The medical examiner system is not fit for purpose

In England and Wales. the concept of a medical examiner emerged from the Shipman, Mid-Staffordshire and Morecombe Bay Inquiries. Its declared purpose became the provision of a:

“transparent system of independent scrutiny to the process of death certification” ¹

However, the Shipman Inquiry had proposed a much different structure to the system which was to emerge. It had recognised that:

“The present system is almost completely dependent upon the professional integrity and competence of the medical profession. In general the profession can be relied upon, but not always. The Shipman case has shown that the present procedures fail to protect the public from the risk that, in certifying a death without reporting it to the coroner, a doctor might successfully conceal homicide, medical error or neglect leading to death. It is said by some that Shipman is unique; there will never be another like him. I hope that is so, but other, less prolific killers have been detected in the medical profession and it is not possible to determine how many killings or how many errors by a health professional have gone undetected.” ²

Indeed, the Mid Staffordshire and Morecombe Bay Inquiries would later confirm that medical errors and neglect were responsible for a significant number of deaths and, as with Shipman’s homicides, had not been detected early on.

Consequently, Dame Janet Smith envisaged:

“a different role for the ‘medical coroner’ from that which is proposed for the ‘statutory medical assessor’. The ‘medical coroner’ would take many coronial decisions and would manage and be responsible for the operation of the district office. He or she should be an independent office-holder under the Crown with the status of the present coroner.” ²

Such a role would have had some similarities to that of the ME in the USA. However, the Coroners and Justice Act 2009 meant that:

“being a legally qualified medical practitioner of five years’ standing”

no longer sufficed and all coroners needed to have been practicing as a barrister, solicitor or legal executive (Fellow) for 5 years, Consequently, rather than involve doctors more deeply in the investigation of questionable deaths, they were moved to the periphery of the process and directed at assessing the accuracy of death certification.

During the Committee discussions on the Health and Social Care Bill, which defined the role of the Medical Examiner in England and Wales, Dr Philippa Whitford was of the view that:

“Clearly, patterns of certification and patterns of death would become obvious to a medical examiner and may produce very interesting and useful information.” ³

It is unclear as to how this could or would happen. Medical Examiners are usually appointed for one PA per week. This means that most Trusts will need to employ in the region of 10 MEs to deliver a hospital and community-based service. As such, there will be problems in identifying trends and patterns within certifications, unless the Senior ME has established an effective data base and utilises programmes capable of searching for patterns. In order to properly interpret such patterns each Trust would need to employ an epidemiologist.

A national voluntary system of Medical Examiners (MEs) was first implemented in England and Wales in April 2019. At that time, the National Medical Examiner indicated that it is important that the service is evaluated locally and encouraged the recognition of thematic issues concerned with the reporting of deaths and this is especially so since the system became mandatory from 2024. ⁴ However, there are no well-established systems for identifying such themes. The ineffectiveness of such approaches is demonstrated by the Future Deaths reports made by Coroners. It was only in 2025 that the Chief Coroner promised to publicise the names of those who fail to respond to such reports. At present (2025) more than 25% of organisations issued with such a report have made no response and 14% only a limited report. ⁵ It seems unlikely that the ‘Badge of Dishonour’ to be awarded to such organisations will have any impact, especially if the failure to respond is not given wide publicity.

On 15 April 2024, Maria Caulfield, the Under-Secretary of State for Health and Social Care, laid before Parliament the Regulations for reform of the death certification process in England and Wales with the words:

“The changes will provide greater transparency on the circumstances surrounding a death. Medical examiners will always offer a conversation to the bereaved, providing an opportunity for them to raise questions or concerns with a senior doctor not involved in the care of the deceased. This will help deter criminal activity, improve practice and ensure the right deaths are referred to coroners for further investigation.” ⁶

On 19 March 2025, her successor, Ashley Dalton, stated:

“Medical examiner offices are staffed at a trust level and arrangements at each office should reflect local health priorities and the needs of communities.” ⁷

Consequently, one of the major roles for the ME will be the support of grieving relatives. In addition, they should be at the forefront in the identification of criminal behaviour and negligent care. s6 of The Medical Examiners (England) Regulations 2024 stresses the importance of the Examiners’ independence. An ME should recuse himself from a case where he/she is:

(a) is the spouse, former spouse, civil partner or former civil partner of—

(i) the deceased person (‘D’);

(ii) the relevant attending practitioner (‘AP’); or

(iii) any other relevant medical practitioner (‘OP’);

(b) is, or was, living together with D, AP or OP as if they were spouses or civil partners;

(c) is, or was, closely related to D, AP or OP;

(d) believes they attended D during the course of D’s lifetime;

(e) is, or was, a partner, employer, employee or associate of D, AP or OP;

(f) has a financial interest in D’s estate; or

(g) has, or had, any other association, relationship or connection with D, AP or OP such as to give rise to a reasonable doubt as to the examiner’s ability to carry out objectively in relation to the death any of the relevant functions.

Within these exclusion criteria there are no references to the Medical Examiner’s employer. However, 6 (1) states:

Where a medical examiner receives a request from an English NHS body to exercise any relevant function in relation to a death, and is insufficiently independent in relation to that death, the examiner—

(a) must not exercise any relevant function in relation to the death or, where relevant, cease exercising any relevant function immediately upon becoming aware of their insufficient independence;

However, this independence must be open to question when it is considered that:

Many Trusts are clear that they will not employ MEs, who are not already working in the Trust, and others express concern over appointing candidates from outside the area

They are appointed by a Trust committee

They are frequently employed by the Trust both as an ME and as a doctor.

They will be long-standing colleagues of many of the doctors with whom they will be discussing the accuracy of death certification.

They may be dealing with doctors to whom they refer patients or from whom they receive referrals in the private sector.

Personal professional conflicts are likely to influence referrals to the coroner with both conscious and unconscious bias playing a role.

A recent example of such issues was in the recruitment of a new Medical Examiner in Leicester:

“We are looking to recruit and train practising LLR GPs* and UHL Consultants* or recently retired (within previous 12 months) to join our LLR Medical Examiner service

*with 5 year’s experience as either a GP or Consultant

You will be joining an experienced team of senior Consultant and GP Medical Examiners. The national training programme will be supplemented by local support and mentoring. Work will initially be based in the ME office at Leicester Royal Infirmary or Glenfield Hospital.” ⁸ (LLR = Leicester, Leicestershire and Rutland PCL, UHL = University Hospitals of Leicester)

This advertisement specifically excludes candidates not working for these two medical organisations. Such conflicts of interest are likely to be commonplace with the present system and raise serious questions as to whether it is fit for purpose. Despite these reservations, a recent study from the East of England has suggested that the Medical Examiner system is:

“better at appropriately identifying those cases which HMC will then proceed to fully investigate than previously when notifications from hospitals were determined by the clinical teams. This may reflect the medical and healthcare expertise within the MEs. This is another positive aspect of MEs scrutiny which was a hoped-for outcome following the introduction of the MEs. ⁹

However, such optimism will need a medical examiner system, which is clearly independent of the trusts and general practices which it covers.

The Health and Care Act 2022 has significantly extended the bureaucracy associated with death certification and the identification of criminal and negligent care. However, it has not given any body or organisation the power to implement changes which will benefit future patients. The role of the ME has become an add-on of 4 hours to a doctor’s regular practice in the hospital or community. There has been no consideration of potential conflicts of interest, which will arise between this role, colleagues and employing trusts. What has emerged is in sharp contrast to the proposals put forward by Dame Janet Smith, as a result of the Shipman Inquiry. Her Medical Examiner would have been on equal standing to the judicial coroner. He or she would have been employed centrally as part of the judicial system and would ideally have had no links to local NHS Trusts, private hospitals or general practices. In addition, any failure to adopt recommendations for better care should have been made legally enforceable by this Act. We are now in a situation where seldom one month passes before some new large-scale failure in the NHS is disclosed and there is an urgent need to develop an independent system for monitoring deaths supported by appropriate analytical software’ including Artificial Intelligence, and epidemiological expertise. In no way can the current Medical Examiner set-up be considered able to address these issues. Following the Mid-Staffordshire Inquiry, Robert Francis was clear in his recommendations about death, its investigation and certification:

“Independent medical examiners

It is of considerable importance that independent medical examiners are independent of the organisation whose patients’ deaths are being scrutinised.

. . .. . .

It should be a routine part of an independent medical examiners’s role to seek out and consider any serious untoward incidents or adverse incident reports relating to the deceased, to ensure that all circumstances are taken into account whether or not referred to in the medical records.” ¹⁰

Both Francis and Smith stressed the need for independence and for an investigative role for medical examiners. Instead, what we now have are Trust employees or local general practitioners assessing deaths and where there is uncertainty referring the case to the Coroner for an inquest – a procedure where the doctors involved in the incident together with their clinical leads are likely to be the major witnesses!!