MEDICAL EXAMINER SYSTEM - IMPLEMENTING THE - National ...
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IMPLEMENTING THE
MEDICAL EXAMINER
SYSTEM
Transition period or non-statutory backstop?
By Morgan Harris, NAFD Policy & Legislation Manager
As members will be all too aware, the death certification
system in England and Wales has remained largely
unchanged for over fifty years and is no longer fit for
purpose. Since The Shipman Inquiry, there has been
much discussion about how the systems for certifying/
scrutinising deaths can be improved. However, little has
happened in practice.
On 1 April 2019, almost a decade since the Coroners and Justice
Act 2009 first made provision for their introduction, it finally
seems that a system of medical examiners will be rolled out
across England and Wales.
Whilst any progress will be welcomed by the profession,
celebration at this stage would be premature. The initial roll-
out of Medical Examiner services will not be underpinned by
legislation and is, therefore, unlikely to deliver the certainty and
simplicity that many have been hoping for. Many questions about
the practical delivery of a uniform national system also remain
unanswered, but it now seems we can add a further question to
the list: how long will the Medical Examiner system in England
and Wales remain in a non-statutory transitional phase?
The NAFD recently attended a special event, hosted by the
Royal College of Pathologists, to learn more about what the
non-statutory implementation of a Medical Examiner system
will look like and how it might affect funeral directors.
20 | FUNERAL DIRECTOR MONTHLY
What is wrong with
the current system?
Cremation
Before a cremation can legally take
place, the relevant paperwork must
be signed by two separate medical
professionals, one of whom must
be of at least 5 years’ standing. This
means that the cause of death is, in
theory, scrutinised twice. However,
the inadequacies of this safeguard
were exposed by the investigation
into the crimes of serial killer Dr
Harold Shipman.
Overstretched medical professionals
are under no legal duty to complete
cremation paperwork, which can lead
to delays in obtaining paperwork and
consequent disputes between doctors
and funeral directors. In addition to
this, families are required to pay a
significant charge for this service
and can often be charged for mileage
and other expenses of medical
practitioners as the paperwork is
often completed at the funeral home,
“
outside of business hours.
Burial introduction of Medical Examiners will Will the new system be
In the case of a burial, the process make it less likely that unnatural causes of mandatory for families?
is relatively straightforward but death will go unnoticed and that national
data about causes of death will be captured WHILE NHS During the non-statutory phase,
only one medical professional is TRUSTS families will not be technically
required to complete the paperwork. more accurately.
WILL NOT BE required to engage with the new
This means that the cause of death While the hope is that all NHS REQUIRED system. For example, if a family is
receives worryingly little scrutiny. TO SET UP
trusts will set up Medical Examiner concerned about the potential for
There is currently no charge to the MEDICAL
services, they will not actually be EXAMINER delay to a burial they could, in theory,
family for the completion of burial required to do so during this non- SERVICES, decide to have the form completed
paperwork. statutory phase. It is, therefore, THEY WILL BE by a willing medical practitioner in
ENCOURAGED the normal way or, in the case of
possible that many will choose not to
The initial roll out of a TO DO SO
do so, leading to inconsistency across AND WILL BE
a burial, avoid Medical Examiner
non-statutory system the country. scrutiny altogether. An example of
F I N A N C I A L LY
Jeremy Mean, Deputy Director for SUPPORTED when a family may want to do this is
When challenged about this, Jeremy BY CENTRAL to avoid a delay in burial, for religious
Health Ethics at the Department of
Mean explained that, while NHS GOVERNMENT or cultural reasons.
”
Health and Social Care, told delegates
Trusts will not be required to set
that the intention remains to work The NAFD has been informed
up Medical Examiner services, they
towards a statutory system of Medical that Medical Examiners will first
will be encouraged to do so and will
Examiners but that the initial roll out be introduced in a secondary care
be financially supported by central
will be conducted on a “non-statutory (hospital) setting. Once the system
basis”. This means that there will government so that the service is
has been established in a secondary
be no initial change to the law but, completely cost neutral to them. The
care setting, the intention is for it to
from 1 April 2019, NHS trusts will Royal College of Pathologists will
be rolled out for deaths that occur in
be encouraged to set up new Medical play an important role in promoting
a primary care (GPs, community care,
Examiner services to replace existing the availability of this funding to etc) setting. It is not yet clear what
death certification processes. NHS trusts. will trigger this expansion to primary
The fact that NHS trusts will be care, or when this will happen.
What is a medical examiner?
able to decide when they wish to Nevertheless, the Government
A Medical Examiner is a specifically make any changes to their existing predicts that, by early 2021, all deaths
trained independent senior doctor (from any death certification processes means in England and Wales will be subject
speciality). The intention is that they will that there is unlikely to be a mass- to Medical Examiner scrutiny.
scrutinise all deaths across a local area that nationwide change on 1 April 2019. It The cost of a Medical Examiner
do not fall under the Coroner’s jurisdiction.
is far more likely that individual trusts system for England and Wales
By providing a greater level of scrutiny over will start to set up Medical Examiner It is not yet clear what the non-
the cause of deaths, it is hoped that the services gradually and sporadically. statutory roll out of the national
FUNERAL DIRECTOR MONTHLY | 21
system will cost or exactly how it the system cost neutral for both NHS important strategic role, overseeing
will be delivered. We were told that trusts and bereaved families. This and supporting the roll-out of
it is broadly estimated that there will means that families seeking to have Medical Examiner services across
need to be one Medical Examiner per a loved one buried will not have to the country, with a view to designing
3,000 annual deaths, but that this will pay anything and families seeking to a national statutory scheme. Once
vary depending on local community have a loved one cremated will not be the name of the appointee has been
and geographical factors. required to pay anything in addition made public, the NAFD will seek
to the existing cremation form fees. to maintain good communication
During the non-statutory phase, each
NHS trust will have a significant How will Medical Examiners with them so that the views of our
degree of freedom to implement the be funded? members are kept in mind when
service in a way that works well for developing a statutory system.
During the non-statutory phase,
the community it serves. The precise The NHS in England is being
families who choose for their loved
number of Medical Examiners one to be cremated will be required split into seven regions, with a
employed, their hours of operation to pay the usual fee when submitting Regional Medical Examiner Lead
and the delegation of responsibility the relevant cremation forms. Once being recruited for each. An eighth
to other parties (such as Medical a trust has set up a Medical Examiner Regional Medical Examiner Lead
Examiner Officers) will all be decided service, this fee will be paid directly will be recruited for Wales. Medical
by individual trusts. to the trust rather than to a doctor. Examiners will report to their
At the event, NAFD Past President This money will then be used to Regional Lead.
Nigel Lymn Rose raised concerns fund the wider service. There will
“
Each Medical Examiner will be
that, unless trusts were given guidance continue to be no charge in respect
supported by a team of approximately
on the amount of money they of burials. The Government has
three Medical Examiner Officers.
should spend on service provision, committed to reimbursing the trust
this could lead to inconsistencies, for any shortfall. What is a Medical Examiner
EACH NHS
both in the cost of the Medical TRUST WILL It is not yet clear how Medical Officer?
Examiner services and the way they H AV E A Examiners will be funded under
SIGNIFICANT Medical Examiner Officers, who
are provided across the country. a future statutory system, but the may have a nursing or other clinical
DEGREE OF
Jeremy Mean conceded that this is, FREEDOM TO Government intention is to abandon background, will provide support to
indeed, a risk but explained that the IMPLEMENT the current system of cremation form Medical Examiners, including being a
rationale for approaching the roll- THE SERVICE fees. The NAFD believes it would be point of contact and source of advice
out in this way is to learn from each I N A WAY wrong to require bereaved families to
T H AT W O R K S for relatives of deceased patients,
trust’s individual experience in order pay and will continue to campaign for
WELL healthcare professionals and Coroner
to inform the design of a universal FOR THE a centrally-funded system. services. It is hoped that the use of
statutory model. COMMUNITY
Structure of a national Medical Medical Examiner Officers, rather
”
IT SERVES.
Jeremy Mean emphasised that, Examiner system than Medical Examiners, to carry out
during the non-statutory stage, the A National Medical Examiner has certain tasks will help keep the cost
Government is committed to keeping now been appointed and will have an of a national system manageable.
22 | FUNERAL DIRECTOR MONTHLY ARTICLE CONTINUES ON PAGE 25 u
Statutory roll-out
The end goal remains the
implementation of a uniform
statutory system for England and
Wales. Disappointingly, there is no
date set for a statutory roll-out. The
NAFD does not expect to see the
roll-out of a statutory system until
late 2021 at the earliest.
However, the Government has
stressed its commitment to
developing a single, aligned statutory
system for England and Wales. Jeremy
Mean said: “The Government’s
commitment to reimbursing NHS
trusts for all costs associated with
the (non-statutory) implementation
of Medical Examiner services
demonstrates its commitment to the
completion of this important work.”
The funding structure for the
statutory system has yet to be decided.
“
It is not yet clear whether bereaved
families will be required to pay a fee as a whole. All other NHS services
NAFD analysis
under the statutory system. Jeremy are free at the point of delivery, and
Mean explained that the funding The Government is certainly keen to we see no reason why this should be
structure will be informed by learning THE NAFD underline its continued commitment any different. For the time being,
CONTINUES to the implementation of a national
and the experiences of stakeholders TO WELCOME however, it seems clear that bereaved
during the non-statutory phase. CHANGE TO
system. Minister of State for Care, families will continue to pay a fee in
THE CURRENT Caroline Dinenage said: respect of cremations, whereas those
What do funeral directors SYSTEM
“I know from the events in my own who choose burial will not. This
need to know before 1 April O F D E AT H
constituency of Gosport that the arbitrary distinction and tax on certain
2019? C E R T I F I C AT I O N
bereaved families is unfair and should
AND IS, ON drivers for the introduction of Medical
Funeral directors should speak to THE WHOLE, Examiners have never been greater. be ended as soon as possible.
their local NHS trusts to establish P L E A S E D T H AT We must now seize this moment to
SOME ACTION
Having already run several successful
what local changes are being introduce a Medical Examiner system pilot schemes across the country, we
I S F I N A L LY
planned. Unless, upon enquiring, you
”
B E I N G TA K E N . that will deliver the benefits identified do not understand the Government’s
are informed of a change, funeral by too many reports into patient decision to roll out a national system
directors should assume that the old safety. The Government remains on a local basis. If local trusts are
death certification procedures are still committed to the introduction of a left to implement new services in
in place. Medical Examiner system which puts completely different ways, this is likely
If an NHS trust notifies you that it the bereaved at its centre, provides to cause difficulties when later trying
is launching an Medical Examiner proportionate scrutiny for all deaths to bring these systems into line. These
service:- that are not investigated by a coroner difficulties will only become more
and enables lessons to be learned.” challenging over time as local ways of
- you should ensure you and your working become more ingrained.
staff are able to explain this service However, with so much of
to the family; Government time being devoted to It is the lack of a concrete timescale
other pressing matters at present, it for implementation of a statutory
- in the case of a cremation, you is perhaps unsurprising that many system that is most concerning. With
should collect the Cremation important questions about the no definite timescales or clear plan of
Form 5 fee in the same way as implementation of a statutory Medical action for the future, a lot rests on the
you do now. However, you may be Examiner system remain unanswered. appointment of a suitable individual
required pay the fee directly to the The NAFD continues to welcome to lead the way as National Medical
NHS trust (in the case of a burial, change to the current system of death Examiner. The NAFD will seek to
there will continue to be no charge certification and is, on the whole, work closely with the new appointee to
to the family); pleased that some action is finally ensure that the statutory system they
being taken. develop is fit for purpose and that,
- in the case that a family expresses
above all, we do not find ourselves
a wish to opt out of Medical We continue to hold the view that
stuck in a non-statutory backstop for
Examiner scrutiny, you should bereaved families should not be
yet another decade.
seek to have the Form completed required to pay for a mandatory service
by a doctor in the usual way. that exists for the benefit of society
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