Blackpool Teaching Hospitals set up new Medical Examiner team

Medical Examiner Officer, Debbie Brearton; Lead Medical Examiner Officer, Liz Pepper and Medical Examiner, Dr Brack

A new department has been set up at Blackpool Victoria Hospital in order to scrutinise all hospital deaths. The Medical Examiner System is a national system being rolled out across England and Wales.

The Medical Examiner team, lead by senior doctors, ensure that all patient notes are reviewed, and a cause of death agreed between the reporting doctor and the Medical Examiner.

Dr Brack, a Trust consultant cardiologist at Blackpool Victoria Hospital who is one of the Trust’s three Medical Examiners, said: “Not only are we responsible for independently inspecting all the medical notes leading up to the passing of a patient, we also act as a point of contact for the bereaved family.”

Medical Examiners (MEs) agree the proposed cause of death and the overall accuracy of the medical certificate of cause of death with the doctor completing it. If there are any concerns, the Medical Examiner’s team will escalate these to Divisional Quality and Governance Leads and contact the Coroner, regional and national MEs teams when appropriate.

As well as the team of medical examiners: Mr Heath, a general surgeon and Dr Gulfam, consultant endocrinologist, there are a team of three medical examiner officers (MEOs).

Liz Pepper is the Lead MEO who has come from a legal services background in a previous role. She said: “We go through all the case notes and flag up any areas of concern straight away to the Medical Examiner. We all have ongoing training with the Royal College of Pathologists in order to spot any areas in the notes that may require further scrutiny.”

Debbie Brearton has worked in the bereavement office Blackpool Victoria Hospital for 20 years and is now a MEO. She said: “We contact every single family who has lost a loved one in hospital to make sure there are no concerns. We also explain the process to them so they know what to expect. We get to know families really well and it is gratifying to be able to help them through such a sad time.”

Louise Phillips is a part-time MEO who has previously worked in the Bereavement Office and for a funeral director in a previous role. Louise is also an experienced HCA and brings a background of varied and valuable experience to the MEO role.

The new service ensures accuracy and identifies areas for improvement across the Trust. Carla McCaffrey, Mortuary and Bereavement Services Manager, said: “This was an opportunity to improve how we learn from patient deaths.

Mr Heath and Dr Brack


“The Trust is working hard to develop End of Life services, and the introduction of the ME system presents us with an opportunity to align some initiatives, such as the ‘Learning From Deaths’ framework and the introduction of the SWAN Bereavement Nurses and their programme of work.

“We are encouraging doctors to champion how we can learn from deaths and ultimately provide a better service for the patient and the bereaved family. We are looking to reduce the length of time families have to wait for paperwork to be completed following a death, and encourage all doctors to present themselves at the ME’s Office within one working day to ensure that families and relatives do not have to experience any additional distress at a sad time.”

Dr Brack added: “The service started last September, and we have streamlined the process around hospital deaths across the Blackpool Victoria and Clifton sites.

“The service gives us the opportunity to look at policies and procedures and identifies how we can improve governance and what we can do better.”

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