Since its introduction in the nineteenth century, the process for certifying death has not changed significantly. When a person dies of natural causes the doctor who attended the patient during their last illness will sign a medical certificate of the cause of death. Consequently, there is no requirement for an external examination of the body (unless the body is to be cremated) and there is no opportunity for concerns to be raised by relatives.
In January 2000, GP Harold Shipman was convicted of murdering 15 of his patients and had probably killed as many as 200 patients over several years. Harold Shipman had signed the death certificates of the patients he murdered.
Following his conviction, an Independent Inquiry was established and the Inquiry highlighted the fact that it is unsafe to have a single doctor certifying a death of natural causes without independent scrutiny. The inquiry made the recommendation that the introduction of a Medical Examiner would resolve this issue.
In 2014 the Gosport Inquiry was commissioned by the Government to investigate dozens of deaths at Gosport War Memorial Hospital from the 1980/90’s. The purpose of this Inquiry was to provide families with a better understanding of what happened to their relatives. The report subsequently revealed in June 2018 that 456 patients died after being given powerful pain killers at the hospital.
The findings of the events at Gosport demonstrate that the concerns of staff and patients are a vital source of information to help both avoid harm and improve patient safety and should not be ignored.
These, and other Inquiries and Reports, from Mid Staffordshire and Morecombe Bay for example, led to a call for the introduction of Medical Examiners to:
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Improve safeguards for the public.
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Ensure that the right deaths are referred to a coroner.
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Improve the quality of certification.
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Offer an opportunity for relatives to ask questions.
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Feed information to the quality assurance systems.
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Provide general medical advice to coroners.
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Collate & share statistical information
These recommendations were accepted by the UK Government and changes to the Coroners and Justice Act 2009 has allowed Welsh Ministers to develop their own regulations on the appointment of Medical Examiners, as well as managing, hosting and funding of the system.
As a result of this, NHS Wales Shared Services Partnership has been asked to establish and run this service on behalf of NHS Wales.
