Implement medical examiner system
There is no mechanism to scrutinise perinatal deaths or maternal deaths independently, to identify patient safety concerns and to provide early warning of adverse trends. This shortcoming has been clearly identified in relation to adult deaths by Dame Janet Smith in her review of the Shipman deaths, but is in our view no less applicable to maternal and perinatal deaths, and should have raised concerns in the University Hospitals of Morecambe Bay NHS Foundation Trust before they eventually became evident. Legislative preparations have already been made to implement a system based on medical examiners, as effectively used in other countries, and pilot schemes have apparently proved effective. We cannot understand why this has not already been implemented in full, and recommend that steps are taken to do so without delay. Action: the Department of Health.
- The medical examiner system was rolled out nationally, and independent scrutiny of non-coronial deaths by medical examiners became a statutory requirement in England from April 2024 under the Coroners and Justice Act 2009 (as amended by the Health and Care Act 2022).
- Medical examiners provide independent scrutiny of deaths to identify patient safety concerns and refer cases to coroners where appropriate (NHS England).
How was this evidence gathered?
Response
Accepted
Response
Accepted106. We accept these recommendations in principle.
The medical examiners
system has been trialled successfully in a number of areas across the country. We
will soon be publishing a report from the interim National Medical Examiner setting
out the lessons learned from the pilot sites.
107. The Government remain committed to the principle of these reforms. Further
progress will be informed by a reconsideration of the operation of the new system in
the light of other positive developments on patient safety since 2010 and by a
subsequent public consultation exercise on regulations required to introduce a
medical examiner system nationally in England.
108. Medical examiners would scrutinise all deaths except for stillbirths (for legal
reasons) and any death that requires a coroner investigation.
However, the
MBRRACE confidential enquiries provide independent scrutiny of all maternal deaths
and topics related to stillbirths and neonatal deaths, which is sufficient to learn
national lessons for improvement of care.
Handling external reviews: 41-42