Patient safety


Medical examiners to be rolled out to investigate unexpected NHS deaths

All non-coronial unexpected deaths within the NHS in England and Wales are to be investigated by medical examiners in order to improve investigations into the cause of death, Jeremy Hunt has announced today.

The announcement coincides with the publication of Professor Sir Norman Williams’s rapid policy review into gross negligence manslaughter in healthcare settings, which was ordered by the health secretary after Dr. Hadiza Bawa-Garba was convicted of gross negligence manslaughter and struck off the medical register following the death of six year old Jack Adcock, sparking outrage amongst the medical community.

Speaking to Parliament today, Hunt explained that the investigation found that prosecutions and convictions of healthcare professionals for gross negligence manslaughter are rare, and that the legal test for the offence is “set at an appropriately high level,” which he said should reassure healthcare professionals.

The report makes recommendations to improve the investigation of gross negligence manslaughter in order to provide greater consistency, which include developing an agreed understanding of the offence, reflecting most recent case law; improving the way in which healthcare professionals provide expert advice and evidence; and improving local investigations.

According to the report, the introduction of medical examiners would deliver “a more comprehensive system of assurance" for all non-coronial deaths, helping to provide a full understanding of the cause of death and ensuring that improvements are made to reduce the likelihood of similar incidents.

Although they will not be specifically concerned with gross negligence manslaughter, it is hoped that their introduction will improve the quality and appropriateness of referrals to coroners, increasing transparency for the bereaved.

Lord O’Shaughnessy, under-secretary for health, explained that medical examiners will form a key element of the death certification reforms.

With regards to the potential for criminal and regulatory investigations to deter medical professionals from reflecting on their practice, the report recommended that regulators that have the power to request reflective material when investigating fitness to practice cases have this power revoked.

Currently, the General Medial Council (GMC) has the right to appeal a High Court decision where it considers the ruling to be insufficient for the protection of the public. It is the only UK health regulator with this power and the report recommends that this right be removed.

Commenting on the recommendations, the health secretary explained: “These recommendations aim to support a just and learning culture in healthcare, where professionals are able to raise concerns and reflect openly on their mistakes but where those who are responsible for providing unacceptable standards of care are held to account.

“This will support improvements in patient safety.”

Dr. Chaand Nagpaul, British Medical Association (BMA) council chair, welcomed the news that regulators would no longer be able to request reflective material from doctors during their investigations, but argued: “We still believe they should be given full legal protection, which would foster an open environment to apply systemic analysis to adverse events to improve patient safety.”

Nagpaul stressed that safe patient care is the number one concern of doctors, but argued that this can only be guaranteed with all parties recognising the need for a learning culture and adequate resources and funding.

He added:  “While we wait to see the impact the roll-out of the medical examiner role, we still believe that the chief coroner should be consulted before any death is referred to the police for a gross negligence manslaughter investigation, and that a more robust, national approach must be adopted to minimise regional variations.”

Top image: Peter Byrne PA Wire PA Images


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