Mortality reviews and the role of the Medical Examiner and medical examiner officers

Medical Examiners (ME) have been introduced to acute trusts in England and Wales to provide greater scrutiny of deaths. The role of the ME is to examine deaths to:

· Agree the proposed cause of death and the overall accuracy of the medical certificate cause of death

· Discuss the cause of death with the next of kin/informant and establish if they have any concerns with care that could have impacted/led to death

· Act as a medical advice resource for the local coroner

· Inform the selection of cases for further review under local mortality arrangements and contributing to other clinical governance procedures.

Case note reviews are routinely carried out in NHS trusts on a proportion of all deaths in their care to learn, develop and improve healthcare, as well as when a problem in care may be suspected.

A clinician (usually a doctor), who was not directly involved in the patient’s care, will look carefully at their case records. They will look at each aspect of care and how well it was provided. When a routing review finds any issues with a patient’s care, we contact their family to discuss this further.

Case record reviews are also carried out when a significant concern is raised about the care provided to a patient. We consider a ‘significant concern’ to mean:

a) Any concerns raised by the family that cannot be answered at the time; or

b) Anything that is not answered to the family’s satisfaction or which does not reassure them.

This may happen when a death is sudden, unexpected, untoward or accidental. When a significant concern has been raised, we will undertake a case record review, and findings may be shared with relatives in these circumstances.

Aside from case note reviews, there are specific processes and procedures that trusts need to follow if the patient had a learning disability, is a child, died in a maternity setting or as a result of a mental health related homicide.