A long gestation

Whilst it was the Shipman Inquiry that started the recent debate on medical examiners, Professor Peter Furness of the Royal College of Pathologists noted that it was a Parliamentary Committee Report in 1894 which first identified the potential for medical examiners and that sadly nothing has been done about this in the intervening period.[1]

To the casual observer it might seem that history was repeating itself. Despite the issue being raised in the Shipman Inquiry in 2005, and repeated after subsequent Inquiries into Mid Staffordshire and the Morecambe Bay tragedies, no comprehensive and nationwide system of medical examiners exists in 2017.

Consultation and pilots

The Department of Health launched a consultation on the issue in March 2016. It is perhaps a sign of the times that many of the responses related to the financial implications. They questioned, in particular, who would pay for this service or whether it would be self-financing.

Anecdotal evidence suggests that the medical examiners pilots had proved positive where they were running. The pilots ran for a considerable period, from approximately 2010, and this allowed the processes to be refined as they went along.

The pilots identified incidents and patterns of poor care, highlighted areas where clinical governance could be improved and on occasions identified a pattern of deaths. In one example a series of deaths at a care home had individually been put down to natural causes but when reviewed collectively appeared to suggest a pattern of poor care.

Recent developments

The Health Secretary, Mr Hunt, indicated in 2016 that he hoped to have a national network of medical examiners in place by 2018. However, the ensuing silence has been deafening until recently.

On 18 October 2017, Lord Low of Dalston raised a question during a debate in the House of Lords. He queried whether the Government still intended to introduce the medical examiner system and the envisaged timescale. The Government’s response confirmed that the Secretary of State has reaffirmed his commitment to introduce medical examiners and that the system will be introduced no later than April 2019.[2]

Whilst little seems to have happened since Jeremy Hunt’s 2016 announcement, the Government says it still intends to introduce the medical examiner system, albeit a year later than intended. As often with these matters, financial issues might still need to be resolved and so it is still a question of ‘watch this space’.