Setting up a medical examiner system
This page provides information for local providers on setting up their local system including advice on establishing need and capacity, funding and recruitment.
The development, construction and staffing of medical examiner systems will need to be managed at a local level. Initial implementations will focus on secondary care deaths, with primary care being added later in most cases. It is recommend that new services are implemented gradually and eventually built up to cover all deaths.
The below video, provided by Dr Alan Fletcher, National Medical Examiner for the NHS, provides a strong overview for providers of the key issues to consider. In discussion with Daisy Shale, Medical Examiner Officer at Sheffield Teaching Hospitals NHS Foundation Trust, Dr Fletcher explores lessons learned from pilots across the country, covering staffing, service provision and the organisation of a medical examiner service.
Timelines for implementation
NHS acute providers
The expectation is that providers will begin to establish the size of the medical examiner system they need and start to recruit accordingly from April 2019.
It will not be mandatory at this stage to have a fully operational medical examiner system in place – the non-statutory period allows for organisations to implement a system in a way that minimises risk.
Community and mental health trusts
The Department of Health and Social Care (DHSC) and the Welsh Government, working with NHS Improvement and NHS Wales Shared Services Partnership, are providing the solution for medical examiners to scrutinise all non-coronial deaths including deaths in the community. The current plan is to be able to share further details about this approach at the next medical examiner information event, planned for 25 April 2019.
National support for local medical examiner systems
NHS Improvement has recruited Dr Alan Fletcher as National Medical Examiner who will provide professional and strategic leadership to medical examiners in their role of providing independent scrutiny and confirmation of causes of death.
He will lead by example and set standards of best practice to improve death certification processes. He will support better safeguards for the public, monitor and improve patient safety and inform the wider learning from deaths agenda.
The National Medical Examiner is employed by NHS Improvement and will report directly to the National Director of Patient Safety. A governance structure for Wales will be through a memorandum of understanding.
The National Medical Examiner will be based within the NHS Improvement National Patient Safety team as such will be part of a team working on patient safety and wider mortality agendas. It is expected that in addition to the National Medical Examiner, there will be seven regional lead medical examiners and seven regional lead medical examiner officers appointed in England. They will be employed by NHS Improvement. One lead medical examiner and one lead medical examiner officer will be appointed in Wales.
Funding to support providers
The DHSC has committed to aiming to ensure the costs of running the medical examiner system cost net-neutral for providers. It is proposed that provider organisations will be reimbursed at the end of the financial year when it has become clear what their actual recruitment and set up costs are. A flat fee is proposed for recruitment costs per post filled.
Until legislation changes, and whilst the system is in the non-statutory period, it will be funded through a combination of the fee paid for cremation form 5, and a top-up from DHSC. Medical examiners will take on responsibility for the completion of cremation form 5, and the fee for this will be paid to the host organisation.
When parliamentary time allows for legislation, the funding of the system will be reviewed. It will, therefore, be important to work closely with provider organisations during non-statutory implementation to ensure that there is good data around the cost of the system.
In future, a national digital solution will allow the medical examiner officer in the host organisation to track all the deaths scrutinised by each medical examiner, and also provide the information that host organisation finance departments need to recover the appropriate costs.
As the system is set up, the appropriate size of each medical examiner office will be determined, with initial analysis suggesting one whole time equivalent medical examiner and three whole time equivalent medical examiner officers per 3000 deaths. This number may change as more information is gathered during implementation of the system, and a sensible size and cost can be agreed.
The DHSC will put in place a system for host providers to recoup the difference in costs for their system and the income they receive from the cremation form fees. The exact mechanism for this is still being worked through. The DHSC has committed to ensuring the system does not create a cost pressure.
In addition, The DHSC has agreed to provide funding to cover the costs of recruitment for setting up the system, via a flat fee / contribution per post. The digital solution will also allow recruiting providers to evidence the number of medical examiner posts they have recruited, and then claim the funding for recruitment at year end in April 2020.
It is anticipated that per approximately 3000 deaths, one whole time equivalent medical examiner (from a pool of varying specialities on a rota) and three whole time equivalent medical examiner officers will be a clear guide on reasonable costs. However, this is an estimate and can be tested during the non-statutory period. It will be recommended for organisations with significantly lower numbers of deaths to work with another local medical examiner office rather that setting up their own system.
Planning your system
Building on the DHSC’s Impact Assessment, current estimates are that per 3000 patient deaths, the system will require:
- one whole time equivalent medical examiner (from a pool on a rota basis based on 10 programmed activities per week)
- three whole time equivalent medical examiner officers.
Of course, the set up must be reflective of the case mix, geography and may necessitate variation based upon the demographics of the population covered. Organisations with significantly lower numbers of deaths are recommended to work with another local medical examiner office rather than setting up their own system.
It is expected that the site with the largest number of deaths will host the principal medical examiner office within the host organisation. It is expected that medical examiners and medical examiner officers will also work from other hospital sites within the host organisation as necessary – there is no reason why medical examiners cannot share offices across sites.
Managing out of hours requests
The intention is for a seven-day medical examiner system, including a medical examiner being available on a rota system to cover weekends but not nights. It is important to note that whilst some requests for rapid release of the deceased are made in order to proceed with a burial the same day, this cannot be guaranteed.
It is the DHSC’s understanding that funerals must take place ‘as soon as possible’. However, whilst the medical examiner will endeavour not to introduce any perceived delays, they must be allowed to perform equal scrutiny of the patient deaths in a way that is robust, proportionate and inclusive of next of kin/informant’s views in every respect.
Staffing for busier periods
During the week, additional staffing/hours should be considered for Mondays as it is the busiest day for the service.
The staffing estimates should allow for an average spread across the year, based on retrospective data. However, the unpredictable nature of patient deaths is a legitimate consideration and only when numerous medical examiner offices are running will this be fully tested.
The following model job descriptions have been created by the Department for Health and Social Care to assist employers with recruiting medical examiners in their area.
The local Coroner should be involved when planning and making medical examiner appointments.
It is recognised that it may not always be practical for host organisations to include external members on interview panels. However, host organisations are encouraged to consider ways that the interview panel can include wider expertise, for example inviting a member of the organisation’s board or council of governors (in the case of NHS Foundation Trusts) to take part in the interviews.
Training of Medical Examiners
Senior doctors intending to work as a Medical Examiner should undertake the required training, which includes completing 26 e-learning modules and attending a face-to-face training day. More details about the training are available on the Medical Examiner Training page.
Issues of confidentiality will be handled in the same way as they are now. If the condition contributed to death then it must be written on the medical certificate cause of death. Best practice would dictate that these rare situations should be handled by both the patient’s consultant and the medical examiner office with sensitivity and compassion.
Below we list some of the additional areas identified by the pilot medical examiner systems across the country, to help providers develop their own medical examiner services.
- A project manager should be identified to scope the creation of the new service including the appropriate facilities, staff and costings based on the population the service is for.
- Throughout, involve registration services as important stakeholders.
- Do not try to include all deaths at the start; learn and refine your system.
- Recruit a Lead Medical Examiner and Lead Medical Examiner Officer initially and test the system.
- Appropriate IT infrastructure should be put in place to review patient records and collate data for the national medical examiners records system. The Department of Health and Social Care is developing a national digital system for data entry.
- The continuity of the service must be considered to allow the service to be delivered to the standard for case conclusion (eg 24hrs from having received a non-coroner case into the office).
- It is recommended that the medical examiner system is used to identify cases for Structured Judgement Review.
- Ensure medical examiners and medical examiners officers are provided a quiet and confidential space for discussions with family and attending doctors.