Professor Peter Furness

The National Medical Examiner

We’ve been here before...

Select Committee report 1893

The Wright Report 1936

The Brodrick Report 1971

The Luce Report 2003

Harold Shipman... Killed patients (morphine injection)

In their home or in his GP surgery

Wrote ‘natural cause’ death certificates

Wrote cremation forms

Never referred cases to the coroner 2 were autopsied, but pathologists

did not identify malfeasance

Was intelligent, up-to-date and generally liked by his patients

i.e. Medical Revalidation won’t catch the next Harold Shipman

The result:

Passed with support from all political parties

Section 19:

The initial plan:

Proposed cause of death for all non-coronial deaths to be scrutinised by an independent and trained Medical Examiner

Include proportionate review of medical records

Include interview with next of kin (the ‘Shipman Question’)

Include external examination of body

Coroners may refer natural deaths to ME for certification if no ‘attending doctor’ is available

Cremation forms (and fees) to be abolished

Service to be funded by a (reduced) certification fee for all deaths

The other problems…

The other problems…

Swift B, West K. J Clin Pathol 2002; 55:275-9. Death certification: an audit of practice entering the 21st century. 1000 ‘natural’ deaths. “Only 55% of certificates were completed to a minimally acceptable standard”

Fernando D, Oxley JD & Nottingham J. J Clin Pathol 2012; 65:949-51. Death certification: do consultant pathologists do it better? “Using the Office for National Statistics guidelines, the authors found that only 56% of the certificates were appropriately completed.”

A more recently recognised problem:

Medical Examiners and clinical governance?

It’s not just secondary care…

The process:

Duty on doctors to refer directly to coroner

Advice available from Medical Examiner (ME)

Certifying doctor proposes cause of death to ME

ME scrutinises records, may examine the body, speaks to staff and speaks to next of kin

ME may refer to coroner or require amended cause of death

ME provides formal confirmation of cause of death, to be delivered to Registrar by the family

Coroners can refer cases to ME for a ‘Medical Examiner’s Certificate’

Training medical examiners…

http://www.e-lfh.org.uk/projects/medical-examiner/

Embryonic implementation guidance:

www.pathology.plus.com/NME/MEimplementationtoolkit

Pilot sites:

Sheffield

Gloucester

Powys

Mid-Essex

Leicester

N. London

Pilot sites:

Reduction in referrals to the coroner

Increase in inquests

Elimination of certificates rejected by Registrar

Access to medical records can be achieved

Process takes a few hours longer on average

Requests for rapid process can be accommodated

External examination of body problematic

Relatives are pleased to be contacted

Medical staff and bereavement office staff value support

Valuable information to clinical governance systems

How have different groups reacted to the pilots?

Impact on mortality statistics:

Impact on mortality statistics:

Broad cause of death (ICD10 chapter) changed in 12%

Cause of death changed without altering ICD10 chapter in another 10%

Death due to:

Neoplasm up 1%

Cardiovascular disease up 5%

Respiratory disease down 7%

Diseases of the nervous system up 14%

Genitourinary disease down 16%

4% alteration in the sequence of causes

Information can be collected centrally… Did info. from the next of kin alter the cause of death?

Did the next of kin offer compliments about the care provided?

Did the next of kin make any complaints about nursing?

Did the next of kin make any complaints about doctors?

Did the next of kin make any complaints about cleaning?

Did the next of kin make any complaints about delays?

Did the next of kin make any complaints about any error in care?

Did the next of kin make any other complaints?

Nature of concerns expressed by the next of kin

Were clinical governance issues identified during scrutiny?

Action taken to correct clinical governance issues

Code number of healthcare institution responsible for care in the final illness

But then…

A senior politician commented:

“So this is a reform which everyone agrees is a good thing. But there are short-term political risks in its implementation that are not matched by short-term political gains.”

“There’s a General Election coming.”

“Hmmmm.”

Could we get smoking on to death certificates?

Agree what to do

Should it be in the WHO format or as a separate item?

What are the criteria?

Then:

Amend Medical Examiner training programme

Include in Medical Examiner CPD

Use regular returns to NME to monitor compliance in different ME offices

Is it a good idea to get smoking on to death certificates?

Can it be done consistently?

What does “a significant contributory factor ” mean?

Does it improve on other methods of collecting the same information?

Is it cost-effective?

Who pays?

Are there other potential benefits?

Why is smoking a special case?

Psychiatric illness?

Alcohol-related deaths?

Obesity-related deaths?

Record the BMI of the deceased?

HIV-related deaths?

Questions?