The Government has announced that unexpected deaths within the NHS in England and Wales, which have not been referred to a Coroner, will be investigated by medical examiners.
The medical examiners will engage bereaved families in the process of investigating deaths to increase transparency for the bereaved and the investigation could also include the care the deceased received prior to death. The proposed regulations will require a doctor’s certification of cause of death to be scrutinised and confirmed by an independent medical examiner. Registration of the death will only be permitted once the death has been scrutinised by a medical examiner or a coroner. The Health Secretary hopes that the changes will facilitate improvement of patient safety and investigations into causes of death.
The announcement comes subsequent to Dr Hadiza Bawa-Garba being convicted of gross medical negligence manslaughter and later appealing against being struck off the medical register, following the death of six year old Jack Adcock. Professor Sir Norman Williams conducted a policy review into gross negligence manslaughter in healthcare settings as requested by the Health Secretary.
Professor Sir Norman reports that the introduction of medical examiners would deliver “a more comprehensive system of assurance” facilitating a full understanding of the causes of death and preventing similar incidents through learning and redevelopment.
The Health Secretary expressed that “these recommendations aim to support a just and learning culture in healthcare, where professionals are able to raise concerns and reflect openly on their mistakes but where those who are responsible for providing unacceptable standards of care are held to account.”
Some clinicians remain sceptical as to whether the above balance is likely to be struck. Unless the problem of an underfunded and understaffed National Health Service is resolved, any significant impact from regulatory change is doubtful.
Dr Bawa-Garba was working in an understaffed unit, where a consultant was absent, there was a shortage of trained nurses and there was no rest break. The above system is unlikely to make a significant impact when it is remembered that human error due to stretched resources can lead to a significant number of deaths in the NHS.
In the case of Dr Bawa-Garba the Court of Appeal quashed the High Court’s decision to strike her from the medical register and applied a lesser sanction of a one-year suspension. It was stated that Dr Bawa-Garba did “not present a continuing risk to patients”. The Master of the Rolls, Sir Terence Etherton, stated that no concerns had “ever been raised about the clinical competence of Dr Bawa-Garba, other than in relation to Jack’s death and she was in the top third of her specialist trainee cohort”.
The debate continues; on one hand, the doctors who funded Dr Bawa-Garba’s appeal are of the view that a doctor being struck off for an “honest mistake…lessens the chances of preventing a similar death” by promoting a closed approach to recognising mistakes and learning from them. On the other hand, Jack Adcock’s mother, Nicola Adcock, is of the view that the public will lose “faith and trust” in the NHS as a result of the Court of Appeal decision. It is difficult to see how a system of medical examiners could have prevented the problems that led to the death of Jack Adcock, although any case involving the loss of a child should surely lead to meaningful and effective changes taking place.
Sumaya Ali, Trainee Solicitor