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F276

Independent medical examiners

Mid Staffs Inquiry · Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry · Issued 6 February 2013 · Addressed to: Department of Health and Social Care

Government responseDepartment of Health and Social Care: Accepted (Nov 2013)

DeliveryDHSC and NHS England say in progress (Feb 2026)Department of Health and Social Care says in progress (Feb 2015)

Recommendation, verbatim from the inquiry

●Inquiry recommendation

Sufficient numbers of independent medical examiners need to be appointed and resourced to ensure that they can give proper attention to the workload.

Mid Staffs Inquiry, Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry · 6 Feb 2013 Source PDF →

Published evidence summary

AI-generated evidence summary

The Inquiry called for enough independent medical examiners to be appointed and properly resourced. In commentary of September 2024, published in February 2026, the Department of Health and Social Care (DHSC) and NHS England stated that the system had become statutory that month, all acute NHS trusts had established medical examiner offices, and trusts had been asked to ensure adequate workforce and support (DHSC and NHS England, Feb 2026). In September 2026, the Thirlwall Inquiry reported that funding for medical examiners was no longer ring-fenced, with integrated care boards (ICBs) instead funded to provide the service (The Rt Hon. Lady Justice Thirlwall DBE, Sep 2026).

AI-generated summary of the record on this page, checked by a second model and automatic checks, 5 Oct 2026.

About this summary
This recommendation applies across many organisations. The record above reflects central policy activity; adoption in individual organisations may vary.

Report-level response context

Government responded via "Hard Truths: The Journey to Putting Patients First" (2014), a single document covering all 290 recommendations with a blanket acceptance. Individual recommendation responses were not broken out.

Government response

●Department of Health and Social Care · Accepted · 19 Nov 2013

Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013

Accepted.
The Coroners and Justice Act 2009 requires the appointment of enough medical examiners, and the availability of sufficient funds and resources, to ensure the functions of medical examiners are discharged within the appointing area.
It is the responsibility of local authorities, who will appoint medical examiners, to ensure that this is the case. However, to support local authorities in this task, the Department of Health will provide each local authority with estimated numbers of medical examiners that may be required locally based on expected levels of death and workload and match resourcing for medical examiners to that estimation.

Response document: Hard Truths: The Journey to Putting Patients First. Volume Two of the Government Response to the Mid Staffordshire NHS Foundation Trust Public Inquiry: Response to the Inquiry's Recommendations

Site note: This is volume two of "Hard Truths: The Journey to Putting Patients First" (Cm 8777-II), the government's response to the Inquiry's 290 recommendations, published by the Department of Health on GOV.UK on 19 November 2013 and dated to that day here. The PDF the row links to is the accessible edition, whose title page reads "January 2014". The Department of Health has been the Department of Health and Social Care since January 2018. The volume says it includes accounts from each of the national organisations the recommendations name, but it does not mark which passage each organisation wrote, so every row is filed under the Department that published it.

Delivery

●DHSC and NHS England say in progress · 27 Feb 2026

See update to recommendation 45 and 275 on medical examiners.

All acute NHS Trusts now have established medical examiner offices. There are also medical examiner offices based in a small number of specialist trusts. The system has been statutory since 9 September 2024 Acute Trusts have been asked to ensure that medical examiner offices based at their Trusts have adequate workforce and support

From: The Thirlwall Inquiry: Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version dated April 2025)

Site note: DHSC and NHS England's own account of progress, supplied to the Thirlwall Inquiry in September 2024 and printed in the Inquiry legal team's Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version dated April 2025, published 27 February 2026). It is not a finding of the Inquiry. Their reviewed extent of implementation reads “Implemented - Ongoing”. Table row: section 18.2 No. 276, PDF page 572.

●Department of Health and Social Care says in progress · 11 Feb 2015

A number of the recommendations in Sir Robert’s Mid Staffordshire Inquiry report refer to our planned reform of the death certification system and the introduction of the role of medical examiner in England and Wales. A new system of medical examiners has been trialled successfully in a number of areas across the country. The work of the two flagship sites in Gloucestershire and Sheffield has been continued and extended to operate a medical examiner service on a city and countywide basis at a scale that will be required for implementation by local authorities when legislation is introduced. We will publish shortly a report from the interim National Medical Examiner setting out the lessons learned from the pilot sites.

The government remains totally committed to the principle of these reforms. Further progress will be informed by a reconsideration of the detail of the new system in the light of other positive developments on patient safety since 2010 and by a subsequent public consultation exercise.

From: Culture Change in the NHS supporting Annex (annex to Culture change in the NHS: applying the lessons of the Francis Inquiries)

Site note: This is the supporting annex published on 11 February 2015 with "Culture change in the NHS: applying the lessons of the Francis Inquiries" (Cm 9009), attached to the GOV.UK page as "Culture change in the NHS supporting annex". The annex has no title page; that title is GOV.UK's and the PDF's own. Its table has four columns (No., Recommendation, Hard Truths Government response, Progress update), and the row carries the Progress update cell. No column says which organisation wrote an update, so the row is filed under the Department of Health (now the Department of Health and Social Care), which published it.

What other bodies have found

In their own words. These do not change the delivery statement above.

●Thirlwall Inquiry · 15 Sep 2026

The most recently available (September 2025) information is that the funding for medical examiners is no longer ring-fenced but ICBs are funded on the basis that they will provide the medical examiner service.

From: Report of the Thirlwall Inquiry: Countess of Chester Hospital, 2015 to 2018, Volume III (accessible)

●Thirlwall Inquiry legal team · 15 May 2024

This recommendation as accepted by the Government.

The Government stated it was the responsibility of local authorities to ensure this was the case, but the Department of Health would provide each local authority with estimated numbers of medical examiners that may be required locally.

From: The Thirlwall Inquiry: Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version of 15 May 2024)

Site note: The Thirlwall Inquiry legal team's own notes on implementation, from its Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version of 15 May 2024). The review does not colour its Extent of Implementation cell for this recommendation green; it leaves the cell uncoloured where a recommendation was rejected, where evidence of implementation was insufficient, or where steps had been taken but implementation was not yet complete. Table row: section 16.2 No. 276, PDF page 526.

How this page is built

The recommendation and the government responses are verbatim from primary documents. Delivery statements and other bodies' findings are shown in their own words, each with its source. The summary is written by this site and labelled as such. The Index does not paraphrase sources or characterise intent; it records what has been published.