Expert Witness Journal Issue 64 December 2025 - Flipbook - Page 9
Behind Every Death: Lessons from
a Transplant Surgeon and Medical
Examiner in Clinical Negligence
by Mohammad Ayaz Hossain, Consultant Renal Transplant Surgeon and Royal College of
Pathologist Medical Examiner Royal Free Hospital NHS Trust
This article explores how the dual role of Consultant
Kidney Transplant Surgeon and Medical Examiner
enhances the quality and credibility of expert
witness practice in clinical negligence cases.
Drawing on over 15 years of surgical experience
and leadership in the National Organ Retrieval
Service, the author re昀氀ects on how Medical
Examiner duties—particularly the structured review
of deaths—sharpens medico-legal insight. Through
regular scrutiny of clinical records, communication
pathways, and systemic processes, the Medical
Examiner role cultivates pattern recognition, ethical
awareness, and objectivity. Recurring themes such as
delays in recognising deterioration, documentation
failures, and missed escalation opportunities are
examined, with anonymised examples illustrating
their relevance to breach of duty and causation
analysis. The article highlights how these insights
inform the structure, clarity, and impartiality of
expert witness reports, and proposes that Medical
Examiner experience be recognised as a valuable
asset for clinicians engaged in medico-legal work.
My experience in transplant surgery has naturally
led to a deeper engagement with clinical
governance and patient safety, which I now apply
in my role as a Medical Examiner (ME) for the
last 5 years. The complexities of transplant care—
from listing patients and coordinating live donor
pairs to leading national organ retrieval—require
meticulous attention to detail, ethical clarity, and
robust decision-making. These same principles
underpin the ME system, where I independently
review deaths, identify potential concerns in
care, and communicate sensitively with families.
This dual perspective has not only broadened my
understanding of systemic issues in healthcare
but also enhanced my ability to scrutinise clinical
events with objectivity and precision—skills that are
invaluable in expert witness work.
The ME system was introduced in England and
Wales to improve the scrutiny of deaths and
enhance transparency in the certi昀椀cation process.
This was done primarily as a response to Shipman
enquiry. Medical Examiners are senior doctors,
often consultants, who review deaths including
those that are referred to His Majesty’s Coroner.
They are independent of the clinical teams involved
in a patient’s care. Their responsibilities include
examining medical records, discussing cases with
the attending clinical team, and speaking with
bereaved families to identify any concerns about
the care provided. The role is designed to ensure
that deaths are accurately certi昀椀ed, that learning is
extracted from adverse outcomes, and that potential
systemic issues are 昀氀agged early. This additional
bene昀椀t improves overall governance and accurate
collection of mortality statistics for public health
purposes.
Introduction
I have worked as a training and Consultant Kidney
Transplant Surgeon for the past 15 years, performing
over 350 kidney transplants across several
leading UK transplant centres. My experience in
transplantation has spanned multiple units, giving
me a broad perspective on surgical practice and
transplant logistics. My role includes assessing
and listing patients for the national transplant
waiting list and selecting suitable donor-recipient
pairs for the live donor programme—tasks that
demand clinical precision, ethical sensitivity, and
multidisciplinary coordination. Outside the role as a
transplant surgeon, I am also a lead surgeon for the
National Organ Retrieval Service, which involves
direct procurement of organs for other transplant
centres around the country for the purpose of
implantation.
EXPERT WITNESS JOURNAL
Unlike coroners, Medical Examiners do not conduct
legal investigations but serve as a vital bridge
between clinical governance and patient safety. In
my own practice as a Kidney transplant surgeon,
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