The Medical Examiner System (MES)

Implementation

A ministerial announcement on 15 April 2024 stated that the MES will move to a statutory footing on 9 September 2024. The implementation was initially set for the start of April 2023, then delayed to April 2024, before the current intended implementation date was decided on. In very simple terms, the MES introduces medical examiner scrutiny to the Medical Certificate of Cause of Death (MCCD) for non-coronial deaths.

The purpose of this guidance is to explain the role and function of the medical examiners, the associated legislative changes that will come into force and what will be expected of you when the MES moves onto a statutory footing.

Which deaths require notification to the coroner?

The obligation to notify deaths to the coroner can be found at the below link:

Notification of Deaths Regulations (2019) (amended March 2020)

If the death does not fulfil the definitions as outlined in the above link, then it will amount to a non-coronial death and therefore will require medical examiner scrutiny (if you are unsure as to whether a death requires referral to the coroner, then the medical examiner will be able to advise you).

What is a medical examiner?

Medical examiners are senior medical doctors, who are trained in the legal and clinical elements of death certification processes.

The role of the medical examiner includes:

• Reviewing the medical records.
• Liaising with the doctor who treated the patient in their final illness.
• Agreeing the proposed cause of death with the attending doctor and the overall accuracy of the medical certificate cause of death.
• Discussing the proposed cause of death with the next of kin, ensuring they understand any medical terms and providing an opportunity for them to raise any concerns, comments or compliments that they may have.
• Acting as a medical advice resource for the local coroner.
• Ensuring any concerns about the care of the patient are acted on appropriately (and if possible that any compliments are relayed to the relevant person[s]).

Aims of the MES

The stated aims of the MES are summarised below:

• To provide greater safeguards for the public by ensuring proper scrutiny of all non-coronial deaths.
• To ensure the appropriate direction of deaths to the coroner.
• To provide a better service for the bereaved and an opportunity for them to raise any concerns to a doctor not involved in the care of the deceased.
• To improve the quality of death certification.
• To improve the quality of mortality data.

Medical examiner offices

Medical examiner offices in London are hosted by acute trusts – your local medical examiner office(s) should have been in contact with your practice in order to explain how they intend to roll-out the MES between now and April 2023. If you are not in contact with your medical examiner office you should contact them using the details below, this will allow you to familiarise yourself with the local procedures and highlight any issues before the MES moves onto a statutory footing.

The table below sets out how medical examiner offices map onto London boroughs.

Contact details for all the Medical Examiner Offices in England a Wales can be found here.

Referral to the medical examiner

In the case of a non-coronial death, the GP who intends to issue the MCCD will need to notify the relevant medical examiner office (this will usually involve completing a brief standardised form and sending it by email to a prescribed email address). Your local Medical Examiner Office will provide details to you on how they wish cases to be referred but this commonly involves completing a brief standardised form and sending it by email to a prescribed email address.

Access to the medical records

Medical examiners will have a statutory right of access to the records for the purposes of their role. The current position is that whilst the legislation is updated, to ensure information governance and data protection requirements are fulfilled, for the period before the statutory system commences, NHS England submitted an application under Regulation 5 of the Health Service (Control of Patient Information) Regulations 2002 (‘section 251 support’) to process confidential information without consent.

The approved application (which has been extended on 19 March 2024 to run until 30 September 2024) can be found on the Health Research Authority (HRA)’s website (ref: 21/CAG/0032). The HRA’s Confidentiality Approval Group approval covers the sharing of medical records of deceased patients or the equivalent access to view those records with both medical examiners and medical examiner officers. It is expected that medical examiners and medical examiner officers will be added to the list of persons with a right of access to patient records in the Access to Health Records Act (1990) when the Medical Examiner System moves onto a statutory footing.

There is no associated funding to facilitate the provision of the records to the medical examiner. In the fulness of time, this may be resolved by medical examiners having access to the relevant records online, in the interim it is important to work with your local medical examiner office in relation to providing the relevant information that they require.

Issuing the Medical Certificate of Cause of Death (MCCD)

The GP will usually indicate how they intend to complete the MCCD and if (after scrutiny) the medical examiner is in agreement, then they may simply send an email to the GP confirming that it is appropriate to issue the MCCD.

If the medical examiner does not agree an/or has any queries, then there will need to be a dialogue with the GP in order that agreement can be reached in relation to the proposed cause of death (this dialogue may take place by either email and/or a telephone conversation).

The medical examiner or medical examiner officer will speak with the bereaved family to discuss the proposed entries for the MCCD, ensure they understand the medical terminology being used and give them an opportunity to ask any questions they may have about the proposed cause of death. They will also ask the family if they have any comments on the care provided to their relative, either compliments or concerns they wish to raise.

After the medical examiner scrutiny has been satisfactorily completed (review of the records, speaking with the attending doctor and speaking with the bereaved family member) the Medical Examiner Office will facilitate the disclosure of the MCCD to the Registrar, once the statutory system is in place. At present the MCCD is still sent to the Registrar by the GP surgery.

There will be the provision to issue a MCCD (where appropriate) promptly in circumstances when for religious (or other reasons) this is required. However, the same level of scrutiny by the Medical Examiner office is still required to occur for every death.

Legislative changes

The primary legislation that underpins the new statutory medical examiner system is the Coroners and Justice Act 2009 and since its passage, the act has been amended (most recently by the Health and Care Act 2022) to reflect changes to the health system.

The regulations that were published in draft by the Department of Health and Social Care (DHSC) in December 2023 can be found under the heading Other resources, and a summary can be found here, however some of the key changes are as follows:

• A medical practitioner will be eligible to be an Attending Qualified Practitioner (AQP) and complete an MCCD, if they have attended the deceased in their lifetime (this removes the obligation to refer the case to a coroner for review if they had not attended the patient within the 28 days prior to death or had not seen in person the patient after death).
• The term attended has not, as yet, been defined however if a GP has made a meaningful contribution to the clinical care of the patient, this is likely to fulfil the definition. Each case will need to be judged on its merits as there may be cases when a GP’s involvement has been minimal or historic. The GP should only complete the MCCD if they feel able to propose the cause of death to the best of their knowledge and belief.
• From April 2024, new MCCDs (one for the deaths of patients under the age of 28 days and one for patients over the age of 28 days) will replace the existing MCCD. The new MCCDs will be made available in due course but will include the following additional fields:
  • The details of the medical examiner who scrutinised the cause of death.
  • Ethnicity, as self-declared by the patient on the medical record (if the patient medical record does not include this information, then the attending practitioner can complete it as ‘unknown’ on the MCCD and should not in any circumstance ask for this information from the representative of the deceased).
  • Maternal deaths (bringing the MCCD in line with international standards).
  • Medical devices and implants will be recorded on the MCCD by the attending practitioner, and this will be transferred to the certificate for burial or cremation (known as the green form) completed by the registrar in order to inform relevant authorities of the presence of any devices or implants.
• The new MCCDs will be in hard copy format, however it will be possible to scan the completed document and forward it electronically. A digital MCCD is currently in development and is likely to be introduced before the end of 2024.
• Once the statutory Medical Examiner System is implemented, the medical examiner’s scrutiny will make the form Cremation 4 confirmation obsolete and the regulatory requirement for the medical referee to scrutinise it will therefore be removed.

In practical terms, this means that GPs will no longer be required to complete cremation certification.

Other resources

• The national medical examiner system (NHS England)
• NHS England medical examiner updates
• Implementing the medical examiner system – good practice guidance
• Medical examiners and general practice (informative video in which two GP medical examiners discuss their experience of the Medical Examiner System to date).

The draft regulations:

• The Medical Examiners (England) Regulations 2024
• The Medical Certificate of Cause of Death Regulations 2024
• The National Medical Examiner (Additional Functions) Regulations 2024