Under the reforms, all deaths in a healthcare setting will become legally subject to either a medical examiner's scrutiny or a coroner’s investigation. Medical examiners are senior medical doctors that independently scrutinise the causes of death.
Reforms to the death certification system in England and Wales have long been in gestation with the importance of death certification reform and the introduction of medical examiners emphasised in several independent reviews and inquiries including the Shipman Inquiry, Mid Staffordshire Public Inquiry, Morecambe Bay investigation and the Gosport Independent Panel. These changes are another important step towards creating a leading system of death investigation and improving patient safety while ensuring the voices of all bereaved people are heard.
A new statutory medical examiner system is being rolled out to provide independent scrutiny of deaths from April 2024. The new system will see all deaths in any healthcare setting subject to either a medical examiner’s scrutiny or a coroner’s investigation. As part of the changes there will be a new medical certificate of cause of death (MCCD) which can be completed by a doctor who attended the deceased at any time.
The relevant primary legislation for these reforms was commenced on 1 October 2023 and on 14 December 2023 the Department of Health and Social Care published three sets of draft regulations to make clear what the legal requirements are in each area:
The Department of Health and Social Care has also published guidance ahead of more detailed guidance to support those involved in the death management system.
The regulations will be laid in Parliament prior to the statutory system coming into force in April 2024.
So, what’s the purpose of the new medical examiner system?
In March 2019 Dr Alan Fletcher was appointed as National Medical Examiner for England and Wales to provide professional and strategic leadership to regional and trust-based examiners. His role supports NHS England’s stated purpose of the new system which is to:
- provide greater safeguards for the public by ensuring independent scrutiny of all non-coronial deaths
- ensure the appropriate direction of deaths to the coroner
- provide a better service for the bereaved and an opportunity for them to raise any concerns to a doctor not involved in the care of the deceased
- improve the quality of death certification
- improve the quality of mortality data
Medical certificate of cause of death
From April 2024, a new MCCD will replace the existing certificate to reflect the introduction of medical examiners, who will scrutinise the proposed cause of death. There will continue to be a statutory form to be used when a death occurs after 28 days of life, and a separate form to be used when a live born child dies within the first 28 days of life. The new MCCD will include details of the attending practitioner who certified the cause of death and will also include new information for maternal deaths and a new line, 1d, for the cause of death bringing the MCCD in line with international standards. Medical devices and implants will be recorded on the MCCD by the attending practitioner. The DHSC will publish a new paper version of the MCCD before April 2024. In addition the DHSC is developing an online version, which will enable the form to be more easily shared between the attending practitioner, medical examiner, and registrar. The online version will be available later in 2024.
Coronial process
While the draft medical certificate of cause of death regulations mainly provide for completion of the MCCD, in practice they reflect the flow of information between the attending practitioner, medical examiner, coroner and registrar in the new system. The Notification of Deaths Regulations 2019 will remain in force (subject to minor amendments flowing from the changes). Attending practitioners should continue to notify deaths that meet the criteria in those regulations to the coroner, who will determine what further action is appropriate.
There will be provision, in exceptional circumstances, for the medical examiner to certify a death where there is no medical practitioner who is qualified to do so, and the coroner’s jurisdiction is not engaged.
Next steps for NHS trusts, healthcare providers and ICBs
For those NHS Trusts who have a medical examiner office they need to ensure that they are supported with the roll-out of the medical examiner system before April 2024.
All other healthcare providers, including GP practices and independent healthcare providers must ensure that they make the necessary arrangements to inform medical examiners of deaths requiring independent scrutiny and share records of the deceased patients with medical examiners in a timely manner.
All providers will need to set up processes with immediate effect to start referring deaths if they have not already done so with medical examiner offices working with regional medical examiners in England and the lead medical examiner in Wales to facilitate processes with all healthcare providers in their area which have responsibility for medical practitioners completing medical certificates of cause of death.
For ICBs they will need to contact all healthcare providers in their patch and require them to establish processes to refer relevant deaths to medical examiner offices for independent scrutiny. While providers can already share records of deceased patients with medical examiners they will be mandated to do so when the regulations come into force from April 2024.
NHS England has also created a webpage providing specific information for health and care professionals working in primary care, and in other non-acute healthcare settings, such as mental health trusts and community trusts.
The lead college for medical examiners is the Royal College of Pathologists who are running an event on 17 January on the new death certification reforms.
Do get in touch if you’d like support with any of the issues discussed here or with getting ready for the rollout of the new death certification system.
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