All deaths in England to be investigated by medical examiner

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Medical examiners to reveiw all deaths in England and Wales from April 2018
Jeremy Hunt to implement recommendation of Dame Janet Smith after 7 year delay
Medical examiner pilots found one in four hospital death certificates were inaccurate

All deaths in England and Wales will be investigated by independent medical examiners from April 2018 in an effort to improve patient safety and tackle inaccurate death certification.

Health secretary Jeremy Hunt is set to announce plans for a nationwide medical examiner service at a patient safety summit in London tomorrow.

The new role will see approximately 300 senior doctors appointed to review the causes of all deaths from April 2018. These examiners will have the ability to refer deaths to a coroner for investigation and it is hoped their work will make it easier to spot trends in deaths and tackle clinical governance problems.

Medical examiners will also be able to liaise with relatives and potentially investigate any concerns they may have about the care their loved one received.

The idea of medical examiners was first recommended by Dame Janet Smith following her public inquiry into serial killer GP Harold Shipman. Legislation was passed via the Coroners and Justice Act 2009 but the role was never implemented. It was also supported by recommendations from Sir Robert Francis QC after the Mid Staffordshire public inquiry and Dr Bill Kirkup’s investigation into failures at Morecambe Bay.

Early pilots, which examined 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.

The pilots also revealed benefits for living patients with examples including a cluster of post-operative deaths due to an infection which had not been spotted by hospital staff. In another case a failure of nursing staff to conduct patient observations was spotted by the medical examiner leading to a review of nurse staffing and education. Another case involved failures in hospital care including misdiagnosis and a lack of senior doctor review which was also not spotted by the provider.

Mr Hunt will also outline the role of the new independent Healthcare Safety Investigation Branch and plans by the government to legislate to bring in protection for anyone giving information following an error.

The Department of Health is hoping the changes will make it easier for clinicians to speak up and will allow the NHS to learn from its mistakes faster.