Unintended consequences
Is the new system of medical examiners allowing GPs to dump work on coroners?
The chief coroner for England and Wales has drawn attention to an “emerging and potentially serious problem” in his latest annual report, published yesterday. It relates to the introduction of medical examiners, whose role is to provide independent scrutiny of causes of death and act as a contact for relatives of the deceased.
As the Department of Health and Social Care explains,
a medical examiner is a senior medical practitioner who is contracted for a number of sessions a week to provide independent scrutiny of causes of death, outside of their usual clinical duties. They are trained in the legal and clinical elements of death certification processes and will not have been involved in caring for the patient.
Medical examiners, supported by medical examiner officers under delegation, carry out a proportionate review of medical records and give bereaved people the opportunity to ask questions and raise concerns.
These arrangements were first introduced on a non-statutory basis in 2019. They have been covered by legislation since 2022 and the government plans to make them mandatory in little more than three months’ time.
But there have been unintended consequences. Some doctors, it seems, are less willing than before to visit the homes of their deceased patients and certify the cause of death, even when the death is entirely normal and expected.
This creates problems for coroners, who are required to investigate only if they have reason to believe that
the deceased died a violent or unnatural death,
the cause of death is unknown, or
the deceased died while in custody or otherwise in state detention.
Judge Teague KC, the chief coroner, writes:
Anecdotal evidence from coroners and others suggests that the number of referrals of deaths outside hospital settings has noticeably increased since March 2022. At least some of these referrals relate to deaths from natural causes where some entirely avoidable problem prevents proper completion of the medical certificate of cause of death.
That is something that can arise where a break in continuity of care in the GP surgery means that the medical certificate of cause of death can only be partially completed; or where no GP has seen the patient within the 28-day window before death; or where the GP declines to see the deceased after death.
This is generating unnecessary work for hard-pressed coroners and their staff and it is also increasing costs for local authorities. Our system of death management, certification and investigation is a highly integrated and sensitive one that can only operate efficiently where all participants strictly fulfil their statutory and other obligations.
Teague wants the government to “continue to monitor the situation and address the root causes of this emerging and potentially serious problem”.
Inquisitorial not adversarial
The chief coroner is also concerned to ensure that coroners retain control over their hearings. Inquests, as the name suggests, are meant to be inquisitorial in nature.
“Where proceedings acquire a more adversarial character,” Teague says, “the focus is liable to be diverted away from the bereaved, where it properly belongs, and channelled instead into a debate between competing disputants, who will not necessarily include the family of the deceased… It is not the function of a coronial investigation to resolve disputes or to serve as a vehicle for those who wish to air extraneous grievances.”
Speaking out
This is not the first time Teague has spoken out. In a lecture four weeks ago, he listed a litany of failings in what could still be regarded as a largely “forgotten service”.
The “annual” report he published yesterday — almost the end of 2023 — covers the years 2021 and 2022. It appears that former chief coroners have not complied with a statutory requirement to “give the Lord Chancellor a report for each calendar year… by 1 July in the following year”. Instead, their annual reports have covered a 12-month period covering the latter part of one calendar year and the beginning of the next. Teague intends to put this right too.