Intended for healthcare professionals


Impact of the new medical examiner role on patient safety

BMJ 2018; 363 doi: (Published 14 December 2018) Cite this as: BMJ 2018;363:k5166

Linked editorial

Death certification reform in England

Re: Impact of the new medical examiner role on patient safety

Having been a participant in the seminars of the Shipman Inquiry that reviewed death certification processes and supported the notion of medical examiners, it's good to hear that examiners are being introduced, but depressing that it has taken 16 years to reach this point and exasperating that the legislation is not yet enacted. Satisfactory death certification and registration procedures should be basic features of well managed nations and it is alarming that Whitehall has been incapable of dealing with this issue. In addition, to someone who has audited the deaths of Shipman's patients and those in a community hospital, it's dispiriting that these sectors are not routinely included in the fledgling medical examiner systems. Delay and refusal of funding among the various government departments is no longer acceptable.

It seems to me that adequate levels of patient safety require services or teams that understand their outcomes and have leadership that enables the achievement of the desired outcomes. The developing clinical judgement review systems have real potential to help trusts and teams understand their outcomes. The doctors and NHS organisations leading this approach or piloting medical examiners deserve both congratulations and the genuine support of government departments in building a better, safer health system.

Competing interests: No competing interests

06 January 2019
Baker Richard
professor emeritus
University of Leicester
Department of Health Sciences, College of Medicine, Biological Sciences and Psychology University of Leicester, Centre for Medicine, University Road LE1 7RH, UK