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What are "Mortality reviews" and "Medical Examiner reviews" and why are they different to PTR or PSI investigations?

Mortality reviews form part of a standard process when someone dies in hospital.  The reviews are designed to assess the care and treatment provided to a person and to identify any opportunities for learning and improvement.  As part of the process, the reviews consider if there was anything that occurred during the person’s care that might have caused or contributed to their sad death. 

Medical Examiner (ME) reviews were introduced recently in England and Wales.  The Medical Examiner Service provides independent scrutiny of all deaths not investigated by the coroner.  The ME service ensures that an accurate cause of death is recorded, and identifies any concerns surrounding the death itself, which can then be further investigated if required. The ME also takes on board the views of the family and friends of the person who has died.

The ME service was not fully implemented in Wales at the start of the pandemic, meaning some people who died earlier in the COVID-19 pandemic will not have been subject to an ME review.

Importantly though, mortality reviews or reviews undertaken by the independent Medical Examiner service, cannot be considered as an investigation according to the Regulations.  These reviews seek to answer different questions to an investigation, which aims to understand what happened, why it happened and what actions can be taken to improve future patient safety, experience and outcomes.

However, a patient safety incident (PSI) review will be started where mortality or medical examiner reviews identify anything unintended or unexpected.  This would then trigger an investigation in keeping with the requirements of the Regulations. Therefore these processes compliment and inform each other.