National medical examiner update – September 2023


As we move into autumn, I am sure we are all looking forward to next steps towards the statutory medical examiner system. In the coming months we expect the government to commence the relevant primary legislation and to publish the draft regulations.

We should be clear that this is very much the home straight – although the regulations are draft, their publication does not represent a consultation, but rather an opportunity for all stakeholders to understand how the new statutory death certification process will work, and to make necessary preparations. I assure you that clear and concise communications are being prepared in partnership with other stakeholders.

We recently finished verifying data from medical examiner offices’ quarterly submissions, and I am excited about the pace at which progress is being made. The proportion of deaths scrutinised in non-acute settings grew to around 30% in June 2023, up from 22% in April 2023 and 16% in December 2022. I would like to thank medical examiners and officers for all you are doing to make this possible.

Of course, numbers are important, but only tell part of the story. Medical examiner offices continue to receive positive feedback, primarily from bereaved people, but also from wider stakeholders in the death certification progress. Medical examiner offices also continue to provide encouraging examples of the impact they are having to improve care.

You may also have noted that medical examiners were cited as a key safeguarding initiative for the NHS and the Government in the wake of the verdict in the trial of Lucy Letby. A similar message was sent to NHS CEOs in Wales. After such horrific and tragic events, the importance of moving to the statutory system is clear.

The prospect of concluding preparations for the statutory system is welcome after many years hard work. I, along with my national team and regional colleagues, look forward to working with you in the coming weeks and months. I am delighted that Danielle Wall has joined us as Regional Medical Examiner Officer for the East and Midlands regions.

Finally, I was delighted to visit the medical examiner office in Southampton, and I would like to thank lead medical examiners Paul Wharton and Harnish Patel, and team, for their excellent work, and extending such a warm welcome to me.

Dr Alan Fletcher, National Medical Examiner

Draft regulations and primary legislation

The government announced in April 2023 that relevant primary legislation will be commenced in Autumn 2023, and draft regulations will be published. It is important to note that the regulations while draft, are unlikely to change significantly.

Their publication does not open a new consultation, but rather gives all stakeholders an opportunity to prepare and to understand how the new statutory death certification processes will operate, before Parliament agrees the final regulations.

Extended hours

Regional medical examiners and officers in England have been working with medical examiner offices to consider options for working at weekends and on bank holidays. Colleagues in Wales have also been considering this (see article below). The work is informed by principles in the good practice papers on extended hours and urgent release of bodies.

As noted in the National Medical Examiner’s Good Practice Guidelines, medical examiner offices must be open at times that meet the needs of the local population, with cover provided for staff on leave.

Some out-of-hours provision is likely to be needed in most areas, but not 24/7 cover. Host organisations should consider the needs of their local population in determining the appropriate service to provide.

Employing GPs as medical examiners

We have heard a number of instances where GPs who are medical examiners are offered different rates of pay to hospital doctors. In most cases of discrepancy, though not all, it appears GPs have been offered lower rates of pay.

The National Medical Examiner has clearly stated that there should be parity of recognition for senior experience for medical examiners from all specialties including GPs, and while unable to mandate terms and conditions, this disparity appears unjustified. Many NHS trusts have mechanisms in place to deliver equitable pay.

World Patient Safety Day 2023

The theme for WHO World Patient Safety Day 2023 on 17 September, was engaging patients for patient safety. NHS England published a blog from Dr Alan Fletcher on how medical examiners support bereaved people and help improve patient safety.

The Royal College of Pathologists have published the latest Good Practice paper from the National Medical Examiner, which considers how to maximise the benefits of the medical examiner system, by ensuring that medical examiner offices escalate trends and themes they have detected, and by evaluating and quality assuring their work.

Podcast – GPs and medical examiners

We are reminding colleagues that we released a podcast exploring how GPs and medical examiners can work together to improve the experience of bereaved people.

The podcast also explores the range of benefits that medical examiners can bring to GP practices by working with them in the period before medical examiners become part of the statutory death certification process.

Implementation in Wales

The Medical Examiner Service for Wales has largely completed the recruitment of medical examiners and officers. After completing training and assessments, the service will be at full operational capacity from the autumn. In line with this, we are now looking to introduce arrangements to support weekend working in a manner appropriate for the statutory system.

We have continued to develop a CPD/training programme that focuses specifically on primary care. This allows medical examiners and medical examiner officers to understand the differences between primary care and secondary care practice, including prescribing, safety netting and referral practice from a GP perspective.

Following a review of operations, we will be introducing changes to the management structure to enhance the day-to-day work, and to improve the quality of feedback and reporting. This will strengthen links to quality and safety systems across all care providers in Wales, and work with health boards will refine and develop the ‘detect and pass on’ pathway.

This will ensure separation between observations, feedback, and concerns, as well as standardising how the Medical Examiner Service notification is managed between the Putting Things Right (PTR) pathways, the HOPE Safety & Learning Network, and the patient safety and quality improvement teams.

The Mortality Framework and pathway is also being expanded to include primary care, and specific processes for thematic reporting back from care providers to the Medical Examiner Service are in development.

This area has been highlighted by recent events, and it is clear that the independence of medical examiners, and the ability of the service to collate and communicate data and information effectively, and to escalate concerns, are crucial to achieving the aims of the service.

As part of our quarterly reporting process, we are developing dashboards for medical directors to understand cases scrutinised from their organisation, and to compare these with other organisations across Wales.

Finally, we are continuing to develop links across the death certification system, ensuring our service is integrated with the work of others so that we can complete our part of this process in the least disruptive way while meeting our service obligations.

This includes working with the coroner areas in Wales to develop a single, agreed, process for managing community deaths that require joint working between the Medical Examiner Service and coroner. This will ensure that we minimise duplication and prevent omissions from both processes.

Quarterly reporting in England

The next date quarterly reports can be submitted is 2 October 2023. Please do check the latest guidance in the annex when completing these returns as it saves follow up calls to verify details.

Training and events

To date 1,997 medical examiners have been trained and over 632 staff have completed the medical examiner officer training. It was particularly good to experience a face-to-face medical examiner training session on 14 June.

We would like to thank all the faculty facilitators who give their time to support the training, without whom this would not be a success. Future training sessions are arranged.

Contact details

We encourage you to continue to raise queries with us and share your thoughts on the introduction of medical examiners, through the contacts list.

The page contains contact details for the national medical examiner’s office, the medical examiner team in Wales, and regional medical examiner contacts in England.

Further information

Further information about the programme, including previous editions of this bulletin, can be found on the national medical examiner webpage.

NHS Wales Shared Services Partnership also has a web page for the medical examiner system in Wales.