Implement medical examiner system
Morecambe Bay Investigation · Report of the Morecambe Bay Investigation · Issued 3 March 2015 · Addressed to: Department of Health and Social Care
Source — verbatim from the inquiry
●Inquiry recommendation
There is no mechanism to scrutinise perinatal deaths or maternal deaths independently, to identify patient safety concerns and to provide early warning of adverse trends. This shortcoming has been clearly identified in relation to adult deaths by Dame Janet Smith in her review of the Shipman deaths, but is in our view no less applicable to maternal and perinatal deaths, and should have raised concerns in the University Hospitals of Morecambe Bay NHS Foundation Trust before they eventually became evident. Legislative preparations have already been made to implement a system based on medical examiners, as effectively used in other countries, and pilot schemes have apparently proved effective. We cannot understand why this has not already been implemented in full, and recommend that steps are taken to do so without delay. Action: the Department of Health.
Morecambe Bay Investigation, Report of the Morecambe Bay Investigation · 3 Mar 2015 Source PDF →
Published evidence summary
Publicly available evidence relating to this recommendation:
- The government accepted recommendations 39 and 40 in principle and reported that the medical examiner system had been tested in pilot sites (Learning Not Blaming (Department of Health, July 2015)).
- The medical examiner system became statutory in England on 9 September 2024 and provides independent scrutiny of non-coronial deaths (National Medical Examiner’s Report for 2025 (NHS England, 6 July 2026)).
- Medical examiners scrutinised 501,427 deaths in 2025 and identified 36,302 for further clinical-governance review and 2,018 patient-safety incidents; the report does not separately establish coverage of perinatal and maternal deaths (National Medical Examiner’s Report for 2025 (NHS England, 6 July 2026)).
How was this evidence gathered?
Response — verbatim from government
●Department of Health and Social Care
106. We accept these recommendations in principle.
The medical examiners
system has been trialled successfully in a number of areas across the country. We
will soon be publishing a report from the interim National Medical Examiner setting
out the lessons learned from the pilot sites.
107. The Government remain committed to the principle of these reforms. Further
progress will be informed by a reconsideration of the operation of the new system in
the light of other positive developments on patient safety since 2010 and by a
subsequent public consultation exercise on regulations required to introduce a
medical examiner system nationally in England.
108. Medical examiners would scrutinise all deaths except for stillbirths (for legal
reasons) and any death that requires a coroner investigation.
However, the
MBRRACE confidential enquiries provide independent scrutiny of all maternal deaths
and topics related to stillbirths and neonatal deaths, which is sufficient to learn
national lessons for improvement of care.
Handling external reviews: 41-42
Department of Health and Social Care · 16 Jul 2015 Written response →
Evidence trail — what's actually happened since
No published activity has been recorded against this recommendation yet.
Each entry above links to a primary source — gov.uk written statement, consultation response document, or inspection report. The Index does not characterise government intent; it tracks what has been published.
How this page is built
Source and Response are verbatim from primary documents. The Evidence trail records published activity since — written statements, consultation outcomes, inspection findings, parliamentary references. The Index does not paraphrase or characterise intent; it tracks what has been published. Where the evidence is the absence of action (a missed deadline, a slipped timetable), that absence is documented from primary sources rather than inferred.
This recommendation's data is verified periodically against primary sources. The Index is monitored for staleness weekly.