Medical examiners working in pilot areas in England have exposed clinical incidents, poor staffing and fatal infections that have led to deaths on hospital wards, according to research shared with HSJ.
The Royal College of Pathologists said the results prove that medical examiners could make a significant contribution to patient safety in the NHS.
The pilots, which involved medical examiners looking at more than 27,000 deaths since 2008, found one in four hospital death certificates were inaccurate and one in five causes of death were wrong.
In 10 per cent of cases the underlying cause of death was changed after the medical examiner’s investigation.
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The college, which is campaigning for medical examiners to be employed across the country, believes the preliminary results of the pilots suggest up to 10,000 deaths that are currently registered as “natural causes” across England and Wales should actually be investigated by a coroner’s inquest.
The pilots have been operating in Sheffield, where 13,000 deaths were examined, along with Gloucestershire, Essex, Powys, north London, Leicester, Brighton and Hove, Birmingham and Southampton.
Findings from the pilot areas include:
- A review of surgical procedures after the medical examiner highlighted a number of deaths among frail elderly patients.
- In Sheffield the examiner identified a cluster of post-operative deaths due to an infection which had not been spotted by hospital staff and led to a review of patient management and prevented further contamination.
- A failure of nursing staff to conduct patient observations spotted by a medical examiner led to a review of nurse staffing and education.
- Allegations of neglect at a nursing home by family members led to a full investigation and a coroner’s “rule 43”, or prevention of future death, report.
- An abnormal X-ray was not followed up for 15 months before a diagnosis of cancer leading to a full coroner investigation.
- Failures in hospital care including misdiagnosis and lack of senior doctor review of a patient which was not spotted by the provider.
Suzy Lishman, president of the Royal College of Pathologists, said she was “absolutely” certain that medical examiners would ensure scandals such as Mid Staffordshire or Harold Shipman would be spotted sooner.
She said: “All the evidence from the pilots shows it doesn’t take many cases to start ringing alarm bells and the medical examiners have the authority to ask questions and make sure something is done about it.”
Dr Lishman said it was crucial there was “independent scrutiny of causes of death”. She added: “One of the really important things about medical examiners is it makes it very clear who you talk to if you have concerns. In the case of Harold Shipman there were doctors who had concerns but didn’t know who to tell.
“It is the medical examiner’s duty to look for these trends and they’re the person you should report them to.”
Establishing the role of medical examiners was a recommendation of the 2013 Francis report into failures at Mid Staffordshire Foundation Trust. Legislation had been passed in 2009 but the government has yet to implement the changes.
The college also believes the role will reduce overall costs from £50m a year to £35m. This will be achieved by ending the current practice of doctors checking bodies before cremation.