The Royal College of Pathologists fully backs recommendations outlined in the Morecambe Bay investigation report to introduce the role of medical examiners without delay and to extend their work to include review of stillbirths and the deaths of newborn babies.
Dr Suzy Lishman, President of the College, said:
“Yet again we are faced with appalling tragedies which might have been avoided if medical examiners had been in post.
The Royal College of Pathologists has repeatedly called for the introduction of the role of independent medical examiners, which has been delayed time and time again, despite clear evidence of the benefits from pilot schemes.
A series of reports into avoidable deaths, including the Shipman and Mid-Staffordshire inquiries, has highlighted the medical examiner system as a way to identify problems at an early stage so that something can be done to prevent more unnecessary deaths.
We now have another damning report about the care and treatment at Morecambe Bay NHS Foundation Trust of some of the most vulnerable NHS patients – newborn babies. I am hoping that this time the Government will act.”
There is no mechanism to scrutinise perinatal deaths or maternal deathsndependently, 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.
Recommendations
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 final 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.
Notes for editors
The Royal College of Pathologists is a professional membership organisation committed to setting and maintaining professional standards and to promoting excellence in the practice of pathology. As well as medically qualified members, the College has scientists amongst its membership and represents 19 pathology specialties. It has over 10,000 members who are senior staff in hospital laboratories, universities and industry, worldwide. The College is a registered charity and is not a Trade Union. It does not negotiate the terms of employment of its members.
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