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 personally given evidence for the BMA to the Luce Review as long ago as 2002, I was delighted to read your linked editorial about the benefits of a possible “world leading mortality review system that will better protect patients” being introduced in England and Wales, even at this late date.

Unfortunately, despite alluding to medical examiners being established “in pilot sites across the UK” this article fails to recognise the innovative developments in the nationwide system of proportionate scrutiny we introduced throughout Scotland in 2015, encompassing both general practice and secondary care with the Death Certification Review Service (DCRS) as a part of Healthcare Improvement Scotland (HIS). This was done successfully on time and well within budget albeit involving a brand new IT system connecting DCRS with National Records of Scotland (NRS). It also does not mention the significant changes effected in Northern Ireland, including the appointment of a medical adviser to the Coroner in 2009, and electronically completed Medical Certificates of Cause of Death in secondary care, which followed the Scottish initiative for all GPs that we are now rolling out for hospital doctors.

One critical issue mentioned within your analysis of the subject is that of independence and impartiality. DCRS is part of Healthcare Improvement Scotland (HIS) which is an independent public body. The independence of the function of DCRS is set out in its own statute through the Certification of Death (Scotland) Act 2011 and strengthens the powers possessed by HIS to ensure a robust and consistent review of Medical Certificates of Cause of Death (MCCD). We have effected a sustained improvement of the ‘not in order rate’ yet done so in a supportive and educative manner which has allowed positive engagement with the medical profession. The medical reviewers employed by HIS are all senior members of the profession covering a variety of specialties and based in 4 geographical areas for local accountability.

It was an enlightened decision by Scottish Government on commissioning the service from HIS not to charge a fee from bereaved families at the time of delivery of the review in marked contrast to the proposals in England. Another important Scottish distinction was the conclusion of Sheriff Brodie’s review (preceding the new arrangements) that reviewing around 14% of cases (excluding those which require to be reported to the Procurator Fiscal) would be sufficient to achieve the desired improvement. Data from the first full three years of the service, has confirmed this to be correct.

One further benefit of DCRS has been regular liaison with the Scottish Fatalities Investigation Unit of the Crown Office and Procurator Fiscal Service, although we have been very careful to avoid duplication of review by both services inquiring into the same case. Our Scottish national advice line has become particularly valued with certifying doctors where medical input has been required to discuss possible terminology on a MCCD.

In conclusion, I wish Dr Fletcher and his medical examiners good fortune in introducing an improved system of scrutiny and believe DCRS and Healthcare Improvement Scotland have already demonstrated that we have a world leading mortality review system that better protects patients.

Competing interests: No competing interests

09 January 2019
C George M Fernie
Senior Medical Reviewer for Scotland
Healthcare Improvement Scotland
Gyle Square, 1 South Gyle Crescent, Edinburgh EH12 9EB