Death is going through change

The Medical Examiners (England) Regulations 2024 come into force this autumn on 9 September and are relevant in private medical practice. Lawyer Liz Hackett guides you through the changes.

There have been many calls for a review and changes to the death certification system in England and Wales. It has remained largely unchanged for over 50 years.

In its third report, the Shipman Inquiry – led by Dame Janet Smith – concluded that the current one was not only confusing, but that it failed to provide adequate safeguards. 

Calls for changes were renewed by:

  • The Francis Inquiry into failings in care at Mid Staffordshire NHS Foundation Trust between 2004 and 2009;
  • The investigation into the management, delivery and outcomes of care provided by the maternity and neonatal services at the University Hospitals of Morecambe Bay NHS Foundation Trust between 2004 and 2013.

Acute trusts in England and local health boards in Wales were asked by NHS England and NHS Wales Shared Services Partnership in 2019 to set up medical examiner offices on a non-statutory basis for the purpose of reviewing their own organisations’ certification of deaths. 

Standard practice

While not currently mandatory, it has become standard practice across England and Wales for deaths in hospital to be scrutinised by a medical examiner.

Those deaths that the medical examiner believes may not have been natural or where a culpable human failing may have contributed to death are referred by them to the coroner.

In addition to the Medical Examiners Regulations, two other regulations will be introduced: 

  1. The Medial Certificate of Cause of Death (MCCD) Regulations 2024;
  2. The National Medical Examiner (Additional Functions) Regulations 2024. 

As part of the Department of Health’s Death Certification Reforms, from 9 September 2024 a new statutory medical examiner system is being introduced across England and Wales.

To a large degree, the new system will look like it does now. But there will be a mandatory requirement for all deaths that are not investigated by a coroner to be subject to review by medical examiners. 

Form teams

Under the leadership of Dr Alan Fletcher, the National Medical Examiner for England and Wales, senior medical doctors with varying specialties form teams of medical examiners contracted by acute trusts – and some specialist trusts – and health boards. 

These teams are supported by medical examiner officers and appropriate training is provided to medical examiners in the clinical and legal elements of death certification. 

Medical examiners and their officers will be funded annually by the National Medical Examiner’s Officer with one full-time equivalent examiner for approximately 3,000 deaths. 

The role of examiners is to:

  • Review the medical records and any supporting diagnostic information;
  • Agree the proposed medical cause of death and accuracy of the MCCD with the completing doctor;
  • Discuss the cause of death with the bereaved and establish any concerns or questions they may have;
  • Act as medical resource for the coroner;
  • Identify those cases for further review under local mortality and governance arrangements. 

As all deaths that are outside of the coronial process will now be examined by medical examiners, all healthcare providers in England and Wales, including GP practices and independent healthcare providers, must ensure they have:

  • Systems in place to inform medical examiners of deaths requiring independent scrutiny; 
  • Share records of deceased patients with medical examiners in a timely manner. Regional medical examiners will support these processes. 

The Notification of Deaths Regulations 2019 – subject to minor amendment – will remain in force and attending practitioners should continue to notify deaths that meet the criteria to the coroner. 

In non-coronial cases the process is therefore:

1. The ‘attending practitioner’ to propose the cause of death for the MCCD;

2. The attending practitioner must send the MCCD to the medical examiner;

3. The medical examiner will scrutinise MCCD, consider the records and decide whether to refer the death to the coroner;

4. If the death is not referred to the coroner, the medical examiner will add their signature to the new MCCD and submit it to the registrar; 

5. If the registrar has any queries, these will be directed to the medical examiner.

There is a change to who can propose the medical cause of death for the MCCD. 

The requirement that the MCCD be completed by an attending medical practitioner who has seen the deceased during their last illness – or if not seen in the 28 days prior to their death, refer to the coroner – has been removed and a medical practitioner will be an attending practitioner if they have attended the deceased in their lifetime. 

This represents a simplification of the current rules, aiming to improve efficiency, mortality data and reduce the number of deaths being referred to the coroner.

There will be additional changes to the MCCD documentation to support the collection of data.

It is hoped that the changes to death certification through the medical examiner system and increased independent scrutiny of all deaths will provide better safeguards for the bereaved and wider public and be a means of improving learning from deaths. 

They will also ensure that appropriate cases are referred to the coroner.

First published in the June edition of Independent Practitioner Today.

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