The role of a Medical Examiner Service in an acute NHS hospital: Perspectives from doctors and next of kin

Abstract

A new Medical Examiner system was introduced in England and Wales in 2019 to scrutinise all non-coronial deaths. The three key roles of independent Medical Examiner scrutiny are to establish accurate causes of death, determine whether coronial referral is required and identify any care concerns. This is the first published service evaluation exploring the views of doctors and next of kin with whom Medical Examiner Services interact. The aims were to understand whether the Medical Examiner Service was achieving its three main roles. Surveys were sent electronically to the qualified attending practitioners, and by post to the next of kin, of a consecutive series of deceased patients reviewed by an acute NHS hospital Medical Examiner Service in the East of England. Recruitment took place over a five month period in 2023. Results are based on 100 returned surveys from doctors (response rate 35%) and 179 completed by next of kin (response rate 65%). Findings suggest the Medical Examiner Service was successfully achieving its three key roles and well received by both doctors and next of kin. Service user feedback is clearly important as Medical Examiner Services continue to develop into the statutory phase during 2024, when they are anticipated to review approximately 400,000 deaths per annum in England and Wales. This study demonstrates such feedback is not only useful for service development, but also eminently possible.

Keywords

Patient safety qualified attending practitioner next of kin medical examiner medical examiner officer cause of death medical certificate of cause of death satisfaction surveys bereaved learning from deaths

Introduction

The Medical Examiner system was introduced in England and Wales in May 2019¹ in response to decades of concerns, hospital scandals and inquiries^2–10 relating to the medicolegal investigation of death. Many of these highlighted poor care or deaths that may have been prevented had an effective system of independent scrutiny been in place.¹¹ Subsequently the Health and Care Act 2022¹² laid the foundations for the statutory system to be implemented from September 2024. The system aims to provide greater safeguards through scrutiny of all non-coronial deaths.¹³

The Medical Examiner Service (MES) addresses three key issues:

What did the person die from?

Does the case need to be notified to His Majesty's Coroner (HMC)?

Are there any clinical governance concerns?¹⁴

To arrive at their decision, the MES must complete the following three steps:

Undertake a proportionate scrutiny of the medical records.

Speak with the doctor who treated the patient during their final illness (the qualified attending practitioner – QAP) to discuss the intended formulation of the MCCD, consider the need for HMC notification and enquire about any care concerns.

Engage with the Next of Kin (NoK) by offering condolences, discussing and explaining the MCCD, and asking whether they had any concerns about care.¹¹

It is these mandatory interactions with the QAP^15,16 and NoK¹⁷ that are the focus of this quality improvement project. Satisfaction surveys were used to better understand whether the MES was achieving its key roles, and to aid service development.

Methods

This study was proposed as a quality improvement project, with the aim being to improve the quality of the MES based on the evidence collected. The National Research Ethics Committee had indicated that a similar service evaluation involving the bereaved did not require research ethics committee approval.¹⁸ However the authors applied for research ethics approval as the project involved a potentially vulnerable population (bereaved relatives) and the team planned to publish the study findings. From this application to the Integrated Research Application System it was confirmed that research ethics approval was not required.

This evaluation project used satisfaction surveys and was planned using guidance within the NHS England Evaluation Toolkit.¹⁹ The team ‘walked through’ the pathways for both QAP and NoK to develop the topics and order of questions in the surveys. Formatting of the questions was informed by an NHS England questionnaire guide.²⁰ National good practice guidelines²¹ were used to ensure survey questions focused on national quality measures. The surveys used largely closed questions, with summative questions at the end. Free-text comment sections were included to optimise the opportunity for team learning, but are not reported here as they have not been subject to formal qualitative analysis.

A consecutive series of MES cases were studied from 1^st June 2023 onwards. The QAP and NoK identified for each case were asked to complete satisfaction surveys on their experiences of the MES. The study was divided into two parts. Part 1 related to MES contact with the QAP, and Part 2 related to contact with NoK. The study finished once the team had received 100 responses from both QAP and NoK.

Part 1 - qualified attending practitioners (QAP)

QAPs were identified from the MES electronic database and were each sent a short email with a link to a structured 11 question online survey (Figure 1). Internet Protocol (IP) tracking was disabled on the surveys so anonymity was assured. Names of doctors to whom surveys had been sent were documented to avoid duplication. This list was stored in a restricted access folder, with access provided to only members of the project team. Only one survey was sent to each QAP, even if they were involved in more than one of the cases in the study. All QAPs were sent one reminder around two weeks after the initial email.

Figure 1.

Qualified Attending Practitioner Medical Examiner Service email and satisfaction survey.

Part 2 – next of kin (NoK)

Whenever possible, the MES team discussed the survey at the end of their telephone call with the NoK of all patients who had died during the study period. Whilst consent was not required (this was a quality improvement project, not research), the team discussed the project with NoK so they could confirm the address to send the survey to for all those agreeing to take part. Addresses were transcribed straight onto an envelope (and not retained).

A short, paper-based 11 question structured survey (Figure 2) was sent on a single occasion to all NoK agreeing to receive one. It was posted around four weeks after the patient's death, and sent with a generic covering letter (Figure 3) including a General Data Protection Regulation Privacy Notice. The survey was sent with a free-post return envelope addressed to the MES Study coordinator. The covering letter emphasised that completion of the survey was voluntary, and that feedback was anonymised. It also gave the contact details of the hospital bereavement support line. The documents were sent independently from other hospital correspondence. If team members did not mention the study as part of the NoK phone call, then the reason for this was also documented (e.g. pressure of work, or NoK unavailable).

Figure 2.

Medical Examiner Service Next of Kin satisfaction survey.

Figure 3.

Generic covering letter sent with Next of Kin satisfaction survey.

Results

The consecutive case series included patients dying from 1^st June 2023 onwards. Recruitment of QAPs continued for 22 weeks until 3^rd November 2023 (at which point the MES had scrutinised a total of 1093 cases). NoK recruitment ceased four weeks earlier on 6^th October 2023 (after the team had scrutinised 847 cases), as it was clear at this point the target of 100 completed surveys from each group would be achieved without the need to send out any further. In total, 100 completed QAP responses and 179 NoK responses were received.

Qualified attending practitioners

During the study period, 295 QAPs liaised with the MES. Seven of these left the Trust shortly after and were uncontactable. The remaining 288 doctors were emailed the anonymised online survey - 100 responded, giving a response rate of 35%. Study respondents were a mix of doctors at different stages in their career: 25% were FY1/FY2 doctors, 42% specialty trainee or registrars, 7% SAS doctors and 26% consultants. Of the doctors who completed the survey, 21% had written 1–5 MCCDs, 21% 6–20 and 58% > 20.

Not all 100 QAPs answered every question, so the percentages of the number who responded to each question are given. Firstly, 93% of respondents (n = 100) considered that conversations with the MES helped them formulate their MCCDs. 3% responded ‘No’ and 4% were ‘unsure’. 76% QAPs (n = 99) responded that the MES had sometimes suggested modifications to the MCCD they were completing. 19% of respondents had not been in this situation, and 5% answered ‘can’t remember’.

The study found that 79% (n = 100) considered that discussions with the MES helped them determine whether cases needed referral to HMC. 16% responded ‘No’ and 5% were ‘unsure’. Furthermore, 91% (n = 99) felt confident about raising concerns about patient care with the MES, 0% replied ‘No’ and 9% were ‘unsure’. When asked whether they felt confident that if they raised concerns about care with the MES these would be acted upon without prejudicing themselves, 76% (n = 100) replied ‘Yes’, 0% replied ‘No’, and 24% were ‘unsure’.

QAPs were asked whether extending the MES office hours beyond 0830–1630 Monday to Friday would be helpful. 33% (n = 97) responded ‘Yes’, 35% responded ‘No’, and 32% were ‘unsure’. In response to the question ‘Do the MES functions significantly impact on your workload?’ 72% (n = 97) replied ‘No’, 12% replied ‘Yes’ and 16% were ‘unsure’. It was clear from the additional comments that the impact on workload was sometimes positive and sometimes negative.

The study found that 70% (n = 100) QAPs felt the MES had assisted them in understanding the processes and procedures required when a patient dies. 23% replied ‘No’, and 7% were ‘unsure’.

When asked ‘Overall, how likely is it that you would recommend a colleague to access advice and support from the MES on a scale of 1 (not at all likely) to 10 (very likely)’, 90% (n = 100) QAPs scored 8–10, with 65% scoring 10 ‘very likely’. A further 10% scored 5–7. None scored lower than this.

Next of kin

Of the 279 postal surveys sent to NoK, 179 were returned - a response rate of 65%. Table 1 shows the responses to the first six questions of the postal NoK survey. Not all NoK answered each question - the total number of responses are given and the percentages have been calculated based on the responses for each question.

Table 1.

Responses by Next of Kin to Questions 1–6 of the postal survey.

Question	Yes (%)	No (%)	Can’t recall (%)
When you first had contact with the Norfolk and Norwich Bereavement service after the death of your loved one, were you advised to expect a phone call from the Medical Examiner Service?	155 (88)	9 (5)	12 (7)
When the Medical Examiner or Medical Examiner Officer phoned you, did they clearly explain their role to you and the reason for the phone call?	164 (93)	2 (1)	10 (6)
Were they compassionate and polite at this difficult time?	171 (97)	0	5 (3)
Did they offer condolences for the loss of your loved one?	167 (95)	1 (1)	8 (4)
Did they discuss what would be recorded as the cause of death of your loved one?	166 (95)	4 (2)	5 (3)
Did your conversation help you better understand the cause of their death?	155 (89)	11 (6)	9 (5)

Questions 7 and 8 related to any concerns the NoK may have had in regard to the care their loved one had received in hospital. First, they were asked had they been given the opportunity to raise any such concerns. Of the 177 NoK who answered this question, 159 (90%) said ‘Yes’, 4 (2%) answered ‘No’ and 14 (8%) could not recall. Next, the NoK were asked if they had raised concerns, had they felt listened to and was a plan for addressing these discussed. 172 NoK answered this question – 95 (55%) of these responses suggested they had no care concerns and 77 (45%) reported care concerns. Of those NoK with care concerns, 71 (92%) of these felt listened to whilst 6 (8%) did not.

Question 9 related to deaths that had been referred to HMC. This was answered by 169 NoK. Of the 23 cases where the NoK responded that the case had been notified to HMC, 19 (82.6%) considered the reason for this was explained clearly during the phone-call. Two (8.7%) responded ‘No’ and 2 (8.7%) could not recall.

The results from Question ten (176 replies) suggest that overall, 156 (88.6%) felt they were given the opportunity to ask questions and voice any outstanding concerns, whilst only 3 (1.7%) responded ‘No’ and 17 (9.7%) could not recall or answered ‘not applicable’.

Finally, 177 NoK answered the question ‘overall how would you rate the telephone call from the MES’. 85.3% of these NoK (151) rated the service ‘Outstanding’ or ‘Excellent’. A further 11.3% (20) rated the MES ‘Good’ or ‘Fair’ and none rated it as ‘Poor’. A further 3.4% (6) were ‘Unsure’.

Discussion

Conversations with QAP and NoK are key to the efficacy of the MES role, hence feedback from both stakeholder groups is vital.²² Service user feedback is widely used throughout the NHS and the team were keen to undertake this quality improvement project with the aim of gaining a better perspective from both doctors and the bereaved with whom we engage. This in turn allowed us to assess whether the MES was achieving its three key roles.

Part 1 of the study focused on the QAP perspective. Doctors are working under unprecedented pressures in the NHS, and there were a number of strikes during the data collection period.²³ Considering these factors, a response rate of 35% feels very respectable. It is not far short of the 44.1% reported in a recent meta-analysis of response rates of online surveys within education-related research.²⁴ Looking at equivalents within healthcare, the 2022 NHS Staff Survey had an overall response rate of 46% (and response numbers from medical and dental staff were much less than other occupational groups).²⁵ Nonetheless, it took us longer than we had hoped to achieve our sample size of 100. Doctors working in specialty areas with higher numbers of deaths are often certifying a number of cases each week. As we only sent the survey once to each doctor, this meant that as the study went on there were fewer new doctors each week eligible to be sent surveys. As a rough guide for other teams considering such a survey, our MES had to scrutinize 1093 cases to get 100 returned QAP surveys.

The NoK perspective was considered in Part 2 of the study. A response rate of 65% is outstanding and confirms teams should not be anxious asking for their feedback. We had not expected such a high response rate, as the MES only has one phone contact with NoK at a difficult time in their lives when they are likely receiving many other calls. The 2023 GP Patient Survey had a response rate overall of only 28.6%.²⁶ Our response rate was also higher than that from an annual survey of bereaved carers of patients dying under the care of a specialist palliative care team (response rate of 22.6–44.7% dependent upon where the patient died).²⁷ It might be that talking to all NoK about the survey helped increase our response rate – this isn’t routinely done with these other surveys.

Whilst the MES aimed to talk to the NoK about the survey in a series of consecutive cases, this was not always possible. If the team felt that discussing the study with the NoK might cause distress, then they did not proceed. Other reasons for not recruiting included there being no documented NoK or the MES being unable to contact them. Staff shortages and high workload during some periods of the study also meant the MES did not always have time to recruit NoK. It is estimated that study recruitment added less than five minutes to each scrutiny. As a guide for teams planning similar surveys, we only sent surveys to NoK in around a third of the cases we scrutinized (279 surveys sent after 847 cases reviewed). Of note, of the 286 NoK we discussed the survey with only seven declined to participate. This suggests NoK are keen to be involved and give feedback.

It is important to acknowledge potential responder bias in regards to both parts of the study. Considering QAP, we were reassured by the range of medical grades and experience completing MCCDs suggesting respondents might be representative of the wider cohort. Some have suggested doctors experiencing very low morale might feel particularly disempowered and less likely to respond to survey requests.²⁸ Studies have suggested that satisfied patients^29,30 and certain patient groups³¹ are more likely to respond to surveys than others.

Several limitations to the final questionnaires are acknowledged, with some survey questions needing amendment. For example, the question to QAP about whether the MES impacted on their workload did not allow us to determine whether the impact was positive or negative. Another limitation was that the electronic survey set-up allowed QAP to both skip and submit more than one response to some questions, which happened on a few occasions. The surveys are being revised taking these factors into account.

This evaluation suggests the MES is successfully meeting its three main purposes. Firstly, in regards to improving accuracy of MCCD completion: 93% QAPs felt conversations with the MES helped with this; 89% NoK felt talking to the MES had helped them better understand the cause of their loved one's death. The second main role is ensuring appropriate and timely referral to HMC. Again, results suggest the MES are successfully fulfilling this role, with 79% QAPs reporting the team had helped them determine this. When cases were referred to HMC, 82.6% NoK felt the MES had helped them understand the reason for this.

The third key role of a MES is to identify care concerns. 91% QAPs felt comfortable to raise patient care concerns and 76% were confident that if they did raise concerns with the MES these would be acted on without prejudicing them. 90% NoK reported they were given the opportunity to raise any such concerns. Of the 172 NoK who answered the question about care concerns, 77 (45%) appeared to have raised some. 92% of these felt listened to and that a plan for addressing these had been discussed. It would therefore seem from this study that the MES is successfully meeting this third key role.

The study finding that around 45% NoK shared some care concerns was more than we had expected. Concerns raised to a MES during the NoK call are wide ranging, from frustrations at delays in ward phones being answered to significant patient safety concerns. There is widespread variation between MES offices in respect to the threshold for escalating concerns to clinical governance, and the mechanisms for doing this. This is inevitable as it is impossible to specify a threshold nationally as concerns will be diverse in nature.³² The 2022 National Medical Examiner annual report noted 10% cases reviewed in England were referred for case record or other clinical governance review.³³ It will be important over time to see nationally whether MES input reduces the numbers of complaints – other proxy data might be useful for this, such as Patient Advice and Liaison Service (PALS) referrals. Ultimately, a key question will be how many concerns would not have been identified but for the MES.

Conclusions

This is the first published service evaluation exploring the perspective of doctors and NoK who have engaged with an acute hospital NHS MES. The work aligns with guidance from the National Medical Examiner that teams should be implementing measures to evaluate their impact.³⁴ The study has provided much useful feedback about the service and given reassurance that it is successfully fulfilling its three key roles.

Service user feedback is clearly important as Medical Examiner services continue to develop into the statutory phase from 9^th September 2024³⁵ when it is anticipated they will review approaching 400,000 deaths per annum in England and Wales based on current figures.³⁶ This study shows such feedback is not only useful for service development, but also eminently possible.

Footnotes

Acknowledgements

The authors would like to thank Medical Examiners Tim Bosworth, Pauline Bryant, Danelia Carlile, Mike Delbridge, Elisabeth Hopman, Shona Lidgey, Nicky Morris, Samita Mukhopadhyay and David Plume, and Medical Examiner Officers Georgia Bishop, Victoria Ducker, Hester Fox and Emily Jennings who were all involved in the study data collection. We would also like to thank our colleagues in the NNUH Bereavement Service.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Katie Carpenter

Jason Payne-James

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