Shaping the medical examiner role in the learning from deaths process

The workshop brought together a mix of 32 clinicians and patient safety leads from NHS organisations. The delegates discussed the pace at which the medical examiner role is being implemented and how the role varies across the country. Some have been involved in pilot schemes, some have been early adopters while others see it taking around two years to fully embed the new role.

The aim of the medical examiner is 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

During the workshop it became clear that NHS organisations are experiencing similar challenges. There have been faltering starts to implementation and there was a realisation that for some it will not be a quick process. There is no universal one-size-fits-all deployment of the new service and, as a result, differing structures are being developed with different levels of capacity according to the relative size of a trust.

However, attendees at the workshop said the purpose of the medical examiner role was very clear and there were common threads in how the responsibilities of the new system should be aligned with national guidance, the expectations and desired outcomes.

Another emerging theme from the workshop was that all too often there is an assumption that learning only comes from mistakes. However, sharing positive stories when things go well can be equally beneficial for learning. Delegates heard that within trusts celebrating success and best practice is routinely disseminated via electronic internal reporting and newsletters. There is also a real commitment to continue this learning and development.

A significant part of the learning process has evolved from the involvement with families. Part of the medical examiner role is to talk to the family to discuss the cause of death and give bereaved relatives a chance to express any concerns.

There was initially some uncertainty about how this partnership working would evolve. However, delegates were very positive about their experiences to date and, without exception, it was felt that families are appreciative when contacted by a medical examiner and involved in the process.

At Dr Foster, we see ourselves as a partner in the learning from deaths process not just through the analysis of mortality rates. We can share real-world context and experience at events like our workshop, provide a springboard to facilitate discussion and a forum to share experiences and best practice.

The use of the hospital standardised mortality ratio (HSMR) and summary hospital-level mortality indicator (SHMI) with learning from deaths national guidance was mentioned and discussed by all the trusts represented at the workshop. Learning from deaths is seen as an initiative that complements mortality data supporting trusts to understand where to focus improvement work. By working together, we can increase the quality and accuracy of death certification and, as a result, mortality data. This information allows trusts to identify areas in need of change and inform improvement which, in the long term, can be expected to raise the overall standard of care for all patients.

Matthew Parry is a senior consultant at Dr Foster.