Professor Peter FurnessLead Medical Examiner,

University Hospitals of Leicester

National Medical Examiner 2013-15

The drivers in Leicester:

Pressure from NHS England to review all deaths in secondary care

Impossibility of doing that in some specialties, using available methods – takes too long

Knowledge of the planned national reforms

My experience of the national reform programme, including 2 years as interim National Medical Examiner

Initial plan:

Recruit and train consultants to act as medical examiners.

After completion of MCCD, medical examiner to speak to certifying doctor, examine casenotes and speak to relatives.

ME to correct glaring errors in MCCD / coronial referral and decide whether detailed case records review was justified.

MEs to complete Part 2 of cremation forms; fees to fund the system.

Didn’t work. MEs now speak to certifying doctor BEFORE completing MCCD or referring to coroner.

Recruitment: Job description and person specification devised.

Work to be done as part of existing employment (i.e. same rate of pay).

One email advertisement; large response.

Training defined (online and 1 day face to face)

Only half of those interested completed training.

About half of those completing training could adjust their work to make time.

10 medical examiners available. Just enough for 1 PA each.

Battle for facilities: An office.

Administrative support.

IT support.

Process: ‘Glaring errors’ very frequent; switch to ‘talk to the ME

first’

Discussion with certifying doctor one day, rest of the process next day – different ME?

Time spent contacting relatives and doctors; having a ‘clinical’ MEO would save a lot of ME time

Looking for problems with care quality can take as long as you want…

Funding from cremation form fees pays for ME time only

Referrals to coroner: Senior Coroner very keen to reduce (eliminate?) referrals

she doesn’t need to investigate.

Senior Coroner personally provided ME training.

Local coroner’s referral rules all rescinded.

Medical examiners got a bit over-enthusiastic…

Causes of death cause concern for Registrar…

Some problems caused by old legislation:

Registrar’s duty to refer to coroner not rescinded. Some of the rules seem odd to doctors:

Ulcer, Perforation, Rupture, Haemorrhage may be unacceptable if not explained.

‘Uncertain’ unacceptable, ‘Unknown’ is OK.

‘Cardiac failure’ unacceptable, ‘Congestive cardiac failure’ not.

Workaround with local Registrar – didn’t satisfy Crematorium Referees

Completing a cremation form must be done by one person. Makes the ME approach very inefficient.

‘You can take a doc to training, but you can’t make him think’

Illogical sequences on MCCD, related conditions in part 1 and Part 2 - despite training

‘Fracture of femur’ last item in part 1, not referred

Failure to notice Adult Safeguarding order

Mesothelioma signed off as natural causes

Four-fold variation in ME workrate. Slowest MEs were causing most problems.

Conclusion: Take care with the recruitment process.

But despite the problems: It’s working

Everyone involved thinks it’s an improvement

Big reduction in 100A referrals to the Coroner(effect on inquests not yet known, but not large)

No delay for relatives(cremation forms probably being done faster than before)

Relatives usually very pleased to be contacted

Fascinating insights into healthcare quality…

Lessons? Recruit carefully. Don’t try to get doctors on the cheap.

You will be far better with a smaller number of good MEs.

Having a ‘clinical’ MEO (Sheffield model) saves a great deal of ME time, even though they cost more.

Crem. form Part 2 fees pay for ME time. So £100 per case ‘feels’ about OK IF:

workload and workforce are matched;

overheads are not exorbitant;

you have a clinical MEO.

But £100 will be tight. Small offices won’t work.Demands for MEs to do other useful work MUST be funded.