Source · Patient safety
National Medical Examiner
Annual reports on independent scrutiny of deaths in England and Wales. Read the national asks, explore annual statistics, and check the original NHS England reports.
6 annual reports
0 national asks indexed
2025 latest reporting year
Annual reports
National Medical Examiner report 2024
National medical examiner annual report 2023
National Medical Examiner's report 2022
Third annual report. The medical examiner system scrutinised over 240000 deaths as coverage expanded nationally.
National Medical Examiner's report 2021
Second annual report covering the continued roll-out of the medical examiner system across England and Wales.
National Medical Examiner's report 2020
First annual report of the National Medical Examiner covering the initial year of the medical examiner system during the COVID-19 pandemic.
Statistics and context
2025 reporting year
Patient safety concerns
2,018
Identified through scrutiny · 2025
Deaths scrutinised by year
Read the chart values
| Reporting year | Deaths scrutinised |
|---|---|
| 2020 | 33,374 |
| 2021 | 125,737 |
| 2022 | 240,562 |
| 2024 | 403,696 |
How the system developed
The medical examiner system followed the Shipman Inquiry recommendation that deaths not investigated by a coroner should receive independent scrutiny.
The annual reports record expansion from 33,374 deaths in 2020.
2,018 patient safety concerns identified in 2025 were fed back to trusts as learning opportunities.
About this source
The National Medical Examiner oversees the medical examiner system in England and Wales. Medical examiners are senior doctors who independently scrutinise deaths not investigated by a coroner. The statutory framework is set out in the Coroners and Justice Act 2009.
This collection includes web reports from 2023 onwards and PDF reports for 2020–2022. Statistics and national asks are recorded from the reports; each report links to the original publication. An absence of indexed asks does not establish that a report contains none.