The creation of a national network of medical examiners (MEs) was recommended in the Shipman inquiry and was alluded to in the Mid-Staffordshire and Morecambe Bay public inquiries.

The Parliamentary Under-Secretary of State for Health, Lord O’Shaughnessy, confirmed in October 2017 that a national system of medical examiners will be introduced from April 2019.

The Medical Examiner (ME) reforms set out in the 2009 Coroners Act will be implemented nationally in two phases. By April 2019, NHS trusts should set up non-statutory schemes, based upon the national pilots (particularly in Leicester, Sheffield and Gloucester), funded in part from cremation form fees, in preparation for the commencement of a statutory scheme in 2020/21.  A National Medical Examiner will be appointed, reporting directly to the National Director of Patient Safety.

There will be two stages to funding the ME system to enable its introduction whilst legislation is in progress. Initially, MEs will be funded through the existing fee for completing medical cremation forms, in combination with central Government funding for ME work not covered by those fees.  Following this interim period, and when Parliamentary time allows for the system to move to a statutory footing, the funding of the system will need to be revisited. The existing medical cremation forms and associated fees payable will continue to apply for the interim period.

Implementation will be in the NHS (not local authorities), initially for deaths in secondary care, based in providers but with accountability outside the organisation to ensure a degree of independence.

The reforms aim to improve engagement with the bereaved in the process of death certification, and offer them an opportunity to raise any concerns, as well as improving the quality and accuracy of Medical Certificates of Cause of Death (MCCD).  Safeguards will be enhanced in the process, to enable MEs to report matters of a clinical governance nature to support local learning and changes to practice and procedures.

MEs are a key element of the death certification reforms, which, once in place, will deliver a more comprehensive system of assurances for all non-coronial deaths, regardless of whether the deceased is buried or cremated.  MEs will be employed in the NHS system, ensuring lines of accountability are separate from NHS Acute Trusts but allowing for access to information in the sensitive and urgent timescales to register a death.

The Government paper outlines seven specific ways that the ME system will benefit the public, the NHS, and local authorities:

  • It will be fair – all deaths will be scrutinised in a robust, and proportionate way regardless of whether they are followed by burial or cremation
  • It will be independent – a Medical Examiner will scrutinise all MCCDs prepared by the attending doctor
  • It will be transparent – families will have the cause of death explained to them, including clarification of medical terms, and be able to ask questions or raise concerns
  • It will be robust – there will be a protocol that recognises different levels of risk depending upon the circumstances and stated cause of death
  • It will be accurate – the Medical Examiner will be an experienced doctor, capable of ensuring that the MCCD is completed fully and accurately, providing the NHS, the Office for National Statistics, local authorities and a wide range of other users, with better quality cause of death statistics to inform health policy, the planning and evaluation of health services, and international comparisons
  • It will be efficient – it will help to make sure that the right cases are reported to Coroners
  • It will improve safety – the new system will allow easier identification of trends, unusual patterns, and local clinical governance issues, as well as making malpractice easier to detect.

Since the Government initially consulted on the package of Death Certification Reforms, new information about how an ME system could be introduced has been generated by the Department of Health and Social Care (DHSC), ME pilot sites, early adopters of the ME system, as well as from the Learning from Deaths initiative.

This case study outlines the approach of South Tees Hospitals NHS Foundation Trust as one of the early adopter sites.

Aims, objective and scope

Following on from the extensive Learning from Deaths work, South Tees Hospitals NHS Foundation Trust (STHFT) agreed to be an early adopter of the ME system and was supported by the Patient Safety Collaborative for the North East and North Cumbria (PSC NENC).

The key objectives were that the service provision should allow MEs to review and / or investigate each case, and that they should seek to answers three key questions:

What do patients die from?

The Medical Certificate of Cause of Death (MCCD) should be accurate, and should be aimed at providing the family with adequate accurate information, as well as improving learning opportunities related to cause of death themes and trends.

Should the death be reported to the coroner?

This aims to ensure that any referral to the Coroner is timely and accurate, and that all relevant cases are referred.

Are there any clinical governance concerns not otherwise reported?

Independent case record review and / or investigation of each case by the MEs aims to highlight any concerns that may not have otherwise been reported, thus improving the Learning from Deaths pathway.

Method and approach

Summary of actions:

STHFT developed the service ahead of the national reform as an ‘early adopter’ and the service level for a Trust with approximately two thousand deaths per year was initially agreed at:

  • Mon-Fri, 8am – 4pm service. Thirteen programmed activities (PAs) were taken up by eight consultants doing one or two PAs, each from a range of specialities: ICU/anaesthesia (x2 including the lead), Acute Medicine, Cardiology (x2), Surgery (Oral and Maxillofacial), Infectious Diseases, Radiology/Nuclear medicine physician.
  • An online and face to face training plan was established, and mentorship was provided by a retired Medical Director.
  • Service was co-located with the Bereavement Service, which includes a registrar.
  • Support from local coroners was sought and the service was discussed with Medical Referees.
  • Key links to the End of Life Care Team and Mortuary Services were established.
  • Forms for recording ME activity were developed. Forms were based upon Leicester and Sheffield national forms used as part of pilots, with some local adaptations.
  • The pathway for referral to the MEs was established and explained to staff by means of Trust level communications and relevant networks.

Summary of process:

  • All deaths are reported to the ME as soon as possible.
  • MEs talk to the clinical team caring for the patient at the time of death, review the notes, examine the body when appropriate, and sign the ‘Part 2’ (Form 5) cremation certificate. Within days, the MEs will speak to the family.
  • If any concerns are raised, an in-depth case record review and/or an investigation takes place, and specialty/attending teams are additionally asked to review the case as per usual governance processes.


Currently, Medical Examiners are covering deaths at The James Cook University Hospital, and roll out in The Friarage is planned.  The service does not yet cover Community Hospitals.

Presently, deaths related to Obstetrics and Gynaecology and Paediatrics are not included as part of the ME role.  This will be explored in the future, but links and crossover to the following should be explored:

  • Child Death Review Panel
  • RCOG ‘Each Baby Counts’ Project
  • HSIB Maternity Investigations Programme
  • MBRRACE Reporting.
Measurement plan

The following were considered as the six key measurements:

  1. Number of reported deaths that had ME involvement
  2. Number of cases that were referred for second stage review or investigation following ME investigation
  3. Number of errors in certification identified
  4. Impact in relation to experience for bereaved families
  5. Impact for junior doctors in relation to the increased support and training in certification of death
  6. Impact for coroners, registrars, mortuary, and funeral directors.
Results and evaluation
  • MEs involved in 719 of the 1009 deaths in the five months May to November.
  • 105 cases were referred for second stage review or investigation all providing opportunity for learning.
  • Some errors in certification were identified by the MEs, leading to related learning.
  • Feedback from bereaved families indicated that correcting misunderstandings has improved the experience. They feel positive about being able to contribute to investigation and ‘have their say’. They also feel that having an identified contact is useful.
  • Feedback from junior doctors is that they appreciate the support and training in certification of death, and this is an area in the past where some have felt under supported.
  • Feedback from coroners, registrars, mortuary, and funeral directors, is positive. Despite initial concerns that the process would be slowed, and capacity issues may arise, the process has been shown to be expedited, which is the reverse of the expectation. Stronger links have been formed with the coroners, and referral pathways are smoother.
Learning points

To date, the following learning points have been identified and explored:

  • End of Life Care, ceilings of care and avoidable admissions
    Some investigations have highlighted cases where the End of Life Care pathway could have either been established or fully implemented, where this would have been of benefit to patients and their families. Some patients may not have been cared for in the right location, and some admissions could have been avoided if the End of Life Care pathway had been suitably established and followed.
  • Early detection and response to physiological deterioration, and effective communication
    Response stretched by implementation of National Early Warning Score (NEWS) but still learning around effective communication of escalation. The use of standardised communication tools is essential.
  • Record keeping and organisation of medical records
    Some learning was identified in relation to the accuracy and completeness of medical records. It was evident that not all records are reflective of the clinical picture.
  • Discussion with specialty teams is vital to support the investigation
    An independent review by the ME should be further supported by speciality ‘experts’, and if possible, peer review from other trusts can be sought to allow for full independent review. Seeking speciality opinion from those not directly involved with the case within STHFT has also been shown to be effective.
  • Pathways for links to wider clinical governance processes have been strengthened.
Plans for spreading learning and encouraging adoption
  • STHFT will be continuing to spread the service across other sites and community hospitals.
  • The Patient Safety Collaborative for the North East and North Cumbria (PSC NENC) and NEQOS will support sharing of learning from South Tees. The PSC are presently exploring how to use the experience of South Tees to best support regional roll out of the ME service.
  • Short video to be used for regional/national spread is planned for completion in November 2018.

‘Top Tips’ for adoption:

  1. Initially agree service level requirement and funding at board level.
  2. Consider if possible, the co-location of service with other related services, eg Bereavement Service, mortuary service etc.
  3. Recruit Medical Examiners (including a lead) from a range of specialities (number required based upon agreed service level requirements).
  4. Establish online and face to face training and consider mentorship (who will provide).
  5. Seek support from local coroners and discuss with Medical Referees.
  6. Establish links with existing networks, eg local PSC, Governance Leads, Mortality Groups, Deterioration Patient Groups, End of Life Care Leads.
  7. Review and modify forms for ME activity from pilot sites or develop something similar.
  8. Establish means of feedback, both formal and informal, from families and junior doctors to support evaluation of service.
  9. Raise the profile of the ME service via Trust level communications and via Governance Teams.
  10. Plan start date – consider staggered roll-out by hospital site, if required.
Start date

May 2018

Contact for further information

Tony Roberts, [email protected]

Patient Safety Lead, Academic Health Science Network – North East and North Cumbria (AHSN NENC)
Deputy Director (Clinical Effectiveness) South Tees Hospitals NHS Foundation Trust 
Deputy Director, North East Quality Observatory Service (NEQOS)