Interview with Dr Gail Browne Intensivist and IME on the role of the IME and how to successfully complete the MCCD
The role of the Independent Medical Examiner (IME)
Summary
This on-demand teaching session is perfect for medical professionals who want to educate themselves on the role of the Independent Medical Examiner (IME). Dr. Gail Brown, an intensive care physician and experienced IME, will discuss the importance of double-checking the medical certificate of cause of death and involve participants in a two-way conversation to ensure accuracy. She will discuss the protocol for contacting the IME, clarifying the process for referring to the Coroner Service, and how to prevent delays for families dealing with a loss. This teaching session is an invaluable educational resource for all involved in the IME and death certification.
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Learning objectives
Learning Objectives:
- Identify the definition of an Independent Medical Examiner and the roles associated with the position.
- Describe the process of contacting an Independent Medical Examiner and preparation prior to making contact.
- Understand the importance of accurately recording and reporting cause of death and how it impacts families as well as public health data.
- Explain the importance of discussing cause of death with senior colleagues and ensuring accurate log ins to the N I see our mortality pathway.
- Appreciate the importance of a two way conversation between the I M E and registering certifying doctor and the process of completing the MCC D within specified hours.
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Okay, let me see. Okay. So everyone. You're welcome. I'm delighted to introduce Dr Gail Brown. And is this an intensive ist who is also an independent medical examiner? And she's very kindly agreed to come and talk to us today about the role of the independent medical examiner, which would be a very useful educational resource for all of doctors who are involved in lazing with the I M E and in undertaking death certification. So Gayle, thank you very much and over to you. Thanks very much, Doctor Hardy. It's so lovely to see you as always. You're always so lovely to me and I remember you when I was a trainee. Um and you taught me so very much. So, it's delighted to, to be here today. So, and I'm going to share some information with regard to the independent medical examiner prototype. So my first question to answer is what, what is an I M E? Um what, what is my rolls and I me and how do you contact myself and my colleagues on a daily basis? So, an I mea is an experienced condition from a wide range of specialties. So I'm from anesthetics and intensive care. There are I AM S across the province which work in nephrology, which work in general medicine in surgery and other other my colleagues that also working anesthetics and intensive care. So, so we're experienced consultants from a wide range of specialties and we work alongside a range of I M E officers that provide us with invaluable support. So what do we do? Well, our, our job, our to review um completed medical certificate of cause of death. So M C C D following a death before the M C C D has been issued to the general register office. We check that the medical certificate of cause of death represents a reasonable conclusion as the likely underlying cause of death. And we also have the ability to review the mortuary or the clinical summary that the the registering doctor has provided an information available to us on N I C R and we will also review hospital desk to ascertain actually whether the death should be referred to the Coroner Service for Northern Ireland. So, so we can we can advise on that as well if there's any um any uncertainty as to whether the death should be reported to the coroner service deal. Would it be fair to say that that the clinician involved in completing the MCC D should you know, not wait for the I M me to contact the coroner if it's clearly a case that the corner should be contacted Absolutely John. So, so if, if, if there is a, a cause of death is unnatural, that's a result of violence or negligence or you don't actually know the cause of death, maybe it's not a hospital cardiac arrest and there there is no information to the actual cause of death. The death should be reported to the Coroner Service for Northern Ireland through the death reporting team without involving the EMA. So if it's clear that it needs to go to the Coroner Service, absolutely, it should go and the Emmy doesn't need to be contacted if, if there's a lack of clarity that the case can be discussed with the M E and the I M E can review the information on the summary and on N I C R and give advice. So our main aims and the main aim is to review the medical certificate to make sure it gives an accurate conclusion of the likely cause of death. So, so why do we want to ensure that we'll all doctors should because we want to support our families. So we want to make sure that the family is completely aware of what happened to their loved one and that they understand what happened. Um And also remember all this data is being fed into public health data, which is where the funding for diseases is directed. So we want to make sure that this is really accurate data. But first and foremost, we want to make sure that the families, there's no surprises and the family's totally understand what happened to their loved one. We want to make sure that the sequence on the medical certificate cause of death is correct. So we will look at this further on in this presentation. So that one A is due to one B that is due to one C. So it actually is accurate and actually makes sense. And we're here to support improvements and help learning. We're all very approachable. Um So it's a two way conversation between the I M E and the registering certifying doctor. Also, we want to look and see if there's any governance concerns, which we're all doing as a body of professionals together so that anything needs highlighted or directed through the morbidity and mortality process that we can make sure that happens. We also our primary aim as you said there, John is to review all that non Caroni Aled deaths and to ensure that the death does not need reported to the Coroner service. So we operate Monday to Friday eight o'clock in the morning, 24 o'clock, we appreciate how busy you are. Um So I'll talk through the process of contacting us in the next number of slides, but we do, we do realize how busy you are and we've all been in your position. So we know how busy the wards are. But as as soon as you complete the medical certificate, cause of death and then I see our lift up the phone and phone that's on that number. So 28905 to 6194, and you will get speaking to the I M A officer who will take the information and let us know. So before you contact us, what would we ideally want you to do? We would ideally want you to discuss this with a senior member of, of your clinical team if you're a junior doctor. So we would want to ensure that you have support in completing a medical certificate, cause of death so that the whole team are involved. Because remember the senior doctor, the consultant will be reviewing this later on on N I cr is part of the mortality pathway. So it's good to get the MCC D right, correct, right from the start. So discuss it with a senior member of your team. Ensure you have a full comprehensive knowledge of the patient's medical history and recent hospital admission because remember you're signing this as an official document. So you want to make sure you have all the information and you're happy with what the information you have provided is on the medical certificate of cause of death and also make sure your clinical summary as comprehensive as possible and then complete your medical certificate of cause of death. So for deaths which do not require discussion with Coroner Service, following discussion with your clinical clinical team, the registering certifying doctor should record the initial record of death on to the N I see our mortality pathway and complete the medical certificate of cause of death. Remember to use your own N I C R log in details. So easy on a busy, busy ward to think you've logged in yourself, but you're actually logged in under another doctors log in details and that can cause problems further down the line with the General register's office if your name doesn't match your General Medical Council number and we don't want to have any delays for families in this process. Remember, families are trying to organize, make their own preparations. We want to make sure this runs as smoothly as possible and causes no distress. So make sure you're logged in under your own N I C R log in details and ensure that all those implant hazard boxes are completed because the mortar will come back to you if needs be if they aren't. So after clicking complete and don't be afraid to click, complete, complete. But before you email the medical certificate cause of death, the General Register's office. Although we're very fortunate in the Southern Trust because the mortuary staff do this for us. But in other trust, the registering certifying doctor has to actually email the medical certificate cause of death to the General Register's office. You should contact the Emmy on the dedicated line that I've given you. This may need to leave a voice mail if the army officers really busy but just leave a voice mail and we'll get back to you. And this is all deaths that are certified between working hours, eight till four Monday to Friday. Okay. Any questions John, um obviously deaths happened at weekends and bank holidays for those deaths. Are they subject to a future review by the I M E? No, they aren't John. No staff available out of ours at present. So as part of the prototype of the minute, it's within working hours, Monday to Friday, eight o'clock to four o'clock. And that's for all deaths that are certified. So for instance, if a death had taken place maybe on a Sunday evening, but it hadn't been um certified, it been verified but hadn't been certified. So the medical certificate cause of death wasn't complete until the next day. Then that, that death should be phoned through the independent medical examiners service. So it's all deaths that are certified and working hours. Now, if ideally, we want you to pick up the phone and contact us in the I M E office. But if we don't hear from you and if it's not a very, very busy day with deaths being reported into the army service, we will contact yourselves and, and please don't, I don't know anybody being annoyed that we do that we're here to help and that's why we're doing that. And as I said, we appreciate you're busy. Um and we will contact you if you haven't contacted us. But ideally we want you to contact us and to get this sorted as soon as possible for families. Because again, I can't stress enough. We don't want to delay anything for families. Okay. And make sure everything is correct. Make sure it's the correct. Um, just decease is, um, name, the deceased health and care numbers, correct? Because this will all be confirmed with the Eye me officer whenever you, you phone in um to speak to us and they will Emmy Officer will also confirm your name and contact number and they might ask for a mobile number just because the words are so busy as everybody knows and we want to be able to get back to you in good time to get this all completed. Okay. So what happens then? So the I M E independent Medical examiner reviews the medical certificate cause of death, the review, the clinical summary that you have provided for us and all the information that we have available to us on N I E C R. But we know more than anybody that you know this patient better than us. We know that and we, that's why we will contact you to discuss the case then in full and, and ask what your opinions are with regard to the medical certificate cause of death and involve you in a two way and it's very much a two way conversation. So depending uh depending on various various factors. To be honest, it might take us up to maybe an hour to get back, but we'll get back to you as soon as possible and we won't keep you on the phone for very long. And we aim to get, as I say, we aim to get this completed and not take up too much of your time. Ok. As I said, it's a two way discussion and we come together to agree and what we think should be the cause of death in the medical certificate. Um And as I say, we will be, we will be listening as well as um giving advice. Yeah, science. That's, that's why it's up to four o'clock because uh it's, it's up to four o'clock because it's going to take you some time to read the death and then come contact back. So it may take up to an hour if you interrogating the FCR. So that's so that the, the junior doctor who's left a message can expect there's gonna be a delay for the I M E was acquiring information. That's right. And, and um but we try not to have too much of a delay, John, it depends, you know, on the complexity of a case. Um it depends how busy the offices um but we aim to get back as soon as possible. So, so we should hear from us and we try and get back with within, within those hours. But we also realize how with it, with how wards work, that ward rounds are very busy in the morning. So the afternoons do tend to be busier with junior doctors complaining tasks and we understand that. Um, so we know the afternoons can be that bit busier. Thank you. Okay. So as I said, you don't be afraid if you're not totally sure that you've got the correct formulation on the medical certificate cause of death to hit complete because following our discussion and our reviews and I mean, we, we can, we can show you and talk you through how to change medical certificate cause of death, which is very simple. And then I PCR and we will talk you through that if you're not aware of how to do that. And this, this just shows you how you do it. So you open and I see. Are you make sure you've got the correct patient, you bring up the medical certificate cause of death as you have it? Remember, this is if we decide between us as we agree that we want to maybe alter the medical certificate cause of death, you select the pathway tab and this is easier to see whenever you're on. N I see. Are you click show all you open the mortality initial record of death box and you click re open task, but don't be worried. We will talk you through this on the phone and whilst you're in front of your screen and you'll be asked for a reason and to edit a death certificate and that's usually following discussion with ourselves and you can make the changes and, and click complete. But what I'm saying is, don't, don't be concerned about clicking complete. It can also be changed whenever we have our conversation and come to agreements if there's any minor changes that need made. So I said, there's a number of times it really is two way we want to give advice. We want to make this a document that a family completely understand what's happened and that it gives a clear cause of, of death for their loved one. But clarification may be required and we may need to, to speak to him or senior member of the team or we may ask to make sure that you ask that you suggest that you, you've spoken to him or senior member of your team if we need a little clarification. Um because as I say, some of the cases can be quite complex and, and, and remember, as I said, the consultant will be completing the mortality pathway. So it's better to get this all correct from the start. Because if when a consultant completes mortality pathway and they disagree with the cause of death, just imagine the concern that might create for the family. If the death certificate has to be changed further during the lines, we want to get it right from the start and that's why we're encouraging you talking to your, your senior members of your team. If you're just not 100% sure of the cause of death. If there is disagreement between the I me um examiner, the independent medical examiner and the medical team, obviously, we haven't been looking after the patient. So we appreciate, you know, this patient better than enough. So it'll then medical shifted. A cause of death will be issued as part of the registering certifying doctor. But we will provide feedback to the trust medical directors. Now that I have never had that. I have never had there been such a disagreement because as I say, we're here, we're here to provide advice, Gayle. Is there any value value in discussing what was going to go on the cause of death to the families beforehand? If there's anything absolute John? Absolutely. I couldn't agree more. That is such a valid thing to do with families. It's a difficult thing to do, but I would encourage um I know I do it in intensive care and I would encourage all the junior doctors to do it if they can. But it's such it needs such skills, doesn't it, John? Because it's such a difficult time for family, it's hard to broach family's in the midst of their grief at that time. But maybe this is what sometimes happens is that earlier on maybe in the whole dying process that this conversation has taken place. And so there are no surprises so that the family understand because at the time of death, understandably, the families are are not in a position to maybe have this conversation and we're there to support them. But I would totally support that John so that there's no surprises. The families are aware. I think that that is part of our job as a doctor to do that. And if a case does need discuss with the Coroner's service that needs discuss with the families, because that would be a big surprise if that hadn't been, hadn't been discussed and that the case needs discussed with the Coroner Service. Thank you. So what about deaths? It should be reported, the Coroner Service in Northern Ireland. So these are deaths, as I said, um such as due to trauma, violence, misadventure, negligence, malpractice on natural illness. So any type of unnatural illness or disease, um self harm, suicide poisoning, drug intoxication, occupational disease. So thinking of your asbestosis um or as a result of an anesthetic or a medical intervention. So anything as unnatural, we can't certify as a, as a, as a doctor that needs to be discussed with the coroner's service or for instance, from natural illness or disease in a disease, but the disease has not been seen by a medical practitioner within 28 days prior to death or any other circumstances that may require investigation or sudden death. That was of natural, it was a natural process. But we just don't know the cause of death. So perhaps and out of hospital cardiac arrest that we're not aware of what caused the out of hospital cardiac arrest that would need reported directly to the Coroner Service of Northern Ireland. And Gail trauma includes a fall a absolutely. Or even if the fact should have benign, they just had a fall that, that still needs discussed with the corner. Yeah, if we feel it's led to their cause of death, abscess and it's only beyond the medical strips, the cause of death. Yes, it needs discussed because what will happen is if it isn't discussed, the medical certificate will be sent to the General Register's office. They will look at it, they will not be happy with it and they will points it back and then again, there's delay for family and, and families won't be able to necessarily to understand this. So it causes such distress for them. Actually, if you're unsure as to whether to report the death to the coroner's service, what you I suggest you do is complete the medical certificate cause of death as fully as you can and um and hit complete and contact us. Then there I meet, um, will, will this review the case and discuss the case with yourselves and decide doesn't need discuss with the Coroner Service of Northern Ireland. So we're here to give advice. So if you're not 100% sure, complete it and sometimes even making yourself complete. It makes you realize it needs discussed or doesn't need discuss. And then we will give advice is whether we think it needs discuss with the Coroner Service of Northern Ireland. If we see anything that we're not, that we, we, we feel need to discuss the Coroner Service Northern and we will explain it to the registering certifying doctor. Does the I M E ever get into direct discussions with the corridor in relation to death? We can two, we can do if, if, if, if the the coroner's service that the coroner's medicals advisors are are very approachable. Um they are very hardworking and they will give it a lot of advice if needs be so sometimes sometimes we will, but they're very, very approachable John. Um the death reporting team are brilliant as well. They're very, very approachable. Okay. So, so doctor Hardy, what do you think of this death certificate? One a this is a common death certificate um cause of death that we would see. So one a broken pneumonia, what do you think? So on the spot here? Yeah, so broken ammonia is pneumonia is a cause of death, but there's no identification of what organism it might be. For instance, if there was information there, there is no information as to how the pneumonia was acquired, was acquired from aspiration or was it a part of the community or any other risk factors leading up to the bronchopneumonia, the pneumonia maybe caused by somebody who's immunocompromised and that might have been the underlying trigger for the patient to get the pneumonia. So, organism site type of pneumonia and underlying policed and for pneumonia. But I would have thought I needed to be included. Absolutely. So what we try and advise if, if it isn't a monarch process that's lead to death was a community acquired pneumonia or was it hospital acquired pneumonia? And as you said, you're spot on as always, Doctor Hardy in terms of, do we know the organism that lead to death? And if we don't know, that's fine. A number of times we really don't know, we haven't got those results to hand. And what we would advise is then after saying, perhaps it's a community acquired pneumonia in brackets organism on the one. So, absolutely. What about this one? Um Doctor Hardy? So we've got one, a community acquired pneumonia, organism unknown. And then in two, remember part to part to as it says, there is other significant conditions contributing to death but not related to the disease or condition causing it. So this is not where we list every past medical history or medical condition that the patient had. It's those specific conditions that contributed to death, but certainly the hyper, yeah, the hypertension is a bit, it's not, it's not just like in um the ischemic heart disease, the asbestos maybe relevant if there was a priest in for underlying lung disease or if there was, if there was evidence of asbestosis, so it could be asbestosis or mesothelioma, uh, causing pneumonia. But the hypertension and the ischemic heart disease are co morbidly conditions and they don't help, but I don't think they could directly implicate them with pneumonia. And what, what if, what if it was a mesothelioma and it was directly related to asbestos exposure? Well, who would need to be contacted, do you think? Well, the coroner would definitely need to be contacted cause that's one of those occupational um, causes of death. Absolutely. So it's really asking ourselves, did the asbestos exposure contribute to death? Did it cause this patient's death? And if we, if we do feel it didn't, it's, it's on the M C C D, then that needs discussed with the Coroner Service, Northern Ireland as an occupational exposure. Ok. Aspiration pneumonia. One a with part to COPD. What do you think of that? One? The aspiration pneumonia is sort of hanging on its own with no clarification as to how that aspiration pneumonia occurred. It could occur because the patient may have an underlying frailty condition or may have an underlying disorder of swallow or may have had an underlying stroke which contributed to the aspiration pneumonia. So it's, it's, it's a mechanism of death, but it doesn't tell us how the patient got to the stage with an IV, but they had an aspiration. It could be a simple choking that caused it. So, I think where the aspiration pneumonia Kayleigh occurred on a background of, um, frailty stroke, previous stroke, stroke or neuro muscular disorder, which could be put in there. That would, that would explain it nicely. But on its own, there's not enough information or I don't think. Absolutely. So, aspiration pneumonia. If it went to the General Register's office without any qualification, they would be asking questions because it could have been as the result of something sinister, like a sinister choking episode. So what we would suggest whenever it's aspiration pneumonia, that's lead to death is to qualify it. So why, why did the patient aspirate, aspirate? Well, was it when I aspiration pneumonia? Judo or a pharyngeal dysphasia as Doctor Hardy Hardy was saying secondary, disagreeable in fart. So any aspiration pneumonia is a cause of death needs qualified COPD, avoid abbreviations. They cause a lot of stress and unhappiness for families. And we use so many abbreviations and every day I see a new abbreviation in medicine. So avoid abbreviations because uh the families may not understand them and they will be googling them and trying to work out what they mean and we don't want to cause any distress for the family. Yeah, there are a few abbreviations HIV or AIDS. Is that right? That can be, yes, that's correct. That's correct. No, you're absolutely right. You're absolutely right. Absolutely right. Doctor Hardy. But if we can avoid them that we should try to avoid them what about this one? A industrial hemorrhage again, it's, it's, it's a mechanism of death. It's, but what's it do to um is there, is there, was there underlying trauma? Was the patient on anti coagulation? Um Did the patient have an underlying bleeding disorder? Um Did the patient have uncontrolled hypertension or after cirrhosis which have contributed to it? Those are kind of the thoughts that would be thinking of. Yeah. Absolutely. Spot on. So was it spontaneous or traumatic? So we would suggest you qualify it so that there's no uncertainty as to what type of insert, industrial hemorrhage. How was it caused? Okay. What about this one? So one a back to community acquired pneumonia organism unknown. But let's look at two scheme of heart disease, right? Hemicolectomy, diabetes mellitus. What do you think John off the right hemicolectomy? Right, hemicolectomy. It was no idea when that. So a right hemicolectomy may have absolutely nothing to do with this condition or the right hemicolectomy may have been a recent undertaking and that this pneumonia closely followed surgery or the right hemicolectomy may have been for a malignant process and that the pneumonia maybe a consequence of that. But the the right hemicolectomy may have been something extremely in the past and uh and it's not telling us what the right hemicolectomy was for, you know, why? Why was that surgery? It's not going appendicectomy when stealing for independence. What was that pathology that it was done for did it have any relevance with the community? Acquired pneumonia if it's historical and was done for something, an illness that has now long gone, it don't think it should be. It's not a significant contributor. Yes. Absolutely. So, it was, it was, as you say, historical and, and, and if it is, and it doesn't contribute to death, it shouldn't be there. If we felt that the right hemicolectomy contributed to patient's death that would need discuss to the coroner's service. But if it's historical, it's just been listed as a patient's medical condition from years ago, it shouldn't be there okay. And for a similar um similar reason here. So looking down into for the for this patient. So this was a patient who passed away than aspiration pneumonia, secondary one B or pharyngeal dyskinesia. And see Alzheimer's dementia you see down in to now we have fractured neck of femur. So for the same reason, if this was a fractured neck of femur years ago, that didn't contribute to this patient's death, then it shouldn't be there. It didn't contribute to the death. It was, it shouldn't be on the medical certificate of cause of death. But if it did contribute, say a patient had been in hospital following a fractured neck of femur and then had aspirated for instance, because there's been a mobile, I'm in bed and we really felt that this fractured neck of femur contributed to this patient's death, then it needs to discuss with the Coroner service. Okay. And coming back to one of my original points, let's look at part too. So look at all the conditions that could be listed and these are all the patient's past medical history, osteoarthritis, chronic kidney disease, hypothyroidism, epilepsy, depression, hypertension. So part two, coming back to an original point isn't for every other co morbidity the patient had it's for those significant conditions that contributed to death. So just think, did that condition really contribute to the patient's death? Okay, John, back to you. What do you think of this one? A metastatic lung carcinoma? Well, it's definitely a cause of death. But what's the metastatic lung cancer from, is it a medicine attack? What tumour is that originally from? It's a metastatic cancer? So it's not lung cancer. So what it may be a lung cancer metastasizes in itself? But what is the primary malignancy here? Absolutely. And also where did it metastasize to give a bit a little bit more information if you know the sites of the spread of the metastases list them that can actually help families and and and also it helps public health data. Okay. So instead of just metastatic lung carcinoma, small cell lung carcinoma with metastases to liver and bone. Ok. To summarize, we're here to help, we're all very approachable. Make sure you know as much about your patient as possible, complete your medical certificate cause of death as fully as possible and phone us, we will return your call and we'll have a two way conversation and come to an agreed um formulation for the medical certificate of cause of death were here ultimately to support you, but also to support our families. Thanks very much. Thanks so much John. Yeah, that's fantastic. Thank you very much. You can stop the sharing. Now, before I started this video, I taught our F one's at lunchtime and I asked F one, what do they think about the I M E s? Um They remembered you, you're extremely kind, but they, all of them said that the I M E service was excellent. There was a real good educational service for them as well. It made them feel much more secure about how the reported death and it really improved their, their ability to complete successfully a medical certificate cause of death. So it's an excellent service that's very much appreciated by all of the staff. Um So it's very, very helpful. I mean, I know they get training and MCC D but nothing replaces the training with the real life situations in which they are faced. Uh That's been very clear, it's very helpful. It's very good to see it from the I M s perspective, especially the timelines when you're looking at the cases and then coming back to them. And I think what you've clearly emphasized is the reassuring nature of an I M E. It's not the Spanish in position. It's for you to work alongside our junior doctors to make sure that they get an accurate MCC D to educate them in the cause of death and to support all the families. So it's, we very much appreciate the service. So I'm going to stop. I don't think of any of it. You've answered all the questions. One of the questions that would come through occasionally on the M and M because I chair R M and M is what if there's a disagreement? But she clearly said um if there's a cause for if the junior doctor filling out the M C C D and the the I may have a discrepancy, then there's time to go to the consultant or the registrar who's been heavily involved in, in the care of that patient who deal with any clarifications. It's really all about communicating and it's our pool of communication if that's needed. That's right, John. That's brilliant. Thank you so much. Lovely to see you, John. Just stay.