Developing a world leading mortality review system: the role and impact of the medical examiner

Steve Goodacre and Joanne Coster, in collaboration with Alan Fletcher from Sheffield Teaching Hospitals, have published an analysis of the new Medical Examiner role in the BMJ.

Joanne Coster

In light of investigations into the crimes of Harold Shipman and reviews of death certification, it was recommended that the Medical Examiner role be developed to ensure that all deaths not referred to a coroner are reviewed by an independent clinician. 

Further reviews of patient safety and avoidable death, such as those into Mid-Staffordshire NHS Foundation Trust and Morecombe Bay Hospitals have reinforced these recommendations.

The Care Quality Commission now requires all acute Trusts to be able to “say something about every death”. The introduction of Medical Examiners will mean that each death receives a second check of the cause and circumstances around the death and can help NHS Trusts meet these requirements.

“Medical examiner assessment and structured judgement review have different origins, purposes, and methods, so we should expect different results. But aligning these two important policy measures to give a robust independent system that is protected by statute has the potential to make the mortality review system in England and Wales the best in the world.”

Jo Coster & steve goodacre

The Medical Examiner role has three key components. Firstly, discussing the case with the attending clinician, secondly, liaising with relatives of the bereaved to discuss whether they have any concerns around the death or the care that was provided, and thirdly, to ensure the accuracy of death certification forms.

[Medical Examiner] “scrutiny of cases could be used to ensure that every death is examined and that families and carers are engaged, while allowing additional structured judgement review to focus on cases with clinical governance concerns. Early identification of clinical governance concerns provides opportunities to reduce avoidable deaths, as well as reducing complaints or litigation if bereaved relatives have their concerns recognised.”

Where cause for concern or clinical governance concerns are identified, these cases will receive detailed review through the National Mortality Case Record Review programme, which uses the Structured Judgement Review (SJR) method. There are also opportunities for learning from deaths, through reviewing and identifying those cases which had good care and those where care could be improved. The detailed review undertaken for SJR is not feasible for all deaths and therefore an accurate filtering system) for identifying which cases receive SJR is necessary. The NIHR’s Policy Research Programme has funded the Safety for Patients through Quality Review (SPQR) study to evaluate the role of the Medical Examiner and how Medical Examiner review can best work with Structure Judgement Review to provide a robust mortality review system.

The study will do the following:

  • Qualitative interviews with MEs to explore what their assessment involves, how judgements are made and identify common themes and variations in practice.
  • Examine discordant judgements from ME assessment and SJR to determine how each process might be improved and work alongside each other.
  • Thematic analysis of ME and SJR reviews to determine the relative strengths and weaknesses of ME assessment, and gain insights that can be used to improve quality of care.
  • Implementation analysis to model different scenarios for implementing ME assessment alongside SJR and to determine the resource implications of implementation.

Many NHS Trusts have already implemented or are starting to implement a Medical Examiner system, prior to the intended launch in April 2019, and it is anticipated that all Trusts will implement the Medical Examiner system within the following 18 – 24 months.