• Pilots in Sheffield and Gloucestershire reveal benefits of medical examiner service
  • Four fifths of medical causes of death recorded by doctors were changed after being reviewed
  • Medical examiners have helped identify patient safety issues requiring action by providers

Poor care at the Mid Staffordshire Foundation Trust would have been spotted earlier if a system of medical examiners had been in place, a report written for the Department of Health has said.

It also highlighted substantial inaccuracies in the medical cause of death given by doctors with more than four fifths of certificates requiring changes after review by the medical examiner.

The government has announced plans to roll out a national system of independent medical examiners from April 2018. This was recommended by the Dame Janet Smith inquiry into serial killer GP Harold Shipman in 2005 and the idea was backed by both the Francis Inquiry in 2013 and Morecambe Bay investigation last year.

Under the proposed system approximately 300 independent medical examiners, as well as associated staff, will review all deaths not referred to a coroner. They will examine bodies and patient notes and determine if the stated cause of death is accurate or should be changed, and whether the death should be referred for an investigation by the coroner.

Now a report by the national medical examiner, Peter Furness, has looked at detailed results from pilot sites in Sheffield and Gloucester, which have been using the medical examiner system for over six years covering 23,000 deaths.

According to the report, a key benefit of the system is that it requires medical examiners to speak with relatives of people who have died. The pilot sites reported the majority of families were grateful for the chance to raise concerns.

The report added: “These conversations make it obvious that the problems with care quality at the Mid Staffordshire hospital would have been detected much earlier if an independent medical examiner had been available to listen to the complaints.”

In an audit of 7,927 discussions with families in Sheffield, 81 per cent had no concerns about the quality of care or cause of death. However in 17 per cent of cases the relatives had questions or concerns that were dealt with by the medical examiner or directed back to organisations involved.

In the remaining 193 cases, the families raised concerns that justified a discussion between the medical examiner and the coroner.

The pilot sites also identified substantial inaccuracies in the medical cause of death certificate filled in by doctors, resulting in changes being made to the certificate in the majority of cases. In the Gloucester pilot this reached 83 per cent.

The report said: “In the same audit, 33 per cent of cases required major changes to the [medical cause of death], indicating a clear failure of understanding of death certification by the attending doctor.” In 8 per cent of cases, the report found, “there was a failure by the attending doctor to understand the law and/or the indications for referral to the coroner.”

It added: “Our observations have confirmed published reports that death certification is usually done very badly. The pilots have also demonstrated the futility of recommending that death certification should always be supervised by consultants; causes of death proposed by consultant staff were very frequently inappropriate, sometimes dramatically so.”

The report also identified benefits from medical examiners in identifying avoidable deaths and recognising patient safety issues that require action by providers.

The report concluded: “The pilots have not identified ‘the next Harold Shipman’; we believe that this is because such criminals are very rare. However, the pilots have detected many unexpected significant events that have as a result been brought to the immediate attention of the relevant authorities.”

The medical examiners service will be funded by replacing the existing cremation form fee of £184 with a new charge paid for by families set at between £80 to £100 and applicable to all deaths including burials.

A public consultation on an independent medical examiner service ends on June 15.