National Medical Examiner Reports
Annual reports from the National Medical Examiner (NHS England) on the medical examiner system,
which independently scrutinises deaths not investigated by a coroner.
Since 2020, medical examiners have reviewed over 1 million deaths — identifying patient safety
concerns and ensuring accurate death certification.
NHS England collection
5
Annual reports
403,696
Deaths scrutinised (2024)
9.3%
Coronial referral rate (2024)
1,922
Patient safety concerns (2024)
Key Context
The medical examiner system was introduced following the Shipman Inquiry recommendation
that all deaths not investigated by a coroner should be subject to independent scrutiny.
Since 2020, the system has expanded from scrutinising 33,374 deaths to
403,696 in 2024
— a 4-fold increase in 4 years.
9.3% of scrutinised deaths are referred to a coroner — up from around
5% before medical examiners, indicating improved identification of deaths requiring investigation.
1,922 patient safety concerns were identified through death
scrutiny in 2024, fed back to trusts as learning opportunities.
Deaths Scrutinised by Year
All Reports (5)
Third annual report. The medical examiner system scrutinised over 240000 deaths as coverage expanded nationally.
Second annual report covering the continued roll-out of the medical examiner system across England and Wales.
First annual report of the National Medical Examiner covering the initial year of the medical examiner system during the COVID-19 pandemic.
About This Source
The National Medical Examiner is an NHS England role established to oversee the medical examiner system in England and Wales. Medical examiners are senior doctors who independently scrutinise all deaths not investigated by a coroner. The system became statutory under the Coroners and Justice Act 2009.
Reports from 2023 onwards are HTML long-reads scraped automatically on each deploy. Earlier reports (2020–2022) are PDFs with key statistics entered manually. Statistics shown are extracted verbatim from each report. Next report expected: September 2026 (covering the 2025 calendar year).