Medical Examiner System - how the NHS e-Referral Service offers support

Requirements for doctors completing Medical Certificates of Cause of Death (MCCDs) are set out in official guidance published by the Office for National Statistics and the General Register Office (HM Passport Office).  GMC end of life guidance notes that doctors 'must be professional and compassionate when confirming and pronouncing death and must follow the law, and statutory codes of practice, governing completion of death and cremation certificates. If it is your responsibility to sign a death or cremation certificate, you should do so without unnecessary delay'. The Notification of Deaths Regulations 2019 guidance sets out types of deaths which doctors must notify to the coroner. 

This document is not intended to add to or replace official guidance referred to in the previous paragraph.  All MCCDs and notifications to coroners must be carried out in accordance with official guidance. This e-Referral set-up document only provides advice and information for setting up e-Referral processes and systems; these processes and systems must follow the requirements set out in MCCD guidance and guidance regarding notification to coroners. 

The Medical Examiner System

Medical examiners are senior doctors who provide independent scrutiny of non-coronial deaths. There are three elements to their scrutiny, which is supported by medical examiner officers. Bereaved people are put at the centre of the process and given an opportunity to ask questions about the causes of death and raise any concerns they have about care before death. There is an interaction with the doctor completing the Medical Certificate of Cause of Death, to agree the causes of death. Medical examiners also carry out a proportionate review of the patient record. In April 2024, the government and DHSC announced that the Death Certification Reforms including the statutory medical examiner system would come into force on 9 September 2024.

There are 125 medical examiner offices based mainly in acute NHS trusts. 

From 9 September 2024 the Access to Health Records Act 1990 provides a statutory right for medical examiners to access health records - the Coroners and Justice Act 2009 (Commencement No. 22) Order 2024 (paragraph 3n) adds medical examiners to those who can access health records (schedule 21 paragraph 29).

The NHS e-Referral Service

The NHS e-Referral Service (e-RS) is a national digital platform used to refer patients from primary care into elective care services. Its use is mandated for GP referrals to first consultant-led outpatient services, and it is also used by other referrers and providers to manage referrals into other types of services. e-RS is also widely used as a platform for the management of Advice and Guidance requests.

As e-RS is used in all GP practices and all acute providers, extending its use to support the Medical Examiner System should minimise the need for training and business change at either end of the process.

1. Services should be set up to support advice requests, as the Advice and Guidance functionality in e-RS is considered the most suitable to support the Medical Examiner System. 
2. Services should not be made available to all referrers. e-RS commissioning rules can be used to ensure referring practices only have one office to send information to.

Service definition

Medical examiners at acute providers should make contact with their NHS e-Referral Service lead to set up their service. If they are unable to identify who this is, they can contact [email protected] to request support.

All acute providers will have at least one Service Definer who will be experienced in setting up new services on e-RS. Full information on setting up services is available. The main considerations relating to Medical Examiner services are: 

Service details: request types supported

It is recommended that services are set up to receive ‘Advice Request’, as this allows a conversation between the medical examiner and referrer, if required, as well as the notification of the final decision.

If providers wish to set the services up as receiving referrals rather than advice requests, then ‘Triage Request’ should be selected this provides similar functionality to ‘Advice Request’ but without the ability to build up a conversation.

‘Appointment Request’ should not be used – for two main reasons:

1. Booked appointments are normally cancelled automatically in provider systems when the patient record is marked as deceased.
2. If the patient record isn’t marked as deceased on the NHS Spine and a referral is left un-booked or any appointment is cancelled, automatic reminder letters will be generated and sent out.

Service details: specialty

In February 2023 a new specialty of ‘Medical Examiners Office’ will be added to e-RS

Service details: Include service on secondary care menu

As each GP practice should only send to a single Medical Examiner office, services should be set up as ‘Do not include on secondary care menu’. Commissioning organisations will then need to establish the relationship between their practices and the relevant service within e-RS

Service details: clinic types

In February 2023 a new clinic type of ‘Medical Examiners Office’ will be added to e-RS (within the specialty of the same name). 

Service specific guidance

There are several fields within this section that are displayed to the referrer as part of process of sending information to the Medical Examiner. These are:

• referrer alert (within service details): This field is limited to 100 characters
• exclusions
• conditions treated
• suggested Investigation

These last three fields can text longer passages of text and contain links to documentation hosted on your webpages, for example. It is suggested these fields are used to convey information such as:

Please attach patient record summary and inform the medical examiner office of the doctors proposed causes of death. This could be through the use of a locally agreed template.

Workgroups/service personnel

Where out of hours cross cover arrangements exist, it will be necessary to ensure all relevant staff have e-RS roles on their smartcards for each organisation and are members of workgroups associated with all services for which they may need to review information.

Integrated Care Boards (ICBs) should make contact with their NHS e-Referral Service lead to commission Medical Examiner Services for their GP practices. If they are unable to identify who this is, they can contact [email protected] to request support.

Full information on setting up services is available. 

The main consideration relating to the commissioning of medical examiner services is:

Applicable organisations

By default, e-RS commissioning rules apply to all organisations parented by the commissioning organisation (typically, all of the GP practices within an ICB).

As each GP practice should only send to a single medical examiner office it will be necessary, where more than one medical examiner service is available in an ICB, to ensure the e-RS commissioning rule for each service is applied to the appropriate practices only.

Users in GP practices will be familiar with using the NHS e-Referral Service to create Advice and Guidance or referral requests, so the following is just a summary guide that will highlight some key considerations. It will focus on the Advice and Guidance process as this is recommended but will note differences if referral assessment services are used. Further training information and support is available. 

Request creation

While there should not be any undue delay to marking a patient record as deceased it is recommended that, where practicable, the e-RS request to the medical examiner office should be made before this is carried out. This is because the GP clinical system may prevent the initiation of an e-RS request once the record has been marked deceased.

If it is not possible to create an e-RS request in the usual manner from within the patient record in the GP clinical system, it will be necessary to access e-RS directly using either the Microsoft Edge or Google Chrome internet browsers. e-RS can be access at https://ers.nhs.uk/. This will need to be done before the patient has been deducted from the practice (this normally occurs the day after recording the death in the practice system).

The patient can found using either their NHS Number or Demographics. After clicking ‘Refer or seek advice’ the following alert will be displayed:

Following review of information by the Medical Examiner Office there are three possible outcomes:

• further information is needed before the medical examiner can confirm the cause of death
• confirmation of the cause of death
• other action required (for example notification to coroner)

In all cases the information will be contained within the practice’s ‘Advice and Guidance’ worklist. The requests will have the status of ‘referrer to review response’ (requests awaiting medical examiner review have a status of ‘provider response required’).

If further information is required, then this should be entered into the advice conversation using the free text box and any appropriate attachments should be added. This will enable the ‘Send request’ button, which will transfer the information to the medical examiner for review.

If the medical examiner response confirms the cause of death, then the practice should add a copy of the Advice and Guidance conversation and any attachments to the local patient record. Once this is complete, the ‘End conversation’ button should be used to close the request and remove it from the worklist.

Any other responses will need to be managed appropriately, depending on the information provided by the medical examiner.

Referral Assessment Services (RAS)

In both scenarios the Medical Examiner will ‘Return to Referrer with Advice’. These will show in the ‘Rejected/Triage response’ worklist with a status of ‘Triage response’.

If further information is requested it will be necessary to, from the referral summary screen, use the ‘Add / remove attachment’ option (or add additional information from the clinical system if that was used in the first instance) and then ‘Change service’ from the ‘Actions’ drop down. The request should then be resubmitted to the same service as first used.

If the response is confirming the cause of death, once all information has been saved appropriately the ‘Cancel referral’ option should be selected from the ‘Actions’ drop down. This will remove the request from the worklist.

Request receipt and management guide (Medical examiner office processes)

While medical examiner office staff may not have experience of using the NHS e-Referral Service, acute providers will have established training and many staff experienced in the use of e-RS. Therefore, the following is just a summary guide that will highlight some key considerations. It will focus on the Advice and Guidance process as this is recommended but will note differences if referral assessment services are used. Further training and support is available. 

Medical examiner office staff may have access to requests for more than one office, where they provide out of hours cover. When first logging in to e-RS the user should select the site for which they wish to review requests. They can switch sites by using the ‘change role’ option from the drop-down menu at the top right of the e-RS screen (where their name is displayed).

New requests (and requests that have had additional information attached) will appear in the provider’s ‘Advice and Guidance Requests’ worklist with a status of ‘Provider Response Required’.

• it may be necessary to change the ‘Clinician’ filter to ‘Show All’ before requests are shown.
• if the user has access to other e-RS services at the provider, it will be helpful to set either the ‘Service’ or ‘Specialty’ filter appropriately to show only the requests for the Medical Examiner Office

Referral assessment services

Requests will appear in the ‘referrals for review’ worklist.

After reviewing the provided information, a free text box response must be completed with relevant information for the GP and any appropriate attachments can be added.

• if more information is required to reach a conclusion, select the ‘Ask the referrer for further information’ option and ‘submit’. The request remains on the ‘Advice and Guidance Requests’ worklist with a status of ‘referrer to submit further information’
• once it has been possible to reach a conclusion on the cause of death, ensure all relevant information has been added to the local patient record and select the ‘Return to referrer with advice’ option. A further audit question will then be presented – select the ‘None of the above’ option and ‘Submit’. The request is then removed from the ‘Advice and Guidance requests’ worklist.
• If some other action is needed for example, notification to Coroner, please provide all the appropriate information to the GP in the free text box and/or via attachments and either ‘Return to referrer with advice’ with the appropriate audit response to close the request or ‘Ask the referrer for further information’ to leave it open, as appropriate.

Historic requests and responses can be found using the ‘Advice and Guidance responses enquiry’ from the ‘Enquiries’ tab.

Referral Assessment Services (RAS)

in all cases, when ‘Record Triage Outcome’ has been selected the ‘Triage outcome’ should be recorded as ‘Return to referrer with advice’. Free text responses and attachments can be included. The request will be removed from the ‘Referrals for review’ worklist if or until any further information is submitted.

Historic requests and responses can be found using the ‘Patient enquiry’ from the ‘Enquiries’ tab.