The Legislation came out of the Shipman Inquiry in 2000 and other subsequent inquiries which identified the need for independent scrutiny of deaths into which the Coroner does not need to become involved.

The examination of all deaths by Medical Examiners becomes mandatory on 9 September 2024.

Medical Examiners are senior clinicians, from all specialties including GPs.  They are independent practitioners to all the cases.  They look at the clinical notes, pathology and radiology and agree or suggest a proposed cause of death.

They act in a supportive role to:

• agree the proposed cause of death with the doctor completing death certificate;
• discuss the cause of death with the next of kin / informant and establish if they have questions or any concerns with care before death;
• identify potential learning and compliments to contribute to clinical governance procedures.

The 28-day time limit has been removed – An attending practitioner can now have attended at any time to complete cause of death form; ie. not just within the past 28 days of life.

Several fields have been populated within the Medical Certificate of Cause of Death (MCCD) form including the addition of 1D, ethnicity, maternal death, medical devices.

All deaths need to be confirmed to have had scrutiny from the ME confirmation is now included in the MCCD.

ME declaration confirming that (a) death has been scrutinised (b) the bereaved have been spoken to and (c) no cause for concern noted.  Exact wording is yet to be decided.

The timeframe for registration which currently stands at 5 days from the date of death will be changed to five days from date of notification of the MCCD to the registration services.

GSTT – Lambeth and Southwark (95 GP practices, Lambeth Hospital, Maudsley Hospital, Trinity Hospice and HCA London Bridge)

KCH – Bexley and Bromley, Royal Bethlem Hospital, St Christopher’s hospice

LGT – Lewisham and Greenwich (83 practices), Demelza Children’s hospice, Greenwich and Bexley Community Hospice

There are additional steps in the process but they should not cause undue delays for the bereaved. Medical examiner review should happen within 24 hours. The GP will need to respond to the medical examiner review and together agree a cause of death. The final certificates will continue to be sent electronically to the registrar by the Medical Examiner.

The practice will need to inform bereaved relatives that they will receive a call from the Medical Examiner’s office. Other than this call bereaved relatives/next of kin should not notice a difference in process.

• Medical Examiners will need to have access to practice records to be able to independently scrutinize; this is enshrined in law and means ME’s can access patient records.
• IG data sharing agreements have been produced nationally and agreed at ICB level
• Next of kin details also need to be provided.

There is no change to the way that the practice will hear about a death in the community. Most are communicated from the relatives or friends of the bereaved, others from the out of hours GP service or community nurses, or the practice may receive a notification of deduction.

• All Medical Examiners will need to be told a community patient has died – in south east London that is the Medical Examiners office for the borough the patient lived in.
• Some Medical Examiners offices have used email with a referral form
• Consultant Connect is being used in most of SEL
• The Medical Examiners will scrutinise the notes and talk to the next of kin
• Ideally there will be a discussion with the GP who will write the MCCD but this may instead just be in the form of a GP note in EMIS suggesting a COD and outlining circumstances briefly
• The ME will send back their opinion:
  • Agree with GP proposed COD – GP then writes the MCCD exactly as agreed
  • Modifies the proposed COD – GP then writes the MCCD exactly as agreed
  • Referral to Coroner required – decisions to be made about who performs this
• It is the GP’s legal duty to complete the MCCD (and cremation paperwork) – this will not change.

• Inner South London His Majesty Coroner (HMC) is happy to receive Medical Examiner referrals on behalf of clinicians
• Referral can be made by Medical team, Medical Examiners, registrar, family, police
• Police involvement / unnatural deaths will be referred to HMC by the police as before
• Main referral to coroner from the community is the Police (sudden unexpected death)
• Coroner duty is to establish circumstances around death but does not seek to apportion blame
• Coroner referral does not mean automatic Post Mortem – if there is a known cause of death, and family accept this, the MCCD will be acceptable and coroner can still investigate
• Legal duty to refer if element of death is unnatural.

Common issues are:

• Full printed name & GMC number missing
• Parts 1-4 or A-C not circled
• “All deaths involving any form of injury or poisoning must be referred to the coroner.”

If in doubt, discuss with the Medical Examiner.

• Causality – 1 c causes 1b causes 1a
  • 1a Renal failure
  • 1b Diabetic nephropathy
  • 1c Type 2 diabetes mellitus
• Conditions in 2 must have “more than minimally contributed to death”
• Pressure sores must go to coroner (possible neglect)
• Fill in to “best of knowledge and belief” do not use terms “likely or probably”
• Do not be afraid to use “Dementia” family often expect.
• Dementia does not cause Frailty OF OLD AGE (it can cause frailty)
• Mode of dying (organ failure, cardiac arrest) must be supported by cause of death
• USE RCPath Cause of death list
• Q: Was the death unnatural?
  • A fall causing injury, leading to death, would be considered unnatural (e.g., NOF, TBI, SDH, polytrauma)
• Q: Was the fall caused by underlying illness, e.g. infection?
  • If a patient fell as they were sick, with no apparent injury, coroner referral might not be necessary – cause of death would be the infection
• Q: Frail patients fall – do I refer?
  • Did they injure themselves?
  • Was there a long lie causing tissue damage or pneumonia?

The Medical Examiner or Medical Examiner officer has the responsibility to ask the family if they had any concerns about the care of the deceased. This is the case even if the regular GP has been present in the home or visited afterwards as the medical examiner service is independent.

It also provides an opportunity for the bereaved to speak to someone independent of the deceased’s care about their treatment.

This process is only for use in the cases of faith deaths requiring urgent burial within daylight hours, or in child cases where there is expected to be immediate repatriation out of the country.

• The death must be wholly natural, non-suspicious, the family and attending clinician should have no concerns about the death and the cause of death must be expected, apparent and known to the attending clinician. If this condition is not met, an expedited MCCD cannot be issued and the next of kin must be informed of this.
• If the attending clinician has ever treated the deceased at any point in their lives, to their knowledge, they can complete the MCCD and should do so to the best of their knowledge and belief.
• If the attending clinician has never treated the deceased at any point in their lives and the MCCD is required urgently for faith reasons, this should be flagged to the Medical Examiner in the referral as, in exceptional circumstance, the Medical Examiner may complete the MCCD with the agreement of the Coroner.