National Medical Examiner's report 2020

This is the first report of the National Medical Examiner for England and Wales. It was published in April 2021 and covers 2020. The report describes the national medical examiner system as being rolled out "initially on a non-statutory basis", ahead of a statutory system. In the foreword the National Medical Examiner says implementation continues "in the non-statutory phase prior to the advent of a statutory system".

What the report says was achieved in 2020

• The number of acute trusts in England with established medical examiner offices rose from 48 at the start of 2020 to 130 by the end. In Wales, four hub sites covering all health board areas were established.
• Trusts in England reported that medical examiners scrutinised 44,256 deaths between October and December 2020. The report says the increase in scrutiny was held back by the response to the coronavirus pandemic until that quarter.
• Medical examiners reported that 4,696 deaths were referred for case record review or other clinical governance review because they had concerns about care.
• The report says medical examiners supported the pandemic response, and that an independent process began in July 2020 for scrutinising the deaths of health service and adult social care staff who died after contracting COVID-19.
• The report says "the overwhelming majority of feedback was positive", and that feedback from bereaved people in Wales was also very positive. It also records that good practice guidelines were published in January 2020 and that virtual training began in September 2020.

What the report says comes next

• NHS Business Services Authority is to develop a digital system to capture scrutiny and a digitised medical certificate of cause of death. The intention is for both to be available "no later than April 2022 or when the medical examiner system becomes statutory".
• The report says the February 2021 white paper confirms the government's intention to put medical examiners on a statutory footing in England and Wales.
• Healthcare providers are encouraged to use the non-statutory system in 2021/22 to prepare to extend scrutiny to all non-coronial deaths.
• In Wales, the report expects all hospital deaths to be scrutinised by late summer 2021.