Deaths in England and Wales to be reviewed by senior doctor if not referred to coroner
The death certification system in England and Wales will get its biggest overhaul in decades next month, with a change designed to improve public protection.
Every death that has not been referred to a coroner will have to be referred to a medical examiner from 9 September, under regulations laid before parliament in April.
The new system will provide independent scrutiny and an opportunity for the bereaved to speak about care and treatment in the lead-up to a death. It is intended that the overhaul will give assurance to relatives and reduce the risk of NHS scandals or malicious action by medical practitioners.
The serial killer and family GP Dr Harold Shipman evaded detection for years because he was able to issue death certificates for his victims, in which he gave “natural causes” as the cause of death.
Dr Alan Fletcher, the national medical examiner for England and Wales, said: “I am delighted that medical examiners will soon review every death in England and Wales not investigated by a coroner. The death certification reforms are a significant step towards ensuring serious issues are identified quickly and passed on for action.”
Medical examiners will be part of a national network of trained independent senior doctors, scrutinising all deaths that do not fall under a coroner’s jurisdiction. They will ensure the accuracy of the death certificate, establish whether the death should be referred to a coroner and whether there are any clinical governance concerns.
Examiners are employed by NHS bodies. The new national system was proposed in 2005 after the Shipman inquiry; the once-trusted family doctor killed about 250 patients between 1971 and 1998.
Other inquiries into NHS failings have also recommended that medical examiners be used. The inquiry into the scandal of failures at Stafford hospital between 2005 and 2008 heard evidence that death-certificate information had often been inaccurate or incomplete.
Since 2019, NHS trusts have appointed medical examiners to scrutinise most deaths that have taken place in acute healthcare settings. As of June 2024, while operating on a non-statutory basis, medical examiners have scrutinised more than 900,000 deaths in England and Wales. Scotland has its own death investigation service using medical reviewers.
Fletcher said: “Rollout of the medical examiner system has enabled us to improve the experience of bereaved people, who have overwhelmingly been positive about the support they’ve received, with many saying they’ve been freed from doubt and worry that they could have done more for a loved one in their last days. Now, thousands more people will be supported by senior doctors in these roles.
“In the majority of cases, there are no serious concerns, and positive feedback from families is often received and passed on to staff providing care,but where there are issues, the independent role of medical examiners, underpinned by statute, will provide a new avenue for bereaved people and NHS staff to share any concerns they have, and for healthcare providers to learn, and improve care for future patients.”
