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Showing results for tags 'Medical examiner'.
Found 24 results
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News Article
‘We took too long’: Jeremy Hunt offers apology to families of Letby’s victims
Mark Hughes posted a news article in News
Former health minister says medical examiners, who spot cases of intentional harm, could have been in place earlier. Jeremy Hunt has said ministers took “too long” to introduce medical examiners to investigate deaths in the NHS, as he apologised to the families of Lucy Letby's victims. Giving evidence at the Thirlwall inquiry on Thursday, the former health secretary said he had “ultimate responsibility” for the NHS at the time Letby committed her “appalling crime” of murdering babies at the Countess of Chester hospital in 2015 and 2016. Hunt, who was health secretary from 2012 to 2018, said his government took “too long” to introduce independent medical examiners to the NHS after they were first proposed in 2004, six years before the Conservatives came to power. Medical examiners are senior doctors who carry out independent scrutiny of deaths that are not investigated by coroners. They were introduced widely last September, 20 years after they were first proposed as a result of the Harold Shipman inquiry in 2004, then again by the Francis inquiry into the Mid-Staffordshire scandal in 2013. Read the full story. Source: Guardian, 9 January 2025 -
Event
Investigation and Learning From Deaths
Patient Safety Learning posted an event in Community Calendar
This National Conference focuses on improving the investigation and learning from deaths in NHS Trusts. By collecting the data and taking action in response to failings in care, trusts will be able to give an open and honest account of the circumstances leading to a death. There will be an extended focus on engaging and involving patients, families and staff following a death, and on learning from deaths including an update from a coroner. By 2024, all deaths in the community or acute settings that do not required to be referred to the coroner (non-coronial deaths) will need to be scrutinised by a medical examiner. The conference will discuss the role of Medical Examiners in learning from deaths which is now being extended to all non-coronial deaths wherever they occur. The conference will also include a split stream where delegates can chose to focus on investigating and learning from either deaths in acute care, or deaths in primary and community care. For further information and to book your place visit: https://www.healthcareconferencesuk.co.uk/virtual-online-courses/investigation-learning-deaths-hospital-mortality or email [email protected] hub members receive a 20% discount. Email [email protected] for discount code. Follow on Twitter @HCUK_Clare #LearningFromDeaths -
Content ArticleHospital leaders need to embed a safety culture across their organisations - read the latest guest blog on the Patient Safety Commissioner website from Maria Caulfield, the minister for mental health and women's health strategy. Maria gives three examples of how we are advancing patient safety across our NHS.
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Content ArticleAs this year’s World Patient Safety Day celebrates the theme ‘Engaging patients for patient safety’, Dr Alan Fletcher, the National Medical Examiner for England and Wales, explains the connection between medical examiners and patient safety, and particularly the support they provide for bereaved people, whose insights and experiences can be crucial in supporting the NHS to learn and improve.
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Content ArticleThis is the first in a series of podcasts NHS England has produced to mark World Patient Safety Day 2023, and celebrate its theme of ‘engaging patients for patient safety’. The series features some of the Patient Safety Partners that work with the National Patient Safety Team, who play a vital role in providing a patient’s perspective to support our work to improve patient safety. In this podcast, Graham, who became a patient safety partner in 2020, shares his insights on the benefits of involving patients and why he feels it is so important in supporting the NHS to improve patient safety, and talks about his experience as a patient safety partner, particularly working to co-design elements of the medical examiner and medicines safety improvement programmes.
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News Article
Causes of death to be scrutinised in revamp of death certificates
Patient Safety Learning posted a news article in News
Public protection and support for bereaved families are at the heart of a government overhaul of how deaths are certified. From September, medical examiners will look at the cause of death in all cases that haven’t been referred to the coroner in a move designed to help strengthen safeguards and prevent criminal activity. They will also consult with families or representatives of the deceased, providing an opportunity for them to raise questions or concerns with a senior doctor not involved in the care of the person who died. The changes demonstrate the government’s commitment to providing greater transparency after a death and will ensure the right deaths are referred to coroners for further investigation. Health Minister, Maria Caulfield said: Reforming death certification is a highly complex and sensitive process, so it was important for us to make sure we got these changes right. At such a difficult time, it’s vital that bereaved families have full faith in how the death of their loved one is certified and have their voices heard if they are concerned in any way. The measures I’m introducing today will ensure all deaths are reviewed and the bereaved are fully informed, making the system safer by improving protections against rare abuses. From 9 September 2024 it will become a requirement that all deaths in any health setting that are not referred to the coroner in the first instance are subject to medical examiner scrutiny. Welcoming the announcement today, Dr Suzy Lishman CBE, Senior Advisor on Medical Examiners for Royal College of Pathologists, said: “As the lead college for medical examiners, the Royal College of Pathologists welcomes the announcement of the statutory implementation date for these important death certification reforms. “Medical examiners are already scrutinising the majority of deaths in England and Wales, identifying concerns, improving care for patients and supporting bereaved people. The move to a statutory system in September will further strengthen those safeguards, ensuring that all deaths are reviewed and that the voices of all bereaved people are heard.” Read full story Source: Gov.UK, 15 April 2024 -
News Article
Rollout of new death certification system could be delayed again
Patient Safety Learning posted a news article in News
A new system requiring GPs to agree death certificates with a medical examiner is unlikely to launch at the beginning of April, it has emerged. The system, which will see medical examiners (MEs) providing independent scrutiny of all deaths in the community which are not taken to the coroner, had previously been due to come in from April last year. However, it was delayed by one year to allow time for Parliament to introduce the necessary supporting legislation and, according to the Department of Health and Social Care (DHSC), this has yet to happen. A spokesperson told Pulse that the Government’s intention is to still introduce secondary legislation ‘from April’ to implement death certification reform. However, it could not confirm the exact date the system will launch and said it would provide an update before the end of March. Nottingham GP Dr Irfan Malik told Pulse that local GPs and practice staff ‘seem to be aware there is a delay’ but have had ‘no official emails’ or communication confirming the delays. Read full story Source: Pulse, 20 March 2024 -
Event
Investigation and learning from deaths
Patient Safety Learning posted an event in Community Calendar
This National Conference focuses on improving the investigation and learning from deaths in NHS Trusts. By collecting the data and taking action in response to failings in care, trusts will be able to give an open and honest account of the circumstances leading to a death. There will be an extended focus on engaging and involving patients, families and staff following a death, and on learning from deaths including an update from a coroner. From April 2023, all deaths in the community or acute settings that do not require to be referred to the coroner (non-coronial deaths) will be scrutinised by a medical examiner. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/investigation-learning-deaths-hospital-mortality or email [email protected]. hub members receive a 20% discount code. Email [email protected] for discount code. Follow on Twitter @HCUK_Clare #LFDNHS -
Event
Investigation and learning from deaths
Patient Safety Learning posted an event in Community Calendar
This National Conference focuses on improving the investigation and learning from deaths in NHS Trusts. By collecting the data and taking action in response to failings in care, trusts will be able to give an open and honest account of the circumstances leading to a death. There will be an extended focus on engaging and involving patients, families and staff following a death, and on learning from deaths including an update from a coroner. The conference will discuss the role of Medical Examiners in learning from deaths which is now being extended to all non-coronial deaths wherever they occur. The conference will also include a split stream where delegates can chose to focus on investigating and learning from either deaths in acute care, or deaths in primary and community care. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/virtual-online-courses/investigation-learning-deaths-hospital-mortality or email [email protected]. With only a few places left, HCUK are offering hub members five discounted places at only £195+VAT with discount code HCUK195PSL. Follow the conference on Twitter @HCUK_Clare #LFDNHS -
Event
Investigation and learning from deaths in NHS Trusts
Sam posted an event in Community Calendar
The National Guidance on Learning from Deaths has driven a strengthening of systems of mortality case review with emphasis on learning. By collecting the data and taking action in response to failings in care, trusts will be able to give an open and honest account of the circumstances leading to a death. This National Conference focuses on improving the investigation and learning from deaths in NHS Trusts and will reflect on learning from deaths during the Covid pandemic and how mortality investigation should be managed in these cases. The conference will discuss the role of Medical Examiners in learning from deaths which is now being extended to all non-coronial deaths wherever they occur. This conference will also update delegates on the New National Patient Safety Incident Response Framework including sharing experience from an early adopter site. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/investigation-and-learning-from-deaths-in-nhs-trusts or email [email protected] Follow the conference on Twitter @HCUK_Clare #CQCDeathsreview hub members receive a 20% discount. Email [email protected] for discount code. -
EventThe NHS is the world’s first health organisation to publish data on avoidable deaths. The National Guidance on Learning from Deaths has driven a strengthening of systems of mortality case review with emphasis on learning. By collecting the data and taking action in response to failings in care, trusts will be able to give an open and honest account of the circumstances leading to a death. This National Conference focuses on improving the investigation and learning from deaths in NHS Trusts and will reflect on learning from deaths involving COVID-19 and how mortality investigation should be managed in these cases. The conference, chaired by Dr Martin Farrier Clinical Director for Quality & Consultant Paediatrician Wrightington, Wigan and Leigh NHS Foundation Trust, will discuss the role of Medical Examiners in learning from deaths. Download brochure Register
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EventThe NHS is the world’s first health organisation to publish data on avoidable deaths. The National Guidance on Learning from Deaths has driven a strengthening of systems of mortality case review with emphasis on learning. By collecting the data and taking action in response to failings in care, trusts will be able to give an open and honest account of the circumstances leading to a death. This National Conference focuses on improving the investigation and learning from deaths in NHS Trusts following the National CQC and NQB guidance, and Department of Health reporting requirements. The conference will also discuss the role of Medical Examiners providing a national system of medical examiners will be introduced to provide much-needed support for bereaved families and patient safety. Further information and to book your place or email [email protected] Follow the conversation on Twitter #CQCDeathsreview We are pleased to offer hub members a 10% discount. Email: [email protected] for the code.
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Content Article
National Medical Examiner’s report 2020
PatientSafetyLearning Team posted an article in Other reports and inquiries
The national medical examiner system is being rolled out across England and Wales, initially on a non-statutory basis, and is part of the Death Certification Reform Programme for England and Wales. It also forms part of the NHS Patient Safety Strategy and the NHS Long Term Plan in England. The all-Wales Medical Examiner Service is a critical part of the long-established mortality review programme. Throughout 2020, medical examiner offices have been established at acute trusts in England and at regional hubs in Wales, initially providing scrutiny of non-coronial deaths in acute care. This remit is being expanded in 2021 and 2022 to cover non-coronial deaths that occur in other settings such as the community. A core part of the medical examiner role is to provide bereaved people with clear information about the cause of death, and an opportunity to raise any concerns they may have about the care and treatment provided to the deceased person. Medical examiners also carry out a proportionate review of patient records and discuss causes of death with the doctor completing the Medical Certificate of Cause of 5 | National Medical Examiner’s report 2020 Death (MCCD). They ensure concerns about patient care are identified promptly and referred for further investigation, to improve services and care for all patients. This report describes progress and next steps, building the foundations of a medical examiner system that will facilitate reflection, learning and improvement across the entire health system. -
News ArticleMedical examiners are doctors who look at every hospital death with a fresh pair of eyes to make an independent judgement about what took place. It is impossible to overestimate the importance of their role, and it is vital that NHS hospitals now get on with appointing them as a matter of urgency, says Jeremy Hunt, former Foreign Secretary, in an article in the Independent newspaper. The big issue is not that bad things happen (sadly in an organisation of 1.4 million people there will inevitably be things that go wrong) but that they take so long to identify and put right. Mid Staffs took four years, Morecambe Bay took nine years and it now looks like the problems at Shrewsbury and Telford could have taken place over 40 years. Anyone who has spoken to brave patient-safety campaigners who lost loved ones because of poor care will know that their motivation is never money, simply the desire to stop other families having to go through what they have suffered. That is why they and other patient groups all campaign for medical examiners – a process through which every death is examined by a second, independent doctor. It was first recommended following the Shipman inquiry but has taken a long time to implement – inevitably for cost reasons. Where they have been introduced, medical examiners have been transformational. The main pilot sites in Sheffield and Gloucester, which scrutinised over 23,000 deaths, found that “medical examiners have triggered investigations that identified problems with post-operative infections faster than other audit procedures, based on surprisingly few cases”. Doctors also felt confident in raising concerns, as they were protected and supported by the independent medical examiner. Remarkably, pilot studies found that 25% of hospital death certificates were inaccurate and 20% of causes of death were wrong. Read full story Source: The Independent, 16 January 2020
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Content ArticleReport summarising the progress of the implementation of medical examiners during 2023. The Death Certification Reforms come into force on 9 September 2024 and from this date independent scrutiny by a medical examiner becomes a statutory requirement for registration of all deaths in England and Wales not investigated by a coroner. Medical examiners are senior doctors employed by NHS bodies in England and Wales. In England, they are supported by medical examiner officers and are based in 126 medical examiner offices in NHS trusts. In Wales, the service is being provided by NHS Wales Shared Services Partnership (NWSSP), an independent mutual organisation, owned and directed by NHS Wales. The four hub sites cover all health board areas with substantial growth throughout 2023 in scrutinising deaths in non-acute healthcare settings. The purpose of the medical examiner system is to: provide greater safeguards for the public by ensuring independent scrutiny of all non-coronial deaths ensure the appropriate direction of deaths to the coroner provide a better service for bereaved people 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. "This statutory footing is extremely good news for the medical examiner system I am grateful for the hard work of all medical examiners and officers leading up to this important milestone. Medical examiners are already supporting patient safety, learning and improvement, along with more consistent and appropriate coroner referrals. The weeks before the Death Certification Reforms come into force will allow time to cement excellent working processes and to ensure we make the most of the insights medical examiners can bring. I am sure, like me, they are delighted to now be planning with certainty. Listening to our podcasts, GPs and medical examiners working together and changes to the death certification process and introduction of the statutory medical examiner system can answer questions about some of the changes from 9 September 2024, as can listening to the recordings of two timely information events The Royal College of Pathologists hosted about the statutory system on 17 January 2024 and 11 June 2024." Dr Alan Fletcher, National Medical Examiner
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Content ArticleMedical examiners are senior doctors who provide independent scrutiny of the causes of death and are supported by medical examiner officers. They provide that independent scrutiny in three ways. They carry out a proportionate review of the medical records They offer bereaved people an opportunity to ask questions and raise concerns. They also talk to the doctor who is completing the medical certificate of cause of death. If medical examiners detect a concern, they pass it on to established clinical governance processes that are in place at the relevant provider to be looked at in more detail. Two patient safety partners (PSPs) were a key part of NHS England's implementation group. As lay representatives, patient safety partners bring a different perspective in terms of patient safety that's been very valuable and ensures that bereaved people are central to the work. They also shared close family experiences with the group and championed an approach that ensured that the key material is available in 12 languages. In this podcast, one of the PSPs describe their experience of working with NHS England and what they would recommend to others to enable real partnership in co-designing healthcare.
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Content ArticleThis podcast features Dr Alan Fletcher National Medical Examiner and Suzy Lishman, Senior Advisor on Medical Examiners at the Royal College of Pathologists discussing what the changes to death certification processes and new requirements to be introduced with the statutory medical examiner system will mean for medical examiners, medical examiner officers and others involved in death certification.
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Content ArticleThese draft regulations from the Department of Health and Social Care set out how the statutory medical examiner system will operate in the NHS in England from April 2024. Medical examiners will be appointed by NHS bodies to provide independent scrutiny of causes of death and will be a contact for bereaved people who want to ask questions or raise concerns. The draft regulations set out: medical examiners’ terms of appointment, training and payment the procedure for independence additional functions
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News ArticleThe death certification system in England and Wales will get its biggest overhaul in decades next month, with a change designed to improve public protection. Every death that has not been referred to a coroner will have to be referred to a medical examiner from 9 September, under regulations laid before parliament in April. The new system will provide independent scrutiny and an opportunity for the bereaved to speak about care and treatment in the lead-up to a death. It is intended that the overhaul will give assurance to relatives and reduce the risk of NHS scandals or malicious action by medical practitioners. Dr Alan Fletcher, the national medical examiner for England and Wales, said: “I am delighted that medical examiners will soon review every death in England and Wales not investigated by a coroner. The death certification reforms are a significant step towards ensuring serious issues are identified quickly and passed on for action.” Medical examiners will be part of a national network of trained independent senior doctors, scrutinising all deaths that do not fall under a coroner’s jurisdiction. They will ensure the accuracy of the death certificate, establish whether the death should be referred to a coroner and whether there are any clinical governance concerns. Read full story Source: The Guardian, 24 August 2024
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Event
Inquests, indemnity and incidents in primary care
Clive Flashman posted an event in Community Calendar
untilThis Royal Society of Medicine meeting will focus on some of the key medico-legal issues that impact GPs, primary care and patient safety, with a specific emphasis on inquests, clinical negligence and incidents. This comprehensive programme will review and explore the latest legal and regulatory developments from national leaders in each of these fields. Delegates will gain an understanding of: The role of coroners and inquests, what to expect and what GPs and those working in primary care need to do to prepare and actively learn from deaths. The role of Medical Examiners and how they will impact on primary care. The support, including education and training, available to GPs in dealing with medico-legal issues and how to access practical support (e.g. via the Medical Defence Organisations) when necessary. The role of NHS Resolution and the Clinical Negligence Scheme for GPs (CNSGP) and their impact upon GPs and patient safety. Developments in learning from incidents in primary care, including feedback from the CQC regarding best practice and areas for improvement. Book here -
Content ArticleThis report by the National Medical Examiner, Dr Alan Fletcher, summarises the progress made by medical examiner offices in 2021 and outlines areas of focus going forward. It highlights that medical examiners continued to receive positive feedback from bereaved people—many said they appreciated being given the opportunity to have a voice in the processes after a death and knowing any concerns were listened to. It includes information on: The national medical examiner system Implementation Guidance and publications Training Stakeholders Increasing the number of non-coronial deaths scrutinised Feedback received by medical examiners in England and Wales
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Content ArticleThis webpage outlines the role of Medical Examiner Officers (MEOs), who provide the continuity and oversight that the medical examiner service requires to have the maximum benefit. It includes information on training, induction and recruitment, as well as a model job description for an MEO.
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Content Article
RCPath - Medical examiners good practice series
Patient-Safety-Learning posted an article in Processes
This Good Practice Series published by The Royal College of Pathologists is a topical collection of focused summary documents, designed to be easily read and digested by busy front-line staff. The documents contain links to further reading, guidance and support, and cover the following topics: Supporting people of Black, Asian and minority ethnic heritage Urgent release of a body Learning disability and autism Organ and tissue donation Post-mortem examinations Child deaths Mental health and eating disorders Out-of-hours arrangements -
Content ArticleWhen a loved one dies, any delay in the registration or release of a deceased patient’s body can be distressing for the bereaved. The medical examiner system is being introduced in England and Wales to provide bereaved families with greater transparency and opportunities to raise concerns, improve the quality and accuracy of medical certification of cause of death, and ensure referrals to coroners are appropriate. These good practice guidelines set out how the National Medical Examiner expects medical examiner offices to operate during the non-statutory phase of the programme. The guideline cover the following topics: Setting up medical examiner offices What do medical examiner and medical examiner officers do? Who can be a medical examiner/medical examiner officer? What requirements should be in job descriptions? What training will medical examiners and medical examiner officers require? How should medical examiners escalate concerns? Principles for medical examiners Operational requirments and ways of working Working with coroners and registration services Process
