A review commissioned by the Health Secretary, Jeremy Hunt, has provided recommendations for when patients die following NHS treatment.
Professor Williams’ review recommends that patient deaths which aren’t referred to a coroner ought to be reviewed by an experienced doctor who will examine the reasons for the death and engage with bereaved families. This is intended to increase transparency and provide families the opportunity to raise any concerns. This medical examiner will also decide whether any further investigations are necessary.
The review was commissioned following the high profile case of Hadiza Bawa-Garba, a paediatrician, who was convicted of gross negligence manslaughter and struck off following the death of Jack Adcock, a boy of six with Down’s Syndrome who died of septic shock in 2011.
The medical profession raised concerns that doctors were under increased pressures which included the threat of criminal sanctions against them if they made mistakes.
The bar for bringing a criminal case for gross negligence manslaughter against a medical professional has always been high and it has always been reserved for the most truly exceptional cases. On the face of it, the reason for the commission of this report and the appointment of medical examiners appears to be protect the medical profession from facing the criminal courts.
However, the use of medical examiners is a unique opportunity for the NHS to share information on medical mistakes throughout all the different trusts in a bid to prevent them from being repeated; ultimately making it a safer place for patients. It is hoped that in this era of transparency and candour, that clinicians will have the chance to admit when mistakes have been made.