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Professor Peter Furness
The National Medical Examiner
We’ve been here before...
Select Committee report 1893
The Wright Report 1936
The Brodrick Report 1971
The Luce Report 2003
Harold Shipman... Killed patients (morphine injection)
In their home or in his GP surgery
Wrote ‘natural cause’ death certificates
Wrote cremation forms
Never referred cases to the coroner 2 were autopsied, but pathologists
did not identify malfeasance
Was intelligent, up-to-date and generally liked by his patients
i.e. Medical Revalidation won’t catch the next Harold Shipman
The result:
Passed with support from all political parties
Section 19:
The initial plan:
Proposed cause of death for all non-coronial deaths to be scrutinised by an independent and trained Medical Examiner
Include proportionate review of medical records
Include interview with next of kin (the ‘Shipman Question’)
Include external examination of body
Coroners may refer natural deaths to ME for certification if no ‘attending doctor’ is available
Cremation forms (and fees) to be abolished
Service to be funded by a (reduced) certification fee for all deaths
The other problems…
The other problems…
Swift B, West K. J Clin Pathol 2002; 55:275-9. Death certification: an audit of practice entering the 21st century. 1000 ‘natural’ deaths. “Only 55% of certificates were completed to a minimally acceptable standard”
Fernando D, Oxley JD & Nottingham J. J Clin Pathol 2012; 65:949-51. Death certification: do consultant pathologists do it better? “Using the Office for National Statistics guidelines, the authors found that only 56% of the certificates were appropriately completed.”
A more recently recognised problem:
Medical Examiners and clinical governance?
It’s not just secondary care…
The process:
Duty on doctors to refer directly to coroner
Advice available from Medical Examiner (ME)
Certifying doctor proposes cause of death to ME
ME scrutinises records, may examine the body, speaks to staff and speaks to next of kin
ME may refer to coroner or require amended cause of death
ME provides formal confirmation of cause of death, to be delivered to Registrar by the family
Coroners can refer cases to ME for a ‘Medical Examiner’s Certificate’
Training medical examiners…
http://www.e-lfh.org.uk/projects/medical-examiner/
Embryonic implementation guidance:
www.pathology.plus.com/NME/MEimplementationtoolkit
Pilot sites:
Sheffield
Gloucester
Powys
Mid-Essex
Leicester
N. London
Pilot sites:
Reduction in referrals to the coroner
Increase in inquests
Elimination of certificates rejected by Registrar
Access to medical records can be achieved
Process takes a few hours longer on average
Requests for rapid process can be accommodated
External examination of body problematic
Relatives are pleased to be contacted
Medical staff and bereavement office staff value support
Valuable information to clinical governance systems
How have different groups reacted to the pilots?
Impact on mortality statistics:
Impact on mortality statistics:
Broad cause of death (ICD10 chapter) changed in 12%
Cause of death changed without altering ICD10 chapter in another 10%
Death due to:
Neoplasm up 1%
Cardiovascular disease up 5%
Respiratory disease down 7%
Diseases of the nervous system up 14%
Genitourinary disease down 16%
4% alteration in the sequence of causes
Information can be collected centrally… Did info. from the next of kin alter the cause of death?
Did the next of kin offer compliments about the care provided?
Did the next of kin make any complaints about nursing?
Did the next of kin make any complaints about doctors?
Did the next of kin make any complaints about cleaning?
Did the next of kin make any complaints about delays?
Did the next of kin make any complaints about any error in care?
Did the next of kin make any other complaints?
Nature of concerns expressed by the next of kin
Were clinical governance issues identified during scrutiny?
Action taken to correct clinical governance issues
Code number of healthcare institution responsible for care in the final illness
But then…
A senior politician commented:
“So this is a reform which everyone agrees is a good thing. But there are short-term political risks in its implementation that are not matched by short-term political gains.”
“There’s a General Election coming.”
“Hmmmm.”
Could we get smoking on to death certificates?
Agree what to do
Should it be in the WHO format or as a separate item?
What are the criteria?
Then:
Amend Medical Examiner training programme
Include in Medical Examiner CPD
Use regular returns to NME to monitor compliance in different ME offices
Is it a good idea to get smoking on to death certificates?
Can it be done consistently?
What does “a significant contributory factor ” mean?
Does it improve on other methods of collecting the same information?
Is it cost-effective?
Who pays?
Are there other potential benefits?
Why is smoking a special case?
Psychiatric illness?
Alcohol-related deaths?
Obesity-related deaths?
Record the BMI of the deceased?
HIV-related deaths?
Questions?