From 9 September 2024, all deaths across all health settings that are not investigated by a coroner will be reviewed by NHS medical examiners. The move comes as part of the government’s wider reforms to death certification.

The College is the lead medical royal college for medical examiners and long campaigned for their introduction. The College worked closely with key stakeholders for many years to implement this important patient safety initiative. Since the roll out of the non-statutory system in 2019, the College has trained over 3000 medical examiners and officers.

Baroness Merron, Parliamentary Under-Secretary, Department for Health and Social Care, said:

'For the first time, all deaths not investigated by a coroner will be scrutinised by a medical examiner, a doctor independent from the care of the patient, who will act as a point of contact for the bereaved and provide support in all cases.'

'These reforms will provide comfort and clarity to the bereaved in the difficult moments following a death, as well as supporting vital improvements to patient safety.'

Dr Golda Shelley-Fraser, Chair of the Royal College of Pathologists Medical Examiners Committee said:

'As the lead medical royal college for medical examiners, we are delighted that the medical examiner system is now statutory. Medical examiners provide independent scrutiny of all deaths not referred to a coroner and offer a voice to the bereaved. They offer an opportunity for family and friends to raise any concerns they may have about the care of their loved one, which can help improve care for the living.'

Dr Suzy Lishman CBE, Senior Advisor, RCPath Medical Examiners Committee, said:

'Since this vital patient safety initiative was introduced, feedback from families has been overwhelmingly positive. People welcome the opportunity to talk to someone about their loved one’s final illness and death, and better understand what happened. The independence of MEs is valued, as is the opportunity to ask questions, understand what is written on the death certificate and raise any concerns. All feedback, the majority of which is positive, is passed on to help healthcare providers improve care for future patients.'

Dr Alan Fletcher, the National Medical Examiner for England and Wales, said:

'More than one million deaths have already been independently scrutinised by medical examiners working in the NHS in England and Wales since the medical examiner system was introduced in 2019. The rollout has also improved the experience of bereaved people, who have overwhelmingly been positive about the support they’ve received.'

'The statutory implementation will further strengthen our well-developed system to help detect any patient safety issues and make sure cases are being referred to coroners when appropriate.'

More information

The move to the medical examiner system to a statutory footing comes as part of the government’s wider reforms to death certification which includes a new medical certificate of cause of death (MCCD) when medical practitioners will be able to complete an MCCD if they attended the deceased in their lifetime. This represents a simplification of the current rules, which before 9 September required referral of the case to a coroner for review if the medical practitioner had not seen the patient within the 28 days prior to death or had not seen in person the patient after death.

The Royal College of Pathologists is the lead medical royal college for medical examiners and plays a key role in the training of medical examiners and medical examiner officers. Their roles provide greater safeguards for the public by ensuring independent scrutiny of all non-coronial deaths.

A national system of medical examiners was recommended by three separate public inquiries: the Shipman Inquiry, the Mid Staffordshire Report, the report of the Morecambe Bay Investigation.

Medical examiners are senior medical doctors who are contracted to provide independent scrutiny of the causes of death, outside their usual clinical duties. They are trained in the legal and clinical elements of death certification processes. The purpose of the medical examiner system is to:

• provide greater safeguards for the public by ensuring independent scrutiny of all non-coronial deaths
• ensure the appropriate direction of deaths to the coroner
• provide a better service for the bereaved and an opportunity for them to raise any concerns with a doctor not involved in the care of the deceased
• improve the quality of death certification
• improve the quality of mortality data