Every Cause of Death to Be Checked by Medical Examiner

Lucy Letby is led away in handcuffs by police after being arrested at her home in Chester, England, on July 3, 2018. Cheshire Police

A medical examiner will review the cause of death given in all those not investigated by a coroner in a policy designed to uncover criminal activity or medical negligence, the government has announced.

The new measures for England and Wales come in the wake of the Lucy Letby murder trial, which saw the former neo-natal nurse found guilty of killing seven babies and attempting to murder six others at the Countess of Chester Hospital.

Such safeguarding measures were proposed more than 20 years ago following the case of Britain’s most prolific convicted serial killer, doctor Harold Shipman, believed to have murdered more than 200 people over several decades by giving them lethal injections of diamorphine and certifying their deaths as “natural.”

The reforms to death certificates will mean several different professions, including doctors, coroners, and registrars, will have to change their practice. The new legislation will come into force from April 2024, although medical examiners have already reviewed 640,000 hospital deaths since 2019 without the statutory requirement.

Medical examiners will have to confirm the proposed cause of death and overall accuracy of the death certificate under the reform as well as support recommended referrals to the coroner.

A coroner’s examination is only required to take place following a hospital death if there is a suspicion of medical malpractice or wrongdoing, and deaths certified as being from “natural causes” are not routinely examined at an inquest.

While the new legislation will not necessarily lead to more inquests, it will introduce an extra layer of scrutiny into the death certification process and has been broadly welcomed across the medical profession.

National Medical Examiner Dr. Alan Fletcher said: “The NHS is pleased the government is putting the work of medical examiners delivering independent scrutiny of all non-coronial deaths in England and Wales on a statutory footing in 2024. Medical examiners ensure that if bereaved people have concerns after their loss, these can be raised as easily as possible.”

Dr. Suzy Lishman, senior medical advisor on medical examiners at the Royal College of Pathologists, welcomed the legislation but said it was “long-awaited.”

Dame Janet Smith called for reform in the Shipman Inquiry third report back in 2003, where she said it was not merely criminal wrongdoing that a doctor might seek to conceal in certifying a death without scrutiny.

“There may be occasions when a doctor knows that a death may have been caused or contributed to by some misconduct, lack of care or medical error on the part of a colleague,” she wrote in her recommendations for the system to be reformed—something successive governments failed to do.

Several other inquiries following the Shipman review also called for public safeguarding to be strengthened through additional scrutiny into the medical causes of death.

Such calls followed investigations into the Mid-Staffordshire NHS Foundation Trust in 2013—where hundreds of patients are believed to have died due to poor practice—and Gosport Hospital in Hampshire in 2018, where more than 450 people are believed to have had their lives ended by the misuse of opioids.

An inquiry into the Furness Hospital in Cumbria, where 11 babies and a mother died due to poor practice in the maternity unit, also highlighted the need for more scrutiny of the death certification process.

Health Minister Maria Caulfield said: “It has taken time to get this right, but it was vital we had the backing of all involved in the process in order to make sure it protects people and supports bereaved families in the way they deserve. Although abuse of the system is rare, what we are announcing will be a significant step in preventing failures in the future.”