Skip to content

Medical examiners and reforms to death certification in England and Wales

The Government has published its response to the 2016 Death Certification Consultation by confirming the introduction of medical examiners to achieve a more comprehensive system of death certification for all non-coronial deaths.

The Government has acknowledged that the death certification system in England and Wales has been long overdue for reform, remaining largely unchanged for more than half a century. An initial high-level consultation took place in 2007 in response to the Third Report of the Shipman Inquiry which suggested a radical overhaul of the death certification. The Mid-Staffordshire (Francis Inquiry) 2013 report included further observations. These relate to certification and inquests where death has occurred in a hospital. Although exact timescales have not been set, the Government has confirmed the introduction of:

  • A non-statutory medical examiner system with the appointment of medical examiners working within the NHS, and the appointment of a National Medical Examiner.
  • Implementation of sections 18 and 21 of the Coroners and Justice Act 2009 which will require medical practitioners to report deaths to the coroner that fall within six specific listed categories, including “otherwise unnatural deaths”.

Once the above are in place, the Government has confirmed that it will continue to work with interested parties with a view to implementation of the full statutory medical examiner system likely to be achieved by April 2019.

The consultation has received a great deal of support with Dr Alan Fletcher, Chair of the Medical Examiners’ Committee at The Royal College of Pathologists saying: “Medical examiners are the last piece of the jigsaw of ensuring patient safety when someone dies; their role is not to investigate but to detect and pass on.”

Prior to publishing its response, the Government trialled the system in two locations, Gloucester and Sheffield, in order to understand how the system would work in practice and to develop an idea of timeframes for implementation. The NHS Trusts in these areas have adopted the medical examiner model to aid work in relation to their learning from deaths, since March 2017.

Please click here for the Government’s response.

Further guidance will be issued in due course and Ward Hadaway will at that time provide a further update. In the meantime, please do not hesitate to contact Liz Hackett for further details and support.

Please note that this briefing is designed to be informative, not advisory and represents our understanding of English law and practice as at the date indicated. We would always recommend that you should seek specific guidance on any particular legal issue.

This page may contain links that direct you to third party websites. We have no control over and are not responsible for the content, use by you or availability of those third party websites, for any products or services you buy through those sites or for the treatment of any personal information you provide to the third party.

Follow us on LinkedIn

Keep up to date with all the latest updates and insights from our expert team

Take me there

What we're thinking