National medical examiner annual report 2023

Summary

Report summarising the progress of the implementation of medical examiners during 2023.

Content

The Death Certification Reforms come into force on 9 September 2024 and from this date independent scrutiny by a medical examiner becomes a statutory requirement for registration of all deaths in England and Wales not investigated by a coroner.

Medical examiners are senior doctors employed by NHS bodies in England and Wales.

In England, they are supported by medical examiner officers and are based in 126 medical examiner offices in NHS trusts.

In Wales, the service is being provided by NHS Wales Shared Services Partnership (NWSSP), an independent mutual organisation, owned and directed by NHS Wales. The four hub sites cover all health board areas with substantial growth throughout 2023 in scrutinising deaths in non-acute healthcare settings.

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 bereaved people and an opportunity for them to raise any concerns to a doctor not involved in the care of the deceased
• improve the quality of death certification
• improve the quality of mortality data.

"This statutory footing is extremely good news for the medical examiner system I am grateful for the hard work of all medical examiners and officers leading up to this important milestone. Medical examiners are already supporting patient safety, learning and improvement, along with more consistent and appropriate coroner referrals. The weeks before the Death Certification Reforms come into force will allow time to cement excellent working processes and to ensure we make the most of the insights medical examiners can bring. I am sure, like me, they are delighted to now be planning with certainty.

Listening to our podcasts, GPs and medical examiners working together and changes to the death certification process and introduction of the statutory medical examiner system can answer questions about some of the changes from 9 September 2024, as can listening to the recordings of two timely information events The Royal College of Pathologists hosted about the statutory system on 17 January 2024 and 11 June 2024."  Dr Alan Fletcher, National Medical Examiner