INTRODUCTION OF THE MEDICAL EXAMINER POSITION IN ENGLISH TRUSTS
A report on the meeting held on 20th September 2018
These are not official minutes of the meeting and are the personal view of the meeting by the writer. They therefore do not represent either BMA or Royal College policy or approval. See official sites for this.
The Royal College of Pathologists hosted a meeting over the introduction of the Medical Examiner in Cause of Death (MEs) at the Royal College of Physicians on 20th September. This the second of its type this year and more are planned. The all-day meeting was introduced by President of the Royal College of Pathologists and immediate past president. The Royal College has been central in developing the training requirements, on line learning, job description and person description for the posts. After many years of frustration and delay these positions will be introduced in England from April 2019.
Topics covered in the all-day conference included:
- The role of the Medical Examiner
- Working with Stakeholders
- How will it work in practice?
- Timetable for the implementation of MEs
- Role of the National Medical Examiner
- Appointment and role of Regional Medical Examiners
- Accountability and independence – who will employ MEs and how will independence be assured?
- Working with the Coroner
- Changes to completion of cremation forms
- The role of the ME Officer
- Forms and data collection – update on digital support
- Training of local MEs – e-learning and face-to-face sessions
The ME system will be phased within the NHS and now not by Local Authorities. It will be a non- statutory ME service and will include MEs and MEOs (Medical Examiner Officers) in salaried posts. ME systems will be phased into NHS secondary care from April 2019. Implementation in primary care will require new statutory changes.
The Government are committed to moving to a statutory medical examiner process to include all deaths, but as yet it is unclear when this will be implemented. The decision to not take “a big bang approach” and implement the system statutorily from the 1st April enables Trusts and the government to introduce the system in a considered way which will allow for learning and the continued dialogue needed with all stakeholders to bring about positive changes.
No Trust is being forced to implement from the 1st April but from the oversubscribed conference it is clear many are keen to bring in the new system for the clear benefits it will bring to the families, professionals and services who feed into the process.
The NHS now have the learning from deaths programme and the safety programme which also need to be fed into the ME system.
There was also the decision to change the appointment of MEs from local authorities back into the Trusts. This still causes some concerns over their independence and accountability, but it is important to state that this is a process government will be learning from and there have been further levels of independence introduced into the roles to ensure this continues. MEs will be reporting to a separate line of accountability for malpractice. The success of this is to do with working with the pilot sites and early adopters.
The conference was given a strategic overview by Jeremy Mean, Programme Director for Implementation who reports directly to Mark Davies
The DHSC has a strong commitment to the implementation and in October meeting of NHS England & NHS Improvement regarding finance will take place. There is recognition of the frustrations but there is a fresh commitment with a new vision of an ME service based in the NHS. In this initial stage it is a non-statutory service. Both the MEs and Medical Examiners Officers (MEOs) will be salaried in secondary care. There will be a process of reform and a move to a statutory system as specified in the 2009 Coroners Act. The interim period is unclear and the parliamentary process, complex. There is also a new impact assessment – which shows differences from the 2016 impact assessment.
This also links in with other patient safety developments such as learning from deaths encompassing all deaths.
The Medical Examiner lead will be appointed locally but there will be a separate line of accountability held centrally to ensure the need for an independent voice separately accountable to the Trust the ME is working within.
The DHSC is working with many to deliver on the following key objectives;
- The bereaved, next of kin or informants are engaged and can raise concerns
- There is joined up thinking with other departments
- They are working with the pilot Trusts (some of which have been running for 10 years) and earlier adopters sites.
- Working with coroners – MEs or Coroner with only two routes
- Working with Registers of Death to avoid delay and ensure the cause of death is acceptable
- Initial non-statutory approach with a move to statutory MEs over time
- Improvement of recording of the MCCD
- Improvement of the five-day timetable
- For the future there will be a focus on urban and rural areas working with Funeral Directors and the BMA regarding deaths in the community.
Regarding IT support the government is committed to developing a system to provide a digital solution for the ME service. There are procurement arrangements in hand with DH Digital and a number of high quality bids for a digital solution we received. A decision has been made but not yet announced. Input for implementation important as no one size fits all. The aim is for improve scrutiny and outcomes for the bereaved together with high quality data
Dr Aidan Fowler, is the newly appointed NHS Improvement National Director of Patient Safety and will working closely with the DHSC on this He is a surgeon by background and has already visited some of the pilot sites. Dr Fowler announced that the National Medical Examiner position will be advertised in October and will report to him regarding
- Patient safety strategy
- Ensuring bureaucracy remains relevant and manageable
Dr Fowler stated the need to improve the process for the bereaved when discussing the cause of death be a better experience of cause of death by relatives. Relatives want to know what the deceased died of and if it was an unexpected death. There needs to be an accurate recording of death recognising the importance of the current Coronial system and maternal and child death reviews. The aim is to assist in preventing excess deaths and spotting concerns earlier. There is also a need to know how data flow works.
Dr Fowler went on to discuss how the MEs are to be employed. They will be employed in the Trust they will be working within as this is practical however their reporting lines will be separate and independent. . There remains practical issues such as HR and pensions to discuss, but it is important that the jobs are desirable and those appointed have the desirable skills required for this role.
Role of the Medical Examiner and Medical Examiner Officer
Dr Alan Fletcher, Lead Medical Examiner in the Sheffield pilot gave an overview gave an overview of his role. Alan has been an ME in Sheffield since 2008 as one of the earliest pilots. Other pilots included Gloucester Mid Essex, Basildon, Brighton Hove and Powys, He gave a map of the current position of Medical Examiners that have been established in England. South Tees, Buckinghamshire, Lincolnshire, Barnsley, Norwich, Royal Devon and Exeter have all established MEs. He gave a background to the changes in the system that date back to the Harold Shipman case.
The purpose of MEs was defined as answering the following questions
- What did the deceased die from?
- Is the MCCD accurate?
- Is there a need for a Coronial referral?
- Is there a governance concern?
The steps of the ME procedure were highlighted as:
- An appropriate review of the medical records
- Interaction with attending doctor and enquiring of any concerns
- Interaction with bereaved.
- Confirmation of the MCCD
All this will be undertaken within 24 hrs. though it was stated Steps 2 and 3 maybe delegated to Medical Examiner Officers (MEOs)
Dr Fletcher gave a number of examples of poorly completed MCCDs highlighting specific areas that would either be queried or rejected by the Registrar of Death including “malnourished”.
He said there is often a need for clarification and to ensure relatives are engaged. Whilst there is a list of what to report to the coroner this may vary a little locally. It was noted that in the Learning from Deaths review the ME is not a replacement for national mortality case record reviewers, but the ME is seen as an initial filter, though independence and transparency is required.
In the pilot areas regarding Coroners referrals there appears to be no difference in the rate of referral but they (the Coroners) are said to be better informed. In most pilot areas the Form 5 forms are completed by the ME.
Part of the ME scrutiny is signposting which is currently undertaken by skilled people e.g. bereavement officers and therefore Trust are very much being encouraged to build on existing systems and good practice. The ME Dataset will include the usual demographics.
The ME training needs will be discussed and appraised. There are core sessions of e-learning (26) which have been refreshed recently by the Royal College of Pathologists. Updating of all documents is taking place by the Royal College of Pathologists and will be available on their website shortly. There is a need to avoid inconsistencies in the system. The list of acceptable causes of death is also being refreshed and revised to emphasise the collaboration that is taking place. As well as e-learning there will be a face to face component 1-day event later this year and early next year which will include input from the faith community.
There were several questions from the floor and answers from the panel:
- There was a discussion of what is a reasonable workload
- In Sheffield there is 1 whole time equivalent ME for 3000 deaths and 4 wte Medical Examiners Officers. In addition to the bereavement officers already in place
- Conversations with the bereaved will include hospital consent autopsy. But consented autopsy is not a replacement for coroner referral.
- There is noted an increased level of complexity of referrals to the coroner
- If there is a coronial referral this ends the MEs involvement.
- MEs cannot instruct what the Qualified Attending Physician (QAP) writes but they are there to help advise them and agree wording that would acceptable to all. Ultimately it is the QAPs certificate, with the consultant in agreement.
There were discussions from the floor on:
- the notion of independence of ME in Trust
- training of junior doctors and medical students on completing MCCDs.
- whether it was the fee from just Form 5 to be used for funding the MEs
- The DHSC representative stated that when the statutory system comes in it there will likely be a fee introduced for all deaths (around £100 each)
- The need or bereavement booklets for families
- Out of hours scrutiny
- The need for business continuity planning in the mortuary
Medical Examiner Officers
Medical Examiner Officers have a role to assist the ME in the three steps of scrutiny though this differs by location. They obtain the medical record which are looked at by the medical examiner. They also complete data entry.
MEOs do not replace bereavement officers but there is no reason why Trusts cannot combine the role. They don’t advise what to write on the certificate as this is still done by bereavement services. There was a discussion of what sort of MEOs, administrative, data entry, more clinical or combined role and who are we going to recruit. This can be a mix or work with what you already have. In one case this is a team of MEOs, nurse registration and bereavement specialties (7 part-time)
How does the ME scrutinise?
- Medical Records reviewed, clinical letters, surgery, nursing note, safeguarding issues considered. This maybe electronic or paper or the combination of the two.
- Conversation with the qualified attending practitioner (QAP)
- Discussion with the bereaved
- Conclude whether the death natural or unnatural
There will be a need for local solutions. The task of discussing with the QAP and bereaved maybe delegated to the MEOs as in Sheffield depending on whether the MEO is clinical or non-clinical.
Role of the Qualified Attending Practitioner (QAP)
At Gloucester the ME asks open questions about the deceased and is given an overview including, medication, procedure and terminal episode. Questions include are there any concerns? Has a coronial referral been considered? Has there been any conversation with coronial officers?
The MCCD is formulated by the QAP. Any fundamental disagreements (which are rare) lead to conversations with other members of the tea. The MEOs bleep the relevant QAPs in the morning for availability but there is a recognised need for flexibility.
There is a 24 hour ME service including out of hours. Though calls out of hours are uncommon. There is a need to cover paediatrics and organ donation.
Practical considerations discussed include:
- who needs to see the body
- who signs the cremation forms (Form4 – QAP Form 5-ME)
- Payment for Form 5 goes towards funding the ME service
- The current Cremation forms remain in place
- New forms
Administrative Information Form ME-1 (Part A)
- Medical Examiner’s Advice and Scrutiny Form ME-1 (Part B)
- ME-2 form
- The QAP must complete death certification summary
- Sheffield has an access database developed by Peter Furness (ME) which includes a summary of the record and medical examiners notes. This is linked to other reviews
- Based on the Sheffield experience the ME time is on average 25 minutes but more complicated cases take longer.
- As an example, review of records can vary between 12 – 15 minutes.
- The ME interacts with both the QAP and with the family
- Bereavement appointments are within 2 working days of death
- Relatives need to have time to reflect often day after
- Faith concerns, paediatric cases and organ donations are prioritised
- The cremation waiting time is around 2 weeks
- There are problems around availability of the QAP.
- It is recognised that the ME system must be responsive as any delay might be directed at the ME system
- The ME system avoids unqualified referrals to the coroner and the coroner receives more information
- The Junior Doctor writing the MCCD gets support more easily.
- It will take a while to embed the system
- There may be an issue of long distances in some rural areas
- Concerns – occasionally there is no agreement on the cause of death
- Current pilots show no increase or decrease in complaints
- Burial within 24 hrs – out of hrs service to facilitate release
Accountability of Medical Examiners
MEs will be regarded as Independent with different levels of accountability than within the Trusts and when introduced into Primary Care. Doctors will behave independently and professionally. There should be a minimal acceptable distance. There will be a need for peer review by a ME colleague. The MEs will be working with but not for the coroner. There will be collaborative working with MEOs. As with other specialties there will be professional accountability and annual appraisal. There will be a “channel of communication” of reporting to the National Medical Examiner.
There will be a need once established for a survey on how to make it a better system
Affects on the Coroner system
Increase or decrease number of inquests?
Sheffield – increase in inquests
Gloucester- no increase in inquests
There is a general reduction in coroners post mortem
Relationship between ME and Coroner
If there is a disagreement the ME has further discussions and a second opinion from another ME is sought. In Sheffield this often arises out of a misunderstanding of the reasons of the report. If the law says so the case must be referred. It may therefore be a matter of improved explanation and polite reporting.
Cases of discrepancy where discussed in one area that had too few Coroners Officers and the fact that Doctors are moving areas with increased locum doctors.
In Sheffield there was a case where the ME was referred to the Coroner and then the case came back, but this is infrequent. There is therefore a need to ensure that the coroner is furnished with the right information.
The Coroner cannot tell a doctor what to put on the MCCD. There was a discussion of how you get the feedback. The MCCD does have a tick box to say that the QAP has discussed the cause of death with the coroner.
There was a general discussion on:
- Examples of undue pressure in the event of a disagreement on a workable MCCD where there has to be an open investigation with a coroner’s autopsy or inquest
- Communication – coercion. “My consultant told me”
- Pressure by hospital on healthcare acquired infections
Interaction with the bereaved
A leading MEO discussed their interaction with the bereaved. When a patient dies there is a booklet given out on the ward which explains the ME system and what steps will take place.
It is crucial the ME has a high level of empathy, be approachable and has good judgment. They are also there to inform the bereaved if there is a concern or if the bereaved raise a concern, understand what the issue is. In the Sheffield pilot care prior to admission is the most common concern raised. There is also a need to adhere to the local escalation policy.
There is a need to establish who needs to be involved in the conversations. Abiding by the openness of Learning from Death if a problem is identified, there needs to be discussions as to whether it will require independent review. If there is a duty of candour issue, sometimes not before death, the team would be there to address this and provide an open discussion without the fear of appearing to cover anything up.
The bereaved should also be asked if there are any problems they are aware of or what worries them and then reassure them there will be an investigation, but not undertaken by the ME.
The interaction with the bereaved has been very well received and all very much positive. But talking to relatives needs appropriate training as there is often a need to explain the terminology. Skilled writing and plain language is also needed particularly when interacting with the bereaved. Bereavement staff have also welcomed an ME being there to talk to difficult relatives. Flexibility and empathy is needed with the bereaved and allowing them the space to process the death before approaching them with information.
Some of the following questions were discussed:
What happens if the relative doesn’t want to talk to the ME?
This is rare but may affect different members of the family. Sometimes this is because there are no concerns.
What do you do if relatives have concerns over their own mental health?
This too is uncommon and is a judgement call. There is a duty of care. Are you the right person to speak to? Similar problems are seen in capacity issues. Coroners also have much experience of facilitating challenging discussion and can offer support to MEs on this.
What will be the impact on the Registrars of England and Wales?
There is a need for collaboration at the outset. Registrars need to accommodate the changes. But engagement has been positive. Under non-statutory changes the registrar still has the statutory function with the 5-day target remaining. The Royal College of Pathologists is working with the registrars on the list of Acceptable and Unacceptable Deaths. These should be in place by April 2019 and there are now good channels of communication.
This is a new welcome level of scrutiny, but it is not a triage system. In Leicester there can be an MCCD release before the ME scrutiny takes (for deaths within faith communities). In a non-statutory system there is also flexibility for any urgent repatriation release.
A Panel discussion took place around the following
- Current pilot schemes have varied some will differ to how it will work from April 19
- Additional resources will be needed for a comprehensive system
- MEs are likely to be part-time
- A Job description will be place
- As this is a non-statutory system the current system will prevail
- There is a need for 7-day service – close to 24 hr consultant consultation
- MEs are not bereavement counsellors but they have the ability to refer
- There are workforce issues. For 2000 deaths which require up to 40 minutes a case Trust will need approximately 10 PAs.
- A knock-on effect maybe an increase in hospital autopsy rate.
LATE AFTERNOON PANEL DISCUSSION
Panel included National SRO for wales, ME Bucks, Project Manager Lead ,
Other topics discussed included;
- ME in Learning from Death strategy
- Mortality review ME involvement is critical as seen in Wales
- Guidance in LfD for those for investigation.
- ME is a flight path to a structured judgement review
- Functions and oversight of ME
- MEs are not working in sealed box if they send a case for a SjR
- It is all about patient safety
- MEs Involvement SjR
- Involvement of ME in Trust Mortality group
- ME recruited on the premise – multispecialty
- Datix can be used for positive excellence
- Evidence of recent ME experience
- Talking for some time
- Started planning mid May, November start
- Planning training raising profile
- Robust mortality review process is needed with positive input.
- Set up a program of gradual role out (e.g start with 3-4 wards and progress to cover the whole hospital over a matter of weeks)
- Link into mortality review
- Scrutiny in the ME office
- Spoken to family and qp
- Document in electronic system that links to the mortality review. Promotes early review.
How to set up a Medical Examiner Service in a Trust
- Consult with all stakeholders.
- There is no need to begin with all deaths – no big bang is needed.
- Identify how many medical examiners will be required in the trust?
- How long should be taken on a case to do based on statutory roll out?
- As this is not a statutory roll out the best we can do is “don’t do too many badly”
- Initially review 50% – 75% deaths. Look at the number of cremations
- DHSC is discussing additional funding for those deaths that result in burial and child deaths which will come to trusts centrally.
- Need to look at Infrastructure, phones, territories, partnerships in the planning phase. Prioritising administrative support. There will need to be a full time administrative person and bring bereavement staff on board with review of job plans.
- How this will work in primary care is under discussion. The Sheffield 23 GP practices are involved. IT solutions are important. The ME has access to GP records for 30 – 40 cases per month. The ME is based in the hospital as remote access to system 1 is easer.
What do Trusts have to do by April 19?
- Don’t have to do anything
- Trusts will want to work towards this
- Roll out as quickly as able to do
- Look at what your requirements would be
- Work needs to be done by NHSE & NHSI
- The enthusiasm and willingness of wanting to reform the system is the biggest incentive to deliver it and will show the benefits
- Advert for National Medical Examiner set for this year
FOR THE FUTURE
Once embedded the next phase will be statutory implementation but this will need future legislation changes.
The official minutes of the meeting can be found at Royal College of Pathologist’s Conference on the Medical Examiner System