All death by natural causes to be cross-checked under new reform to prevent another Lucy Letby case

14 December 2023, 21:16

A new reform will cross-check all deaths not referred to the coroner.
A new reform will cross-check all deaths not referred to the coroner. Picture: Alamy

By Jenny Medlicott

All deaths from natural causes will be checked by a second doctor to prevent another Lucy Letby or Harold Shimpan case under a new reform.

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Under the change, medical examiners will have carefully scrutinise any deaths in England and Wales that are not set to be referred to coroners.

The reform, which ministers have said will “help prevent criminal activity and poor practice”, will be implemented from April next year.

Officials have said the move is to “strengthen safeguards” and “protect the public” following the Lucy Letby baby murders.

A national system to cross-check deaths was first recommended two decades ago at a public inquiry in the wake of serial killer GP Harold Shipman, who killed more than 200 people.

Medical examiners will have to confirm the proposed cause of death and overall accuracy of the death certificate under the reform, as well as support any appropriate referrals to the coroner.

The proposed cause of death will also be discussed with families to give them the chance to ask questions or raise any concerns.

Health minister Maria Caulfield said: “It has taken time to get this right, but it was vital we had the backing of all involved in the process in order to make sure it protects people and supports bereaved families in the way they deserve.

“Although abuse of the system is rare, what we are announcing today will be a significant step in preventing failures in the future.

“I want to thank all those involved in the process – from medical professionals, to coroners, to registrars – for helping this government fulfil its promise of introducing a safer system of death certification.”

The reform hopes to prevent another case such as Lucy Letby.
The reform hopes to prevent another case such as Lucy Letby. Picture: Alamy

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The reform hopes to prevent another case such as Lucy Letby or Harold Shipman through extra safeguarding measures.

Harold Shipman, Britain’s most prolific serial killer, managed to evade detection by marking patients he murdered as having died by natural causes - circumventing coroner examinations.

Lucy Letby, a former neo-natal nurse, was found guilty of murdering seven babies and trying to kill six more between June 2015 and June 2016 at the Countess of Chester Hospital.

It comes just days after Letby was stripped of her nursing credentials after a panel ordered she be struck off from the register at a Nursing and Midwifery Council (NMC) hearing.

The panel found she was unfit to practice nursing before it went on to make the striking-off order, a move they have heard Letby did not resist, despite maintaining her innocence in respect of her convictions.

Harold Shipman was Britain's most prolific serial killer.
Harold Shipman was Britain's most prolific serial killer. Picture: Alamy

Dr Suzy Lishman, of the Royal College of Pathologists, said of the reform: “Medical examiners are already scrutinising the majority of deaths in England and Wales, identifying concerns and helping improve care for patients and support for bereaved people.

“The move to a statutory system in 2024 will further strengthen those safeguards, ensuring that all deaths are reviewed and the voices of all bereaved people are heard.”

National Medical Examiner Dr Alan Fletcher said: “The NHS is pleased the government is putting the work of medical examiners delivering independent scrutiny of all non-coronial deaths in England and Wales on a statutory footing in April 2024.

“As the medical examiner system lead, I have witnessed the care medical examiners take to support bereaved people, increase safeguards, and identify opportunities to improve care.

“Medical examiners ensure that if bereaved people have concerns after their loss, these can be raised as easily as possible, which is why it is great to see this progress towards a comprehensive system.”

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