The national medical examiner system is being rolled out across England and Wales, initially on a non-statutory basis, and is part of the Death Certification Reform Programme for England and Wales. It also forms part of the NHS Patient Safety Strategy and the NHS Long Term Plan in England.
The all-Wales Medical Examiner Service is a critical part of the long-established mortality review programme. Throughout 2020, medical examiner offices have been established at acute trusts in England and at regional hubs in Wales, initially providing scrutiny of non-coronial deaths in acute care. This remit is being expanded in 2021 and 2022 to cover non-coronial deaths that occur in other settings such as the community.
A core part of the medical examiner role is to provide bereaved people with clear information about the cause of death, and an opportunity to raise any concerns they may have about the care and treatment provided to the deceased person. Medical examiners also carry out a proportionate review of patient records and discuss causes of death with the doctor completing the Medical Certificate of Cause of 5 | National Medical Examiner’s report 2020 Death (MCCD). They ensure concerns about patient care are identified promptly and referred for further investigation, to improve services and care for all patients.
This report describes progress and next steps, building the foundations of a medical examiner system that will facilitate reflection, learning and improvement across the entire health system.