1. The Leicester Medical Examiner Model
Professor Peter Furness
Lead Medical Examiner, University Hospitals of Leicester
National Medical Examiner
RCPath President

2. Tomorrow: “Medical Examiner – Jeremy Mean, the Future”
Phased introduction from April 2019
No change in law, no new fee till April 2021
Medical Examiners employed by NHS, not Local Authorities
Implications remain for Registrars and Coroners

3. We started from here: Coroners and Justice Act 2009
Dame Janet Smith’s report into the murders of Harold Shipman
Initial focus on:
Identifying all deaths that should be referred to the coroner Getting the cause of death right
(Identifying problems with care quality?)
Coroners and Justice Act 2009

4. But we’ve had a bit of a delay since 2009…

5. The focus has shifted: Francis inquiry into care at Mid-Staffordshire
Several subsequent care-related scandals
Winterbourne View care home
Morecambe Bay maternity unit
Southern Health (Connor Sparrowhawk) …

6. The two main pilots have evolved differently:
Sheffield:
‘Senior’ or ‘Clinical’ Medical Examiner’s Officers (MEOs)
MEOs usually speak to relatives
MEOs now usually advise on MCCD completion and coronial referral
MEs normally present 2h per day
Gloucester:
‘Administrative’ Medical Examiner’s Officers
MEs advise on certification and referral
MEs advise on coronial referral
MEs available all ‘office’ hours

7. The drivers in Leicester in 2015:
Pressure from NHS England to review all deaths in secondary care
Impossibility of doing that in some specialties, using available methods – takes too long
Knowledge of the planned national reforms
My experience of the national reform programme, including 2 years as interim National Medical Examiner

8. Initial plan:
Recruit and train consultants to act as medical examiners, but with emphasis on identifying problems in care delivery.
Medical examiner to speak to certifying doctor, examine casenotes and speak to relatives after completion of MCCD (to avoid delays).
ME to correct glaring errors in MCCD / coronial referral and decide whether detailed case records review is justified.
MEs to complete Part 2 of cremation forms; fees to fund the system.

9. Developing the process:
Glaring errors in proposed causes of death were very frequent; early switch to ‘talk to the ME before completing the MCCD’
Followed by ‘Also talk to the ME before referring to the coroner’
Looking for problems with care quality can take as long as you can afford…
Funding from cremation form fees pays for ME time only
Note this is the ‘Gloucester’ model, not the ‘Sheffield’ model: the discussion with certifying doctor, scrutiny of the record and the conversation with family are all done by the medical examiner, not the medical examiner’s officer.

10. Referrals to coroner:
Senior Coroner in Leicester very keen to reduce (eliminate?) referrals she doesn’t need to investigate.
Senior Coroner personally provided ME training.
Local coroner’s referral rules all rescinded:
Death within 24 hours of admission to hospital
Death under age 18
Death within 12 months of an invasive surgical procedure
Etc…

11. Referrals to coroner: Medical examiners got a bit over-enthusiastic…
Causes of death caused concern for Registrar…
Regular meetings of Lead ME, Coroner and Registrar
System now settled down. MEs Registrar or phone Coroner if there’s any doubt.

12. ‘You can take a doc to training, but you can’t make him think’
Illogical sequences on MCCD, related conditions in part 1 and Part 2 - despite training
‘Fracture of femur’ last item in part 1, not referred
Failure to notice Adult Safeguarding order
Mesothelioma signed off as natural causes
Four-fold variation in ME workrate. Slowest MEs were causing most problems.
Conclusion: Take care with the recruitment process.

13. Could we extend the process?
Medical examiners need to be available for advice throughout normal office hours (‘Gloucester’ model).
Cremation form legislation does not allow handovers and insists on an external examination of the body.
With 2,000 deaths per year, one medical examiner is busy full-time and can be paid for by part 2 cremation form fees.
Leicester’s other hospitals have 400 and 200 deaths p.a. We can’t run multiple offices and balance the books.

14. Some problems caused by old legislation:
Completing a cremation form must be done by one person. This makes the ME approach inefficient.
Process not completed in one day? Next day’s ME must re-contact certifying doctor (can be very difficult!)
Covering deaths at a smaller hospital or in the community; how can the ME view the body of the deceased?
Sheffield model (‘clinical MEOs’ speaking to certifying doctor and relatives) does not put the ME in a position to complete cremation forms.
Running the service at a distance (a.k.a. efficiently) will only work if the cremation regulations are repealed or radically changed to allow delegation of tasks.

15. Some problems caused by old legislation:
Registrar’s duty to refer to coroner not rescinded.

16. Some problems caused by old legislation:
Registrar’s duty to refer to coroner not rescinded. Some rules seem odd to doctors (including coroner’s pathologists!):
‘Cardiac failure’ unacceptable, ‘Congestive cardiac failure’ OK.
Ulcer, Perforation, Rupture, Haemorrhage may be unacceptable if not explained. (Duodenal ulcer? Perforated diverticular disease? Ruptured caecum? Cerebral haemorrhage?)
‘Chest infection’ unacceptable under 70, ‘Bronchopneumonia’ OK.
‘Uncertain’ unacceptable, ‘Unknown’ is OK.
‘T-cell carcinoma’ and ‘Arterial fibrillation’ are OK, even though they doesn’t exist….
Solution: ME training, communication with local Registrar – didn’t always satisfy Crematorium Referees – now settled down.

17. But after the teething problems:
It’s working
Everyone involved thinks it’s an improvement
Bereavement office staff delighted to have senior doctors on hand to address issues with relatives
Big reduction in referrals to the Coroner (effect on inquests minimal in Leicester)
Big reduction in unacceptable MCCDs
No delay for relatives (cremation forms probably being done faster than before)
Relatives usually very pleased to be contacted
Fascinating insights into healthcare quality… About 20% referred for more detailed review.

19. From the relatives…
“My mum was admitted with terminal cancer. We all knew she was going to die. Everyone was very caring, I won’t fault the care she was given. But we gave the nurse in charge a list of her medications when she was admitted and it seemed to get lost. So they stopped her arthritis drugs. Perhaps they thought she didn’t need them in bed? The result was that she spent her last days of life in terrible pain from her arthritis.”

20. Key differences in Leicester:
Emphasis on identifying problems in care
Emphasis on avoiding delays
Death can be registered before ME process complete
Not acceptable after 2021 under the new system
Coroner and Registrar accept that occasional cases will be changed by ME review (but it’s rare)

21. Outcome of ME Screening
Type of Further Review Requested Q1 Q2
18/19 to date
None
544
423
967
SJR 65 54
119
Clin Review 98 61
159
Feedback 43
104
Theme Review 2 1 3
PST F/up
BSS f/up 4 6
759
602
1361
72% of cases screened were not considered to need further review
9% referred for SJR and 12% for Clinical Review

22. Number and % of Adult Deaths Referred to / Taken by The Coroner
Apr-Sep 16
Apr-Sep 17
Apr-Sep 18
ADULTS
Inpatients only
ED/Inpatients
Deaths
1393
1395
1419
No. Referred
392
301
239
% Referred
28%
22%
17%
No. Taken
127
187
194
% Taken
32%
62%
81%

24. Handling ‘lessons to be learned’ (& compliments)
Be prepared to identify serious problems that are outside your organisation’s control.
A system focussed on ‘avoidable deaths’ will miss a lot of problems (e.g. all problems relating to terminal care!)
Identifying acutely ill patients with learning disabilities or severe mental illness is difficult (i.e. unreliable)
Morbidity and Mortality leads had unrealistic expectations of non-specialty MEs
Feedback is often in the form of a question
Feedback is often to other organisations
It’s often unclear who to send the message to

25. Bereavement support
Occasionally, contacting the relatives identifies problems that can’t be resolved quickly.
Some form of follow-up system (such as a Bereavement Support nurse) is invaluable.

26. Published June 2018:
NHS secondary care Trusts to appoint Medical Examiners by April 2019
No change in the law at that point
Funding from MEs completing cremation forms
Top-up funding where that won’t work
Progressive roll out to primary care, care homes etc.
Change in law to allow full activation 2 years later

27. Change in law to allow full activation 2 years later
Approval by an ME or coroner mandatory for all deaths
Abolish cremation forms and fees
Replace with registration fee for all deaths (about £100)

28. Overview of Proposed Process for Death Certification
Clinical Governance/Learning from Deaths Input / Review / Audit using ME’s local information and data from ONS
Data from ONS
QAP Completion death certification summary and ME1A forms with proposed cause of death. Completion of MCCD after advice from ME / MEO / HMCO
Notification
To registrar of confirmed certified cause of death
Confirmation of Disposal
Death
ME office & QAP notified after verification
Advice* provided by Medical Examiner’s Officers to Doctors, Coroners and/or Coroner’s Officers
Scrutiny (B) Discussion with QAP – confirmation of the cause of death for the MCCD. MCCD written and copy sent to ME office
Scrutiny (C) Discussion with the bereaved (when not already done so by HMC)
Conformation of cause of death and opportunity to raise concerns
Registration usually before burial / cremation (except if urgent or where inquest
Burial or Cremation after green form from registrar or coroner’s order / cert
Completion of cremation forms - part 4 by QAP and Part 5 by ME
MCCD Issued to informant
If identified as cremation ME to examine body & complete crem form 5
(where applicable)
Deaths notified to Coroner as a result of scrutiny
Scrutiny (A) Review of the medical records and completion of the ME1B
Form 100A
Form 100A
Notifiable Deaths
Deaths notified to Coroner by the registration services
Deaths notified to Coroner as a result of scrutiny
Form 100A
Form 100B
Form 99 or 120 & 121
Investigation
Coroner’s office
Initial enquires made by the Coroner’s office including discussion with QAP, Coroner & family
Post-Mortem
if required
Inquest or any associated criminal proceedings, public inquiry or investigation in another country
Disposal Order
Advice that investigation is not required
Decision to investigate
Key: Process carried out by:
Local process
HMC office
Clinical Governance department or equivalent
QAP (Qualified Attending Practitioner)
Bereavement services or equivalent (e.g. GP staff)
* It is expected that for the majority of cases, medical examiners will not provide initial advice regarding cause of death before scrutiny of records. Where there is an urgent requirement, medical examiners may need to do so, for example for out of hour cases.
ME office
Registration services
Draft September 2018

29. QAP Completion death certification summary and ME1A forms with proposed cause of death. Completion of MCCD after advice from ME / MEO / HMCO
Notification
To registrar of confirmed certified cause of death
Scrutiny (C) Discussion with the bereaved (when not already done so by HMC)
Conformation of cause of death and opportunity to raise concerns
Advice* provided by Medical Examiner’s Officers to Doctors, Coroners and/or Coroner’s Officers
Death
ME office & QAP notified after verification
Scrutiny (B) Discussion with QAP – confirmation of the cause of death for the MCCD. MCCD written and copy sent to ME office
Completion of cremation forms - part 4 by QAP and Part 5 by ME
MCCD Issued to informant
If identified as cremation ME to examine body & complete crem form 5
(where applicable)
Deaths notified to Coroner as a result of scrutiny
Scrutiny (A) Review of the medical records and completion of the ME1B
* It is expected that for the majority of cases, medical examiners will not provide initial advice regarding cause of death before scrutiny of records. Where there is an urgent requirement, medical examiners may need to do so, for example for out of hour cases.

30. Implications for gradually developing Leicester’s medical examiner service
Inclusion of paediatric deaths (also requested by the Registrar)
Provision of ME advice out of hours
Attempting to complete ME review before the MCCD is taken away by the relatives?
Is it possible for the ME to review the notes before discussing the case with the certifying doctor?
Considering how the ME service might be extended to cover deaths in primary care???

31. Training medical examiners…
Update of online training planned
We can offer site visits and / or a package for a face-to-face ME training day
Third DHSC / NHSE / RCPath ‘Medical Examiner’ day April 2019
Leicester Medical Examiner meeting February 2018

32. Take-home message for Coroners, Registrars, would-be Medical Examiners and Bereavement Office Staff:
TALK TO EACH OTHER!
You can develop a system which, once established, works better for everyone.

33. Questions? Requests for help?