Table 2

Features of how the ME role operates to identify problems in care—illustrative interview quotes

Who are MEs and what does the role require?
Different specialties perceived as beneficial Medical examiners, all of them at the moment that I know are consultants. But they are from various different specialities. So there are two of us who are geriatricians, but there are anaesthetists, surgeons, palliative care consultants. So there is a variety of specialties, which is very useful and important actually. ME10
My background as a pathologist probably helps because I’ve spent my life, my professional life, reading clinical notes about people who have died. ME18
We were playing catch up a little bit as pathologists, I think it was very much about formulating the cause of death.(…) governance issues, safeguarding issues are something that has been brought to our awareness as pathologists whereas the clinicians, that’s part of their everyday job so I think that’s enhanced the role. ME4
MEs should not focus solely on issues linked to cause of death End of life care is the biggest single category of problems we’re picking up, which says something about the ill-advisedness on focusing on avoidable deaths because we’re talking about people where death isn’t avoidable but things go really badly wrong with end of life care. ME8
ME differences may generate inconsistency I think the biggest issue that we’ve had to deal with is getting consistency between the different medical examiners. ME3
Sometimes we may miss certain things or not consider them particularly relevant because we are not into that speciality particularly. And that’s why I think it would be good to have, you know, quality control with all the MEs. ME10
The ME role may not suit all doctors I think it’s necessary to have experience, some clinical credibility and I think the ability to raise concerns without causing huge drama.(…) But it’s not for everybody, that’s for sure, because I think you’ve got to have the ability to communicate with families in a sensitive manner but not be frightened to tackle difficult clinical governance issues within the organisation. ME12
What does the ME review process involve?
The process was not a forensic review I think we have to be very careful that we are seen as a screening process, trying to identify where there are potential problems, but not trying to sort the problems out. ME7
At the end of the day my responsibility here is to identify issues that I believe require further investigation and not to investigate them myself. ME3
Variation in the order of obtaining information from attending doctors and medical records I make a judgement from the notes from what’s gone on, about whether what I think, has happened, and therefore the junior doctors really confirm that. And I use the family as a way to check that what I’ve read in the notes, there’s nothing else gone on that I’ve not been made aware of. ME20
The process is in two parts, first of all it’s talking to the certifying doctor or the doctor who's going to refer to the coroner, that is purely a conversation we don’t look at any notes or talk to anybody else at that stage because we didn’t want to delay issuing the death certificate until the end of the medical examiner process the medical examiner then does what we call the screening process. ME8
There is a risk I think, that a medical examiner who has already had an interaction with the doctor would look for the confirmatory aspects of that case when they review the records. ME1
The perceived value of speaking to relatives Talking to the family, is the part that you cannot get from the notes. ME15
90% of relatives are more than happy, but I think when you do get an unhappy relative, it is helpful to them to speak to someone with a degree of seniority, and it also is a pointer to us, to actually look with a little bit finer toothcomb through the records. [Example of care issue] That sort of thing you wouldn’t necessarily just pick up automatically from the notes.(…) That discussion with the daughter highlighted that there was clearly an issue. ME6
The perceived value of the service to bereaved relatives We did survey families anonymously and asked them to give feedback about that call, it was unanimously universally positive, they liked the idea that somebody independent has reviewed things, they liked the opportunity to get something off their chest, it was an opportunity to have some questions answered, a few felt it was unnecessary because they had no concerns. ME1
I do think people appreciate a doctor phoning them, I think they appreciate that time that’s given to them, I think they appreciate the breakdown of medical terminology if needs be.(…) I always explain that I’m an independent doctor(…) and that I haven’t been one of the doctors caring for them. ME4
Delegation of specific tasks to suitably qualified MEOs Rather than having a medical examiner sat in the office all day, every day, what our medical examiners do is they come in for a couple of hours, they review the cases and then they go away. And it’s the MEOs that coordinate all the office functions and have discussions with the doctors and with the family and with the bereaved and with the bereavement office.(…) The contact with the relatives is always done after the medical examiners review.(…) We always feed everything back to the medical examiner, whether it’s discussions with the family or discussions with the doctor.(…) It’s always the medical examiner that makes the ultimate decision, as they have to sign off on the case. MEO
They’re [MEOs] very experienced, and they will often highlight, things that, need to be reviewed, so they generally look at the records before we do, and say, we’re a bit concerned about X or Y. ME2
How do MEs act on potential quality of care problems?
Referral via internal pathways when problems are unlikely to have contributed to death, but there appears to be potential learning They’re quite often omissions, maybe omissions in recording, maybe omissions in a drug or omissions in undertaking an investigation. ME7
Issues with the choice of antibiotics, which might not be the best ones, and there were some issues with the escalation of the patient. Which ultimately didn’t contribute to the cause of death so we didn’t think it was necessary to refer to the coroner, but we felt there was some learning there. ME17
Where I don’t think the fluid management has been particularly helpful, there’s been a delay to them getting antibiotics, but I don’t think that delay has contributed to their death. Those sort of things, where I think there’s learning, and process that needs to be improved. ME20
Referrals for RCRR are also influenced by national and local requirements The Trust [hospital] doesn’t influence what the medical examiners look at or do, but(…) we recently discovered that the Trust was an outlier in terms of deaths after myocardial infarction, and there’s one or two other things like that, where the Trust wants to have a particularly close scrutiny of that type of death(…) and for that period all deaths fitting into the category that the Trust’s defined are sent for more detailed case note review. ME8
We’ve introduced certain parameters, fractured neck of femur actually is one of them, where all of those cases go forward to the structured review. ME3
Differences in implicit criteria for referral of concerns to the various internal pathways available I would certainly have very low threshold to refer for SJR [RCRR] if there are a family concerns. ME10
I also quite frequently pick up things that I haven’t picked up from the notes that the relatives are unhappy about, sometimes that will lead to a structured judgement review, more often it will result in a clinical review. ME7
If I am doing a PALS [referral], I would do an SJR [RCRR] as well because obviously there has been a concern raised. ME15
It would be a very small number [of relatives] do have questions about quality of care, I can count them on less than one hand I would think, and then you forward them to the PALS service. ME5
How are ME services organised?
Covering multiple hospitals presented challenges, for example, delayed access to records So deaths at the other two sites,(…) it’s probably the area I feel least comfortable about. If we get the notes back within two to three weeks of death, then we will phone up the relatives to talk through with them about the care the patient received.(…) I don’t feel overly comfortable about that because it’s a difficult time for relatives, it’s two or three weeks down the line. ME6
Electronic records afforded greater flexibility for MEs The medical records are electronic and so what I have got into the habit of doing most days, is logging on either in my office or remotely… so I can flick through and review those patient records, either in my office or remotely and make an initial assessment of what the direction of travel looks like. ME14
Administrative support was beneficial in helping MEs to manage their workload MEO’s are essential because they have the heads up on everything really, so when I go to bereavement in the morning, if there are tricky cases, difficult relatives, particularly complex cases they’re on it straight away and they make us aware of that so that when we get the phone call from the junior, we already have an idea of what’s coming our way. ME4
They [ME assistant] basically prepare all the notes for us, they make sure that all the details that we need about relatives, contact details, that sort of thing, are all available, they identify the patient episode that resulted in death, they make sure that all the notes are available and appropriately stacked so that we do things in the right order, they liaise with the bereavement office over relatives seeing us. ME6
Scope for improving the structures for meaningful feedback to ‘close the loop’ It is really helpful to have feedback though and I think that’s perhaps that one aspect of the system that isn’t as strong yet as it might be, I need to have some kind of quality assurance to know that, am I detecting the right kinds of things and also it’s good to know what learning came out of things and what changes have been made because that can inform future reviews as well. ME1
I am pushing it out to a black hole and hoping someone else is taking care of it. The black hole is fairly robust I think and there is monitoring. ME11
There is a proper feedback process. There is a central data set from where learning points are taken off and disseminated. ME9
How are ME services resourced?
Professional accountability perceived to safeguard the independence of MEs I do understand the concerns about independence of medical examiners. My only experience in [location] is that those concerns are unfounded because we employ medical examiners who are senior doctors who know that they have a responsibility to the General Medical Council overall, rather than their own Trust [hospital].(…) quite apart from the GMC, medical examiners should have recourse to a National Medical Examiner to say ‘‘this has happened, I think I’m being put under undue pressure’’. ME8
The flexibility needed to accommodate fluctuating demands and cremation form requirements is challenging I struggle with flexibility because of my other jobs. ME17
I can try and shift the whole thing around so that I am free for that [ME] work, and that’s how it has to be, especially in winter times, so it’s a matter of me time shifting really. ME4
It is quite tricky to say to somebody I will pay you for four hours work but actually I would like you to be available between ten and four. ME15
Ensuring availability of supporting staff is important to maintain service continuity When the MEO isn’t there, it just falls apart. ME17
Bereavement care is currently very short- staffed and I am directing more of my energies than I was at the beginning to supporting bereavement care because if they fall over, we’ve got a problem. And it does rather limit the time I’ve got in terms of family follow up. So I’ve switched it for the time being to only following up the families who have requested a cremation. ME18