The Medical Examiner s Process

The Medical Examiner s Process A generic description, for local adaptation. It is anticipated that local groups of medical examiners, coordinated by a lead medical examiner, will develop local processes for optimal working. Local variation is to be expected, but must comply with national standards. This document is intended to assist medical examiners and others to plan and to establish locally appropriate processes. Points where it is expected that the text will be edited to reflect local circumstances are identified in italic font. An overall flowchart of the new process of death certification is provided below. Confirmation of the fact of death Confirmation of the fact of death is not altered by death certification reform and is not expected to be part of the medical examiner s role. The following description of process relates to the majority of cases of death due to natural causes, where a medical certificate of the cause of death (MCCD) is completed by an attending medical practitioner (the Attending Practitioner s Certificate, APC). Note that a different certificate is used in respect of deaths of children aged 28 days or less. The

following description does not cover cases referred from the coroner to the medical examiner with a request for the medical examiner to complete a Medical Examiner s Certificate of the cause of death, because there is no available Attending Practitioner. Notifying the medical examiner s office and/or referring to a senior coroner Referring to a senior coroner If it is clear that a death must be referred to a coroner (hyperlink to guidance on referring deaths to the coroner), the attending doctor has a statutory duty to do so directly. It is not necessary to contact the medical examiner s office (although local protocols may indicate that the medical examiner s office should be informed of such deaths, especially if they occur in hospital, to facilitate analysis for clinical governance purposes). If an attending doctor is uncertain whether a death should be referred to a coroner or not, advice should preferably be sought from a medical examiner (rather than from a coroner s officer, as has been the case in the past). The procedure for referral to a coroner is fundamentally the same as before the reforms, although there is more detail specified in relation to the information that must be provided. Note that deaths that are reported to a coroner but not investigated by him/her must still be notified to the medical examiner s office, because proportionate scrutiny will still be required to enable registration of the death after an Attending Practitioner s Certificate has been completed. Notifying the medical examiner s office Insert details of how to contact a medical examiner here, including office hours and arrangements for outside office hours, if any). The medical examiner s office must be notified of all deaths in the area that are not investigated by a coroner. It is the duty of the doctor who completes the certification of the cause of death to do this; this is a new requirement so there is a need for publicity, national and local, to inform doctors of this change. To facilitate this, a list of contact details of all medical examiners offices will be made available on the National Medical Examiner s website before the reforms go live. Plans for local publicity may be inserted here. Local medical examiners offices may however have additional processes to ensure that they are made promptly aware of relevant deaths, especially in secondary care; for example, by an early morning phone call to the hospital mortuary or by regular contact with the bereavement office. Describe such local protocols here. The MEO will establish a new record in the office database for each death and will record, as far as is practicable, identification information and other relevant details such as the medical team responsible for the care of the deceased, the named nurse, if any persons were present at the time of death, details of family members/next of kin and so on.

The MEO will arrange for relevant medical records to be made available to the medical examiner, whether by electronic means of by transfer of paper casenotes. It is usually not necessary, at least in initial scrutiny, to make available more than a summary of the record (in primary care) or the record of final admission (in secondary care). (Local arrangements for this transfer of information may be described in more detail here). A doctor must be identified who has completed or will be expected to complete the Attending Practitioner s Certificate (APC) of the cause of death (one of several forms of the Medical Certificate of Cause of Death or MCCD). This may be done by bereavement services in secondary care, the GP or practice staff in primary care, or by the Medical Examiner s Officer. Insert any local guidance here on who should undertake this task in specific circumstances. If reasonable attempts to identify and contact such a doctor are unsuccessful, it will be necessary to discuss the case with the coroner. Informing the next of kin of the death certification process The next of kin must be informed of the process to be followed leading to collection of the APC and registration of the death, including the timescale. This must include an explanation of the purpose of the medical examiner s scrutiny and an explanation that someone from the medical examiner s office will call to discuss the cause of death. How this will be achieved will depend heavily on the location and the circumstances of the death; it might be the responsibility of the general practice, a bereavement officer or the medical examiner s officer. An explanatory leaflet is available which can be amended to suit local arrangements. But it is important that, by some mechanism, this preliminary explanation is provided in all cases. Local mechanisms should be described here. The Attending Practitioner and the certified cause of death There is no absolute requirement for an attending practitioner to consult the medical examiner before completing a certificate of the cause of death (the APC), but experience indicates that it is often helpful to do so. Experience from the pilots indicates that the medical examiner is often better placed to advise the certifying doctor if he/she has already had an opportunity to examine the medical record of the patient. However, this is not always practicable so firm rules are not appropriate. Before discussing the cause of death, the attending practitioner should be asked to suggest a cause of death, and that cause should be recorded verbatim in the medical examiner s office database, even if it is: 1a Cause of death unknown. That is necessary if we are to be able to audit how the intervention of the medical examiner modifies the proposed cause of death.

If at any point during the process the medical examiner forms the opinion that the death should be investigated by a coroner, then the appropriate coroner should be informed immediately and the medical examiner should cease work on the case (other than recording the referral to the coroner in the database), unless and until the coroner communicates a decision not to investigate. In every case, the attending practitioner MUST provide information, preferably on a form rather than by telephone, about any implants (physical or radioactive) and any potential infective risks including a positive affirmation of the absence of implants or infective risks. That information must be recorded. The medical examiner s office must have a reliable mechanism to pass that information (including circumstances where such information was not available) to those who must subsequently take responsibility for the body, especially crematoria, because some implants can be extremely hazardous if cremated. (Insert details of local process here). Providing the Attending Practitioner s Certificate The attending practitioner must complete and sign the Attending Practitioner s Certificate of the cause of death (APC), whether before or after discussing the case with the medical examiner. The content of the APC must be made known to the medical examiner, either by the provision of a copy to the medical examiner s office or by secure storage of the original in that office. Local arrangements should be specified here. Where a copy is to be transmitted to the medical examiner s office the process must be carefully documented and sufficiently secure. Proportionate scrutiny The requirements of proportionate scrutiny are discussed in detail in the online training package for medical examiners (http://www.e-lfh.org.uk/programmes/medicalexaminer/scrutiny/ ) so that material will not be repeated here. The conversation with the next of kin The ME or MEO must in every case discuss the proposed cause of death with a representative of the family unless all reasonable attempts to contact the next of kin have failed, in which case that failure must be recorded. Conversation will in most cases be by telephone. As explained above, the family should already be expecting this call. There are two central functions to this conversation: 1. To ask whether the proposed cause of death makes sense to the family, and if not, to offer an explanation 2. To ask the family whether they have any concerns about the circumstances around the death, such as circumstances that might justify investigation by the coroner. It is obvious that this conversation requires knowledge of the case so it must occur towards the end of the process of scrutiny.

If the conversation is conducted by the MEO, the expression of any significant concerns or any questions that the MEO feels unable to answer must result in the MEO referring the matter to a medical examiner, who can then decide what further action is necessary. This may necessitate a second telephone call at a later time, or even a meeting at the medical examiner s office; in which case, arrangements should be made with the family to identify a convenient time. Coroner s officers will contact the next of kin where a case has been referred to a senior coroner. Such cases will sometimes be referred back for certification as natural causes. In these cases only, the medical examiner may decide that it is not necessary to have a further telephone discussion. Completing the documentation If scrutiny indicates that the cause of death proposed on the APC is incorrect, the doctor who completed the APC must be contacted and asked to prepare a new one, which must be provided or copied to the medical examiner. The word Cancelled must be written across the incorrect APC and its counterfoil. If all is well, the medical examiner s confirmatory certificate (ME-2) is prepared and signed. The attending practitioner is informed that this has been done and the date of confirmation by the medical examiner is entered on the APC. This is a requirement before the APC can be accepted by the Registrar. The MEO will send the ME-2 to the registrar s office to confirm the ME s scrutiny, and for it to be signed by the representative of the family when the death is registered, to confirm that a discussion with the medical examiner has taken place. A mechanism is needed to advise the family when and where the APC can be collected, and to advise the family of the next steps (how to register the death and where). Local agreement on how this will be achieved is needed and an explanation should be inserted here. The MEO will ensure that the documentation of the case in the office database is appropriately completed. After the death is registered, the Registrar will return the signed paper copy of the ME-2 to the medical examiner s office for filing. The medical examiner s office must have a mechanism to check, at least at weekly intervals, that the process is being completed in a timely manner for all deaths. This should include a check that each death has actually been registered after an ME-2 has been issued. There is a specific risk where cases are transferred to or from the coroner that cases may be lost, with both parties assuming that the other is dealing with it. Describe the local mechanisms here. There may also be local processes to deliver information regularly to the clinical governance processes of local healthcare providers. In Wales, this will include the Wales Mortality Review. Include details of local agreements here.

Handling causes for concern (or compliments!) As noted above, any information that justifies referral to a coroner must be acted upon immediately. If the ME uncovers any cause for concern which does not require escalation to a coroner, or where the coroner has decided not to investigate further (i.e. part A ), the ME will report these to the appropriate authority, as proportionate to the details of the case, including but not limited to the following: Insert a list of appropriate actions here of relevance to the local area Be aware that your information might be inaccurate or incomplete. Such concerns will often best be handled by asking an appropriate authority to investigate whether or not a concern is justified or not, rather than stating confidently that there is a problem. In most cases, the medical examiner should explain to the recipient of such a message that a response is expected even if the response is only to state that the matter has been investigated and no further action is justified. If the medical examiner is not satisfied by the response, or if repeated complaints indicate that a significant problem has not been resolved, then the matter should be escalated in writing to the relevant person in authority in the local area. It is one of the coroner s duties to consider unusual patterns of deaths within his/her jurisdiction. The medical examiner should consider whether it is appropriate to discuss a group of deaths with the coroner on that basis, even if the individual deaths, studied in isolation, did not justify coronial investigation. If the medical examiner feels that all local processes have been exhausted, and a serious problem remains unresolved, escalation at a national level should be considered (for example to the GMC or Care Quality Commission). Such cases should be rare. It is strongly recommended that the circumstances be discussed first, in confidence, with the National Medical Examiner. Compliments should also be passed on appropriately! Deaths with no Attending Practitioner If a coroner decides that there is no reason to investigate a death, but there is no doctor able to provide an APC, then the coroner may ask a medical examiner to complete a Medical Examiner s certificate of the cause of death. This process has not been tested in the pilots because it requires implementation of the primary legislation. The process should follow essentially the same sequence of events as confirmation of the APC, as above. There will be no conversation with an Attending Practitioner, but the possibility of speaking to a healthcare professional who knew the deceased should be considered.

If, after scrutiny, the medical examiner feels unable to identify a cause of death to the best of his/her knowledge and belief, the case must be referred back to the coroner. If all else fails, coroners are able to certify deaths as being of unascertained cause. Medical Examiners are not.