Extend medical examiners to stillbirths
Given that the systematic review of deaths by medical examiners should be in place, as above, we recommend that this system be extended to stillbirths as well as neonatal deaths, thereby ensuring that appropriate recommendations are made to coroners concerning the occasional need for inquests in individual cases, including deaths following neonatal transfer. Action: the Department of Health.
- The government stated that MBRRACE-UK confidential enquiries "provide independent scrutiny of all maternal deaths and topics related to stillbirths and neonatal deaths" as an alternative mechanism (Learning Not Blaming, Cm 9113, Department of Health, July 2015).
- The statutory medical examiner system does not extend to stillbirths. Stillbirth scrutiny continues through MBRRACE-UK and the Perinatal Mortality Review Tool rather than through the medical examiner system as recommended.
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