Since June 2021, plans have been in place to extend the role of the Medical Examiner (ME) in England and Wales, to include all deaths not investigated by a coroner, wherever they occur. In April 2024, the Department of Health announced that this would become a statutory requirement across England and Wales from September 2024.
For hospices, this means all deaths that occur in the in-patient unit or in a patient's home, that are not investigated by a coroner, will need to be reviewed by NHS medical examiners before a Medical Certificate of Cause of Death (MCCD) can be completed.
Rather than wait until the process became mandatory for hospices, Compton Care worked with the Medical Examiner at Royal Wolverhampton NHS Trust to develop a new way of working together.
Outcomes
When somebody dies in Compton Care’s in-patient unit (IPU), the IPU's medical team makes a referral to the medical examiner (ME).
The IPU medical team contact the ME to discuss the case and offer a cause of death.
The ME contacts the patient’s family to discuss the proposed cause of death and ensure there were no concerns regarding the care they received at the hospice.
If no concerns are identified, the ME emails the IPU team with the agreed cause of death and authorises the hospice to complete the Medical Certificate Cause of Death (MCCD).
Referrals were initially made by telephone, but over time, the ME office started moving toward electronic referrals. Compton Care developed a data sharing agreement with the ME office, which would allow the ME to access and review electronic hospice records via a secure IT portal.
Now when a patient dies on the IPU, the medical team complete a referral template for the ME within that patient’s electronic record. This includes a short summary of the case and a suggested cause of death. The ME office will be informed by e-mail and have access not only to the referral form but also the full hospice record for that patient. This makes it much easier for them to find the information they need and make an accurate decision regarding cause of death.
So far, the system has run relatively smoothly and has proved to be very helpful. The hospice team's understanding of what information is valuable for the MCCD has improved, and they appreciate having a ‘second pair of eyes’ in more complex cases.
The number of cases being referred to the coroner’s office has decreased since the hospice started working with the ME.
The ME office is a useful source of patient feedback about the care Compton provides. The ME collates and anonymises positive feedback, which is shared with the hospice. If a patient's family raises concerns with the ME, this is also fed back to the hospice and actioned promptly.
Facilitators, challenges and advice
Text
Key facilitators
Compton Care already had a good working relationship with Royal Wolverhampton NHS Trust. The Lead Medical Examiner (ME) was keen to work with the hospice and provided training for staff to help them understand the ME process. This also helped the ME team to learn more about how the hospice works, and what would be needed for a robust and workable referral process.
Early engagement with the ME process meant that changes could be implemented gradually, which enabled the team to learn and make improvements.
The most helpful development so far in the process has been the data sharing agreement. Enabling the ME office to access records quickly and safely has resulted in a smooth transition from telephone to electronic referrals.
Challenges
The main concern when developing the system was that it would delay families receiving the necessary paperwork after a loved one has died. However this has not been an issue with the current system. Sharing electronic records means the hospice team can make early referrals to the ME, and the ME can make timely decisions.
The ME office is not available at weekends, which can be an issue if a patient needs to be buried quickly for religious or cultural reasons. Fortunately, the ME office has a flexible approach which enables the team to accommodate different needs. For example, if a death is expected over the weekend, the hospice staff can discuss the case with the ME prior to death so that they can complete the MCCD at the weekend. During normal working hours, the ME office is very responsive to the usual referral process.
It was really important that the ME referral system did not add to the workload of the hospice medical team. The electronic referral template is quick to complete and clinicians can continue with their work whilst awaiting a reply from the ME. The system gives clinicians confidence that the MCCD is accurate and has been agreed with the family, and that any decisions about referral to the coroner have been made collaboratively.
Tips and advice
Text
Keep things simple and work closely with your local medical examiners! They might not have much experience of how hospices work, so invite them to visit and collaborate on the processes that need to be developed.
Make sure you (and they) have a named contact to get in touch with if you have any questions.
Future development
Text
From September 2024 there are likely to be further changes to the processes required after a patient dies. Compton Care continue to work closely with the ME office, who are providing regular updates and opportunities to pilot new ways of working.
