing of community nursing teams meaning bloods were delayed, or repeated cancellations of hospital appointments delaying treatment.

The purpose of this ‘proportionate review’ is more to identify issues with the systems that were in place than to look at the actions of individual clinicians.

Following this, the medical examiner service may have a discussion with the GP who issued the certificate, in order to elicit any concerns or questions they may have. Finally, they will have a conversation and discussion with the next of kin. This will usually consist of a discussion of the MCCD, if appropriate, with a view to helping them to understand the proposed cause of death, as well as to make sure this fits their expectations. Importantly, there is also an opportunity to discuss any concerns about their loved one’s care (or, equally, any particularly diligent or kind care they received).

Locally, our medical examiner service aims to complete its scrutiny within 24h, and 90% are done the same day! This is likely to vary by locality as the system is rolled out and becomes mandatory for all deaths not referred to the coroner.

There are usually three possible outcomes to the medical examiner’s scrutiny.

• In most cases, the medical examiner will agree with the cause of death proposed by the referring clinician. They will send on the completed MCCD to the registrar and inform the next of kin that they can now register the death.
• The medical examiner may suggest altering the MCCD, e.g. proposing a different ordering of the form, suggesting additions or even altering spelling(!). In many cases, this is to avoid issues when the family comes to register the death. If the medical examiner is proposing more than minor alterations, they, or a delegated MEO, will usually contact the referring clinician to seek more information, to explain their logic and to see if they would feel happy altering the MCCD. Once an amended MCCD is sent through, the medical examiner will then send it to the registrar as normal.
• The medical examiner may come back and suggest that, on further review, it has become clear that a referral to the coroner is needed, and, with our agreement, they will then make this referral.

What happens if we, as the clinician who has written the MCCD, disagree with suggestions made by the medical examiner?

If we don’t agree with the medical examiner, and we feel that ‘to the best of our knowledge and belief’ the MCCD is correct as it stands, we don’t have to amend it.

In most of these situations, however, discussion with the medical examiner will often end up with a mutually agreed MCCD, which will allow registration. In the small number of cases where there remains an insurmountable gap between our opinion and that of the medical examiner, the local lead medical examiner may be called upon to offer their opinion.

Although both medical examiners and medical examiner officers are often hosted within NHS structures or directorates, they have a separate line of accountability via the regional and national medical examiner teams. They are therefore independent of the normal NHS structures. This, combined with an overview of all the deaths in a locality, puts the medical examiner service in a strong position to identify trends and gather high-quality data around deaths.

If significant concerns were identified during review, e.g. if the community nursing team was understaffed or resourced so important blood tests were delayed, with a knock-on effect on the patient(s), the medical examiner service would note these concerns. They would be reported back to:

• The practice for discussion, e.g. at a clinical meeting, in a post-death review or maybe in a complex patient meeting.
• The community trust which delivers the community nursing service.
• (Potentially) the ICB, to be addressed via its usual clinical governance structures.

To put this in context, in a study which looked at the workload of the Norfolk and Norwich Foundation Trust (NNUHFT) medical examiner service between 1 June 2020 and 31 May 2021, only 8% of the 2687 deaths scrutinised needed onwards escalation (Med Sci Law 2023;63(1):6). However, this was data from hospital trust deaths only so, while a helpful indicator, we don't yet know how this figure may differ for community deaths.

In most places in England and Wales, medical examiner services are still in their infancy. Therefore, there is not yet a wealth of high-quality research around the impact of the MES for Qualified Attending Practitioners (QAP: the doctor who has completed the death certificate) and the next of kin, nor around its impact on referrals to the coroner service.

As yet unpublished data from two studies done by the NNUHFT medical examiner service in Norwich suggests that these interactions with the medical examiner service team are beneficial for QAPs and bereaved relatives/next of kin, improving QAP confidence in completing the MCCD, and providing them with a route to raise patient care concerns safely and confidentially, without significantly impacting on workload.

In addition, the roll out of the MES seems to have reduced the number of referrals to the coroner service (HMC), and improved the appropriateness of these referrals, which has led to more of the referrals received culminating in postmortems and/or inquests.

We all know that deaths don’t occur only during working hours!

In most cases, if a death occurs overnight or at a weekend, a referral can be done on the next working day and can be processed by the medical examiner service as usual.

An exception to this would be for patients who are Muslim or Jewish (where burial rituals need to start as soon as possible) or individuals who need to be repatriated as soon as possible after death.

In this case, most medical examiner services will have out-of-hours cover, often by the lead medical examiner. They can usually be contacted via hospital switchboard, and can perform a proportionate review of the notes remotely.

	The Medical Examiner System From 9 September 2024, all deaths now need to be reviewed by the coroner service (HMC) or the medical examiner service. All death certificates need review by the medical examiner service before the death is registered. The GP will need to provide: A proposed cause of death. Reasoning for this. Contact details of the next of kin. The medical examiner service will review the notes, and talk to the next of kin and the clinician who completed the MCCD. The medical examiner service may agree the MCCD, suggest changes or suggest a referral to the coroner service (HMC). Issues identified will be reported back to the relevant organisations and escalated as appropriate. If needed out of hours, the number for the medical examiner can usually be obtained via the hospital switchboard.
	How will systems in your practice need to change now the new system is in place? Do you know how to use the coroner portal?
	Useful resources: Websites (all resources are hyperlinked for ease of use in Red Whale Knowledge) Royal College of Pathologists - cause of death list gov.uk – an overview of the death certification reforms Royal College of Pathologists – medical examiners Ministry of Justice - guidance for registered medical practitioners on the Notification of Deaths Regulations