Introduction to the medical examiner system
The system will also offer a point of contact for bereaved families to raise concerns about the care provided prior to the death of a loved one.
Acute trusts in England and local health boards in Wales have been asked to begin setting up medical examiner offices to initially focus on the certification of all deaths that occur in their own organisation.
The purpose of the medical examiner system is to:
- provide greater safeguards for the public by ensuring proper 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 examiners are senior medical doctors who are contracted for a number of sessions a week to undertake medical examiner duties, outside of their usual clinical duties. They are trained in the legal and clinical elements of death certification processes.
Medical examiner offices at acute trusts in England
Medical examiner offices at acute trusts will be staffed by a team of medical examiners, supported by medical examiner officers.
The role of these offices is to examine deaths to:
- agree the proposed cause of death and the overall accuracy of the medical certificate cause of death
- discuss the cause of death with the next of kin/informant and establishing if they have any concerns with care that could have impacted/led to death
- act as a medical advice resource for the local coroner
- inform the selection of cases for further review under local mortality arrangements and contributing to other clinical governance procedures.
Initially medical examiner offices are being asked to focus on the certification of deaths that occur within the acute trust where they are based. In time, they will be encouraged to work with local NHS partners and other stakeholders to plan how they can increase the service to cover the certification of all deaths within a specified geographical area. This will expand the service to cover deaths in other NHS and independent settings, as well as deaths in the community.
During the non-statutory phase of implementation we, along with the Department of Health and Social Care, will collectively support acute trusts to manage the financial impact of establishing and running local medical examiner offices.
Coronavirus Act – excess death provisions: information and guidance for medical practitioners
The Coronavirus Act of Parliament gained Royal Assent on 25 March 2020, and the commencement order for the clauses relating to death certification and cremation forms was signed on 26 March 2020. Guidance and information on these clauses are set out in this document, along with previous COVID-19 advice issued on 10 March, also included in the document for completeness.
National Medical Examiner’s good practice guidelines
To support medical examiners to ensure there is consistency in the implementation of medical examiner offices, we have produced good practice guidelines setting out how the National Medical Examiner expects medical examiner offices to operate during the current non-statutory phase of the programme. The document sets out good practice from the National Medical Examiner, and learning from pilot sites and early adopters.
How reasonable costs for operating a medical examiner system will be determined
It is anticipated that for approximately 3,000 deaths, one whole time equivalent medical examiner (from a pool of varying specialities on a rota) and three whole time equivalent medical examiner officers should provide adequate cover and should be used as a guide to reasonable costs. However, this is an estimate and can be tested during the non-statutory period. It will be recommended that organisations with significantly lower numbers of deaths work with another medical examiner office rather that setting up their own system.
Funding for medical examiners
On 11 September 2019, we issued a letter with the Provider Bulletin to give trust and foundation trust medical directors (cc chief executives and finance directors) further information on what the introduction of medical examiners in England means for their organisation. The annexe to the letter is available below, and provides details on the regional structure, the digital system and plans for funding the system.
Reimbursement process 2019/20 and 2020/21
The National Medical Examiner team has published an explanatory note on the reimbursement process for trusts and foundation trusts for 2019/20 and 2020/21. If your organisation is planning to submit a request for top-up funding for your medical examiner system, please read this note and contact firstname.lastname@example.org if you have any queries.
Guidance on medical examiner system financial arrangements during the COVID-19 emergency period
- In line with recently published guidance, we appreciate that some medical examiners and medical examiner officers may be redeployed to provide direct or indirect support to patient care to alleviate pressures associated with COVID-19. Salary costs related to the redeployment should be included with the trust’s COVID-19 costs, and not in the medical examiner system reimbursement return.
- Where medical examiners and medical examiner officers continue to undertake some of their medical examiner office duties, the salary costs that relate to this work should be included as usual in the medical examiner system return.
- Section 19 of the Coronavirus Act 2020 suspends the requirement for a confirmatory medical certificate for cremations (cremation form 5). This will lead to a temporary shortfall of cremation form 5 income which will be covered through the medical examiner system reimbursement – approved medical examiner and medical examiner officer salary costs will be reimbursed in full, therefore, without deducting cremation form 5 income.
- Collection of cremation form 4 income by trusts is not part of the financial model but we are aware some trusts have been collecting this income in place of cremation form 5 income. If collected, this income will not be taken into account when calculating the reimbursement for medical examiner system costs.
Each NHS region will have a regional medical examiner to support the development of medical examiner offices. Regional medical examiners will oversee the provision of services and provide an independent line of advice and accountability for medical examiners at trusts in their region.
The national medical examiner
In March 2019, Dr Alan Fletcher was appointed as National Medical Examiner for England and Wales.
The role of the national medical examiner is to provide professional and strategic leadership to regional and trust-based medical examiners. The role supports better safeguards for the public, patient safety monitoring and improvement, and informs the wider learning from deaths agenda.
National medical examiner updates
We will be issuing regular 'National medical examiner updates' providing useful information and news to support providers in the process of establishing medical examiner offices.
This update includes details of recommencing medical examiner scrutiny and implementation, implementation in Wales, medical examiner activity reporting, regional and national teams, lay representation in England, reimbursement in England, and training and events.
This update includes details of good practice guidelines, funding, regional infrastructure in England, implementation in Wales, learning from deaths guidance for ambulance trusts in England, and training.
This update includes details of the national and regional infrastructure, good practice guidelines, funding for the national medical examiner system, and medical examiner and medical examiner officer training.
This update includes details of the national and regional infrastructure, funding the medical examiner system, medical examiners and referrals to coroners, working with registrars and training.
This update includes details of the appointment of regional medical examiners and lead medical examiner for Wales, recruiting regional medical examiner officers and lead medical examiner officer for Wales, Medical examiner training, medical examiner system in Wales, setting up local medical examiner offices, Children’s Funeral Fund for England, and notification of deaths regulations.
This update includes details of the role of medical examiner officers, neonatal and child deaths, alignment with Learning from Deaths and recruitment to local medical examiner posts.
This update includes details of the recruitment to national and regional roles, arrangements for funding and reimbursements for trusts and health boards, the piloting of a digital system to support medical examiner offices, and details on extending the medical examiner service to community deaths.
Events and training
Implementing medical examiner events
The Royal College of Pathologists (RCPath) has been hosting a series of events on implementing medical examiners, the most recent took place on 25 April 2019. A report from the event is available on the RCPath website.
Medical examiner training
Medical examiner training involves the completion of 26 core e-learning modules, followed by attendance at a face-to-face training day. More details can be found on the RCPath medical examiner training web page.
National exemplar forms
Coronavirus Act – excess death provisions: information and guidance for medical practitioners
The Coronavirus Act of Parliament gained Royal Assent on 25 March 2020, and the commencement order for the clauses relating to death certification and cremation forms was signed on 26 March 2020. Guidance and information on these clauses are set out in the document below, along with previous COVID-19 advice issued on 10 March,* included here for completeness.
Appraisal and revalidation of medical examiners
The Royal College of Pathologists has produced the document Supporting information for appraisal and revalidation, including specialty specific information for medical examiners (of the cause of death).