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 Then: Should it be in the WHO format or as a separate item? What are the criteria? 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?