The medial examiner explained

The Medical Examiner Explained

by Jude Brennan-Calland

The way we as a society investigate, certify, and notify death has changed considerably over time, and continues to change with the new role of the medical examiner. First proposed after the Shipman inquiry, the idea has taken decades to come to fruition; however, the Department of Health and Social Care published draft regulations in December 2023 for a gradual nationwide rollout on September 9th 2024. 

So, what is the medical examiner, what will the system look like, and why do we need it? Put simply, the medical examiner’s purpose is to investigate the deaths which are not referred to the Coroner. It is an update to a system that has changed very little since the Victorian era. Currently, deaths in England and Wales are either coronial or non-coronial. If the criteria are met, and a death does not need to be reported to the Coroner, non-coronial deaths are typically certified in hospital/hospice with no requirement for significant examination of the body, and little input from the bereaved. In addition, it is a job often paradoxically delegated to the most junior members of the team as admin work – most would think that senior input and wisdom would be paramount in certifying the death of a patient in a medical team’s care, but often it is not. Such arrangements obviously create discrepancies and inaccuracies – for example, research has identified that the causes of death recorded on certificates were actually different 22% of the time when a death was reinvestigated by a medical examiner, quite a stark statistic. The system aims to modernise and improve how death is ratified in England and Wales, and to give the bereaved a greater voice and insight with medical examiners being that first port of call for concerns. 

The role will also attempt to combat the effects that a poorly completed death certificate can invoke. Currently, around 10% of certificates are graded as poor, and may warrant further investigation. In the scenario that a recently bereaved family attempts to register a death, only to be informed by the registrar that the certificate is inadequate, currently the case would have to be referred to the Coroner. This can understandably be a massively stressful and dreadful experience, and prolong funeral arrangements. The medical examiner role, through the review of both death and certification, would aim to minimise this from occurring. 

So how would it work? The medical examiner role would be a 2-step process - firstly to ensure the cause of death is accurate, and secondly to ensure that the death does not need subsequent referral to the Coroner. Investigating the causes of death would involve a review of medical records and imaging, discussions with the medical team that looked after the deceased, and, critically, interaction with the bereaved. Evidence has consistently shown that the role of the medical examiner with the bereaved helps families feel reassured. Medical examiners would discuss the causes of death, the next steps, and listen to concerns. Providing a complete review of every death in a local authority as a 3rd party, the medical examiner should act as another element in James T. Reason’s Swiss Cheese model of risk analysis – it should help to improve safeguards for the public and prevent errors in death certification.

Who would carry out this role? Any doctor that has been licensed with the GMC for at least 5 years could apply to become a medical examiner, although the national system recommends that those at consultant grade or equivalent are preferred. Training and certification is headed by the Royal College of Pathologists - training is a mix of e-modules and face-to-face practical training days. On average, 3000 deaths would require 1 full-time examiner, and it is likely the system would see a mix of full-time medical examiners (taking up leadership and admin roles alongside this) as well as many working part-time along their regular clinical duties. Medical examiners are also supported by medical examiner officers, who help with communication and case management. Medical examiner offices exist in various trusts around the England and Wales already, showing tangible improvements to the way we deal with death as a society. 

I am hopeful that the rollout of a statutory nationwide system will improve outcomes for families, improve data collection and identify trends, and streamline our transition to a system more befitting of the 21st century. 

By Jude Brennan-Calland on behalf of the Pathological Society of GB&I