The 2024 report from NHS England’s national medical examiner, Dr Alan Fletcher, marks a milestone in the transformation of death certification across England and Wales. Following the statutory rollout of the medical examiner system on 9 September 2024, the report reflects on the system’s performance and its wider impacts, including those on bereaved families.
The statutory implementation of the medical examiner system represents the most significant change to death certification in over 50 years. It ensures that every death not referred to a coroner is independently scrutinised by a medical examiner, offering families the opportunity to ask questions and raise any concerns with someone outside the deceased’s care team.
Key impacts in 2024
Volume of scrutiny
By July 2024, over one million deaths had been reviewed under the non-statutory system. Medical examiners also increased the proportion of non-acute deaths scrutinised from 41% to 58% in England following improved connections with primary and community healthcare providers.
Medical examiners have also referred 7-8% of deaths in acute trusts for case record reviews, and 5-6% of all deaths for clinical governance review. Of those reviews, 2873 were deaths of people with a learning disability or severe mental illness.
In addition, 1,922 patient safety incidents in England were notified by medical examiner offices as a result of scrutiny. The example given is a cluster of infected implants, which was escalated to the clinical lead for orthopaedics to investigate, and dealt with via the Learning from Deaths team.
Medical examiners have also referred a few matters to coroners and the police.
Deaths reported to coroners fell by 10% in 2024 compared to 2023 and are expected to fall further in 2025, reflecting the role of the medical examiners in ensuring more consistent notifications to coroners and avoiding unnecessary referrals. The Chief Coroner’s annual report 2024 provides further comment on the medical examiner system.
Sharing patient records between healthcare providers
While current arrangements allow medical examiners to access patient records adequately, there is recognition that greater use of electronic records and enhanced digital connectivity across the NHS are essential. These improvements would facilitate easier and more efficient sharing of patient records with medical examiners.
It only became clear this year that medical examiners in England can only access some parts of shared care records – social care records – if the attending practitioner reviews them and shares them with the medical examiner. A change in the regulations will be required to remove this obstacle.
Family engagement
Medical examiners report overwhelming positive feedback from families, who value the opportunity to engage in the process.
Quality and safety
Medical examiners identified patient safety concerns, quality issues, and clinical governance matters, contributing to system-wide learning.
The scrutiny process helped detect poor practice and supported continuous improvement in care delivery.
Improved data quality
The redesigned Medical Certificate of Cause of Death now includes mortality data on ethnicity, pregnancy status, secondary causes, and presence of medical devices.
Inquiries
Recent inquiries – Thirlwall and Lampard – have asked the national medical examiner to provide a witness statement and appear as a witness. The Royal College of Pathologists has published an updated good practice paper to support medical examiners, and an e-learning module.
Comment
2024 marked a milestone as recommendations originating from the Shipman Inquiry were finally implemented. Feedback from families and medical examiner officers has been ‘overwhelmingly’ positive, with many offices reporting enhanced collaboration with local partners involved in the death certification and registration process. Despite these advances, some regions continue to face challenges, highlighting the need for further efforts to strengthen local relationships and ensure consistent improvements across all areas.
The report concludes by urging Integrated Care Boards and NHS Trusts in England to continue supporting medical examiners and their offices. Ongoing collaboration is essential to maintain high standards and ensure the continued effectiveness of the death certification system.
Our content explained
Every piece of content we create is correct on the date it’s published but please don’t rely on it as legal advice. If you’d like to speak to us about your own legal requirements, please contact one of our expert lawyers.