The SPQR study

Safety for Patients through Quality Review.


Study aims

We aim to determine how Medical Examiner (ME) assessment of death certification and retrospective cases record review (RCRR) can best work together to identify potentially avoidable deaths due to shortcomings in care. We also aim to use the ME assessments and RCRR recorded in this study to identify features or patterns related to problems in care that might be addressed to improve quality of care.


  • Estimate the sensitivity and specificity of ME assessment for identifying potentially avoidable deaths compared to a reference standard of RCRR and determine whether the ‘miss rate’ of ME assessment (the proportion of potentially avoidable deaths among cases screened out by ME assessment or 1 minus the negative predictive value) is low enough to allow ME assessment to be used to ‘pre-screen’ deaths for RCRR.
  • Examine discordant judgements between ME assessment and RCRR (i.e. potentially avoidable deaths missed by either ME assessment or RCRR) to determine how ME assessment and RCRR might be improved and how they could work alongside each other to identify problems in care and potentially avoidable deaths.
  • Identify themes in the problems in care revealed by ME assessment and RCRR, such as the nature of harms and the patients or processes involved, thus providing insights to improve quality of care.
  • Increase understanding of the ME role in identifying potentially avoidable deaths, particularly through interaction with relatives, and explore how the role can be developed to maximise learning opportunities alongside RCRR.
  • Explore the impact of implementing systems combining ME assessment and RCRR.


  • June – September 2017: Obtain study research approvals (ethics, HRA etc)
  • September – November 2017: Reviewer training
  • September – November 2017: Qualitative interviews with medical examiners
  • January 2018 – June 2018: Participating Trusts review records


Impact of the new medical examiner role on patient safety. BMJ 2018, 363:k5166 



Lay summary (Word, 16KB)

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