Safety for Patients through Quality Review (SPQR)

  • Research type

    Research Study

  • Full title

    Evaluation of medical examiners’ review to identify potentially avoidable deaths due to problems in care



  • Contact name

    Steve Goodacre

  • Contact email

  • Sponsor organisation

    Sheffield Teaching Hospitals NHS Foundation Trust

  • Duration of Study in the UK

    1 years, 11 months, 31 days

  • Research summary

    The public are worried about the risk of suffering an avoidable death in hospital. The NHS has a process for identifying potentially avoidable deaths by looking at hospital records called a case record review. This is being rolled out across the NHS, but reviewing every death will take a huge amount of work.

    A new role, known as the medical examiner, offers a possible solution. This is an independent experienced doctor who reviews the certified cause of death and checks whether the death should have been referred to the coroner.

    It is intended that all deaths in the NHS should be reviewed by a medical examiner. Although their assessment is brief, the medical examiner can identify poor care, and ask the hospital to undertake an inquiry when poor care is suspected. This process could also be used to select patients for a more detailed review.

    This project aims to compare medical examiner assessment, to case record review. We will identify 2500 deaths that have been assessed by the medical examiner across 5-10 hospitals. Case record reviews for these cases will be checked to identify poor care and determine whether death was potentially avoidable. We will consider whether the medical examiner assessments identified avoidable death. We will specifically look for cases where the medical examiner decided that no further investigation was required, but case record review suggested that death could have been avoided. Where differences are identified, we will look more closely, to determine how the two processes could best work alongside each other. We will undertake interviews with medical examiners to learn more about how they work. We will also look for common themes, in poor care and avoidable death, in the study cases. This will be used to improve care and hopefully reduce the risk of avoidable deaths in the future.

  • REC name

    Wales REC 5

  • REC reference


  • Date of REC Opinion

    21 Jul 2017

  • REC opinion

    Favourable Opinion