Implement medical examiner system

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.

The Maternity and Newborn Investigations Programme conducts independent investigations of specific perinatal deaths, including term intrapartum stillbirths, and neonatal deaths of all term babies born following labour when the baby died within the first week of life (0-6 days) of any cause. The programme was established in 2018 as part of the HSIB and has been hosted by the CQC since 2023.

From 9 September 2024, all deaths in any health setting that are not investigated by a coroner are reviewed by NHS medical examiners. The new statutory medical examiner system was rolled out across England and Wales to provide independent scrutiny of deaths, and to give bereaved people a voice. Medical examiners were introduced on a non-statutory basis from 2019 to provide independent scrutiny of the causes of all non-coronial deaths, to support the appropriate direction of deaths to the coroner. This includes neonatal deaths.

NHS England progressed support for the introduction of medical examiners, specifically:

• A national medical examiner has been appointed and a monthly National Medical Examiner Bulletin is published to communicate progress.
• Regional medical examiners and regional medical examiner officers have been appointed to each region in England.
• E-learning and face to face training is available for the medical examiner and medical examiner officer workforce.

Medical examiners have been introduced on a non-statutory basis from April 2019 to scrutinise all non-coronial deaths and ensure the right deaths are referred to coroners. This includes neonatal death.
Since April 2018, the Healthcare Safety Investigation Branch has been investigating all term intrapartum stillbirths (at least 37+0 completed weeks of gestation), neonatal deaths of all term babies born following labour when the baby died within the first week of life (0-6 days) of any cause and maternal deaths.
MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the United Kingdom) conduct surveillance of all late fetal losses, stillbirths, neonatal and maternal deaths and produce Confidential Enquires to provide valuable learning and inform service improvement.

It was not, however, until 9 September 2024 that the full statutory scheme of medical examiners was fully operational.

Department of Health response (July 2015):

Accepted in principle.

“The medical examiners system has been trialled successfully in a number of areas across the country …

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.” (p. 94)

Hansard – September 2023 “We have already committed to moving medical examiners to a statutory basis and will table secondary legislation on that shortly. It will ensure that deaths not reviewed by a coroner are investigated in all medical settings, in particular extending coverage in primary care, and will enter into force in April.” (col 36-37)

We found that parts of the recommendation are on track to be met. A system of medical examiners is in place and is due to be put on a statutory footing in April 2024, nine years on from when the recommendation was made and accepted.