Professor Peter Furness National Medical Examiner Past President, Royal College of Pathologists

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

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 other problems…

Swift B, West K. J Clin Pathol 2002; 55: Death certification: an audit of practice entering the 21st century ‘natural’ deaths. “Only 55% of certificates were completed to a minimally acceptable standard” Fernando D, Oxley JD & Nottingham J. J Clin Pathol 2012; 65: 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?

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, examines body, speaks to staff and speaks to next of kin ME may refer to coroner or require amended cause of death ME provides confirmation of cause of death to be delivered to Registrar Coroners can refer cases to ME for a ‘Medical Examiner’s Certificate’

Training medical examiners…

Pilot sites: Sheffield Gloucester Powys 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 to pay for this? Abolish Cremation Forms and fees No objection from BMA or doctors!!! Fee for scrutiny, to be less than total of current cremation form fees Central government funding for startup costs How to avoid new fee for those who choose burial?

How have different groups reacted to the pilots?

Pros and cons for coroners? More inquests Less time wasted Opportunity to work with doctors who understand death certification No need for ‘just in case’ rules on referral Route to certify deaths where no attending doctor available A better service to the community An opportunity to review that vague boundary between natural and unnatural causes?

The vague boundary between natural and unnatural? Roberts IS, Gorodkin LM, Benbow EW. J Clin Pathol. 2000; 53: What is a natural cause of death? A survey of how coroners in England and Wales approach borderline cases. Clinical scenarios circulated to all coroners in England & Wales “There is considerable variation in the way in which coroners approach these borderline cases, many of which are common in clinical practice. This study indicates a need for discussion, working towards a national consensus on such issues. It highlights the importance of good communication between coroners and medical staff at a local level.

What’s still to be done? Public consultation and Ministerial Regulations! Training for Medical Examiner’s Officers System for external examination of the body Local Authorities – organisational readiness Recruitment of Medical Examiners and their Officers System(s) for collection of fees Information (for doctors, members of the public, coroners…) Plans for ‘go live’ date (Is there a ‘Plan B’?) Working relationships with coroners Quality assurance Revalidation for Medical Examiners? We are creating a new medical specialty!

So what will the future hold? Any questions? Better - any solutions???