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NHS patient deaths to be investigated by medical examiners


Health secretary makes announcement after BMA feared doctors were being criminalised for errors
Medical examiners will investigate patient deaths in the NHS as part of changes to improve patient safety and protect medical staff from being criminalised for their mistakes.
Jeremy Hunt, the health secretary, announced on Monday he was rolling out the appointment of the examiners across the service. The move comes after the case of Hadiza Bawa-Garba, a trainee paediatrician, convicted of gross negligence manslaughter and struck off following the death of a child in her care, Jack Adcock.
Medical professionals rallied to her cause, saying the real culprit was NHS understaffing not individual error.
Hunt said the examiners would look at all deaths that had not been referred to a coroner, and examine whether they were unnatural or concerning issues that meant a coroner or other investigator should become involved.
He said: “When something goes tragically wrong in healthcare, the best apology to grieving families is to guarantee that no-one will experience that same heartache again. I was deeply concerned about the unintended chilling effect on clinicians’ ability to learn from mistakes following recent court rulings, and the actions from this authoritative review will help us promise them that the NHS will support them to learn rather than seek to blame.”
Hunt ordered a review after Bawa-Garba was struck off the medical register by the GMC after being found guilty of manslaughter for mistakes in the care of Jack, six, who died of septic shock at Leicester Royal Infirmary in 2011, hours after being admitted with sickness and vomiting.
Bawa-Garba’s 2015 trial heard Jack, who had Down’s syndrome and a heart condition, was the subject of a “catalogue” of errors including missing signs of his infection and mistakenly thinking he was under a do-not-resuscitate order.
But the doctor’s trade union, the British Medical Association, said they feared doctors were being criminalised for making errors.
Bawa-Garba was suspended for 12 months from the medical register following her conviction. But the General Medical Council successfully appealed, saying this was not enough to protect the public, and she was struck off.
The review – led by Prof Sir Norman Williams – recommends vital changes for the system regulating healthcare professionals so they are supported to reflect on their practice when things go wrong, including:
the appointment of experienced doctors as medical examiners to look at all deaths and engage with bereaved families
the removal of the General Medical Council’s power to appeal the outcomes of their tribunals.
Prof Norman said: “A clearer understanding of the bar for gross negligence manslaughter in law should lead to fewer criminal investigations which are limited to just those rare cases where an individual’s performance is so ‘truly exceptionally bad’ that it requires a criminal sanction.
“These recommendations will, we hope, reassure the families and loved ones of the bereaved that lessons have been learned from their tragic experiences.”