NHS hospitals need to appoint medical examiners now or risk mistakes such as Mid Staffs happening again

Most people won’t have heard of a medical examiner, but to anyone who has lost a loved one in hospital care, they are one of the most important people they will ever encounter. Simply put, medical examiners are doctors who look at every hospital death with a fresh pair of eyes to make an independent judgement about what took place. It is impossible to overestimate the importance of their role, and it is vital that NHS hospitals now get on with appointing them as a matter of urgency.

During my six years as health secretary, I met far too many families who had suffered heartache when things went wrong in the NHS. If anyone thought Mid Staffs or Morecambe Bay were just a bad dream for the NHS that it has now got over (with some important reforms such as the new CQC inspection regime along the way), then the revelations about the maternity issues at Shrewsbury and Telford will have disabused them of that notion.

In each of these scandals, the big issue has been not that bad things happen (sadly in an organisation of 1.4 million people there will inevitably be things that go wrong) but that they take so long to identify and put right. Mid Staffs took four years, Morecambe Bay took nine years and it now looks like the problems at Shrewsbury and Telford could have taken place over 40 years.

Anyone who has spoken to brave patient-safety campaigners who lost loved ones because of poor care – James Titcombe, who lost his eight-day-old baby after a catalogue of errors; Deb Hazeldine, whose mother died a harrowing death after neglect and poor care; Melissa Mead, whose toddler died after sepsis went undetected – will know that their motivation is never money, simply the desire to stop other families having to go through what they have suffered.

That is why they and other patient groups all campaign for medical examiners – a process through which every death is examined by a second, independent doctor. It was first recommended following the Shipman inquiry but has taken a long time to implement – inevitably for cost reasons. But the £40m a year was found in 2018 when I instructed every hospital across the NHS to have one in place by April 2020.

Where they have been introduced, medical examiners have been transformational. Southampton told me it had transformed their end-of-life care because it had identified numerous improvements they would not otherwise have made.

The main pilot sites in Sheffield and Gloucester, which scrutinised over 23,000 deaths, found that “medical examiners have triggered investigations that identified problems with post-operative infections faster than other audit procedures, based on surprisingly few cases”. Doctors also felt confident in raising concerns, as they were protected and supported by the independent medical examiner. Remarkably, pilot studies found that 25% of hospital death certificates were inaccurate and 20% of causes of death were wrong.

The real reason to make this change, though, is to give families confidence that if they have a concern about a loved one’s death, it will be looked at by another doctor who was not directly responsible for their care. This was the reason Robert Francis reiterated the need for medical examiners in his ground-breaking inquiry report in 2013. And this is why it is so concerning that the majority of NHS trusts appear not to be on track to implement this reform by the start of April as required.

But there is still time. And to any hospital CEO who thinks they have other more pressing priorities, please just reflect on some of the terrible scandals that have happened because internal systems were not strong enough to identify patient harm. Every time a major scandal surfaces, the government and NHS leaders promise families who have suffered unimaginable pain, “Never again”. That promise has been broken too many times. This is our chance to make it right.