He said: “I think one of the things that could have potentially meant that what happened at the Countess of Chester was spotted earlier and the dots were joined up would have been having medical examiners.”
The introduction of medical examiners across the NHS in England and Wales – to provide independent scrutiny of causes of death, address any concerns from bereaved families, work with coroners and review medical records – had been recommended by previous healthcare inquiries.
The system was first suggested at the inquiry into the crimes of serial killer GP Harold Shipman in 2004 and then further recommended by Sir Robert Francis in his 2013 report into the neglect of hundreds of patients at Mid Staffordshire NHS Foundation Trust, the Thirlwall inquiry heard.
Mr Hunt said it was only when the issue of funding medical examiners came across his desk again in 2023 when he was chancellor that he “pushed it through”.
Since last September all deaths in any health setting in England and Wales that are not investigated by a coroner are being reviewed by NHS medical examiners.
He suggested medical examiners should be trained to see the signs or patterns of malicious harm in the work of a healthcare professional and that having “malicious actors” such as Shipman and Letby at the backs of their minds could make a “big difference”.
The inquiry heard a non-statutory rollout of medical examiners in England and Wales began in 2019.
Mr Hunt said: “I think the medical examiner system, when it works well, is incredibly important to a healthcare system because I think it’s not just important for learning from mistakes, it’s also very important for families who have been bereaved to have someone independent that they can talk to and raise concerns.
“Feedback from relatives was a very important clue for them as to where things might be going wrong.”
