Following my mother’s recent death in a nursing home (about which I had no concerns) I was surprised but pleased to be contacted by what I now understand is a new institution, the Medical Examiner’s Office. I have since learned that their role is to examine every death in England and Wales which has not already been referred to the Coroner part of which includes consulting with the family to ensure that concerns are not missed as well as examining all the relevant medical records and reports. They are able to refer deaths to the coroner where they feel this is appropriate.
If it works as intended this should surely address some of the issues raised in your article. Or do you think that it does not go far enough?
Thank you for your comment. I am sorry about to the loss of your mother. Although the introduction of medical examiners is a positive one, an unnatural death can still be referred directly to the coroner. If the coroner in question does not have a medical background, this is where difficulties can occur when it comes to identifying acts or omissions that could have led to a person’s death.
Angela, a very written and accurate article that highlights the huge flaws in our Coronial process. What rings the loudest for me, is regarding the information provided to legal and coronial services - being unreliable at best, or as stated intentionally manipulated. NHS Trusts investigating themselves should be enough of a red flag on its own to ensure the system is changed. Couple feeding accurate and honest information into the system, with Coroners needing to have medical knowledge, and the system suddenly becomes tenable again. It really doesn't seem like rocket science - it actually seems very straight forward.
I am campaigning for the first half of that new equation in the introduction of an Independent NHS Complaints Service. By removing the scope of Trusts to investigate themselves, the truth will out, and the accurate and honest data provided, for example, to the Coroner - to ensure the review is done and complete based on he facts.
I do not have any experience of the coronial system in England, but do have personal experience of the equivalent system in Ontario, Canada. My mother died in November 2012. She had been living in a nursing home and it was clear to my sisters and me that she was dying, slowly and in agonising pain. She had been ill for the previous year and a half, but had never received a diagnosis, and her primary care physician refused to refer her to palliative care, though it was obvious that she needed it - one of my sisters had experience as a palliative care nurse, so was well aware that palliative care could provide pain relief that the nursing home and her PCP could not provide. Eventually we three sisters managed to persuade him to refer her - about 36 hours before she died. After she died, the assistant coroner for the area, who was an emergency department doctor at the hospital where she died and who had treated Mum on a previous occasion, came to see the three of us and explained that he was not happy with her case and felt that a post mortem was in order. We wholeheartedly agreed. The post mortem took place - turned out she had cutaneous T-cell lymphoma - and there was agreement that she should have been referred to palliative care much earlier. Her PCP was required to attend a training course on palliative care and the coroner recommended that palliative care awareness training should be added to the ongoing training doctors were required to take. Clearly the coronial system there worked well, and we were pleased that it would be less likely that other patients would go through unnecessary suffering.
I’m so sorry to hear about the death of your mother, and what she went through. I’m glad to hear the coronial system where you live served its purpose and resulted in action which could help prevent future cases. I wonder if all coroners in your country are medically trained?
Following my mother’s recent death in a nursing home (about which I had no concerns) I was surprised but pleased to be contacted by what I now understand is a new institution, the Medical Examiner’s Office. I have since learned that their role is to examine every death in England and Wales which has not already been referred to the Coroner part of which includes consulting with the family to ensure that concerns are not missed as well as examining all the relevant medical records and reports. They are able to refer deaths to the coroner where they feel this is appropriate.
If it works as intended this should surely address some of the issues raised in your article. Or do you think that it does not go far enough?
Thank you for your comment. I am sorry about to the loss of your mother. Although the introduction of medical examiners is a positive one, an unnatural death can still be referred directly to the coroner. If the coroner in question does not have a medical background, this is where difficulties can occur when it comes to identifying acts or omissions that could have led to a person’s death.
Thanks. I can see that could be a problem. It seems that an opportunity to overhaul the whole system has been missed which is a great pity.
Angela, a very written and accurate article that highlights the huge flaws in our Coronial process. What rings the loudest for me, is regarding the information provided to legal and coronial services - being unreliable at best, or as stated intentionally manipulated. NHS Trusts investigating themselves should be enough of a red flag on its own to ensure the system is changed. Couple feeding accurate and honest information into the system, with Coroners needing to have medical knowledge, and the system suddenly becomes tenable again. It really doesn't seem like rocket science - it actually seems very straight forward.
I am campaigning for the first half of that new equation in the introduction of an Independent NHS Complaints Service. By removing the scope of Trusts to investigate themselves, the truth will out, and the accurate and honest data provided, for example, to the Coroner - to ensure the review is done and complete based on he facts.
www.keepingthenhshonest.co.uk - if anyone would like further information or to support his campaign.
I do not have any experience of the coronial system in England, but do have personal experience of the equivalent system in Ontario, Canada. My mother died in November 2012. She had been living in a nursing home and it was clear to my sisters and me that she was dying, slowly and in agonising pain. She had been ill for the previous year and a half, but had never received a diagnosis, and her primary care physician refused to refer her to palliative care, though it was obvious that she needed it - one of my sisters had experience as a palliative care nurse, so was well aware that palliative care could provide pain relief that the nursing home and her PCP could not provide. Eventually we three sisters managed to persuade him to refer her - about 36 hours before she died. After she died, the assistant coroner for the area, who was an emergency department doctor at the hospital where she died and who had treated Mum on a previous occasion, came to see the three of us and explained that he was not happy with her case and felt that a post mortem was in order. We wholeheartedly agreed. The post mortem took place - turned out she had cutaneous T-cell lymphoma - and there was agreement that she should have been referred to palliative care much earlier. Her PCP was required to attend a training course on palliative care and the coroner recommended that palliative care awareness training should be added to the ongoing training doctors were required to take. Clearly the coronial system there worked well, and we were pleased that it would be less likely that other patients would go through unnecessary suffering.
I’m so sorry to hear about the death of your mother, and what she went through. I’m glad to hear the coronial system where you live served its purpose and resulted in action which could help prevent future cases. I wonder if all coroners in your country are medically trained?