National Medical Examiner's report 2021

This is the National Medical Examiner's report for England and Wales for 2021, published on 18 May 2022. The report describes the national medical examiner system as being rolled out "on a non-statutory basis". In the foreword the National Medical Examiner says Royal Assent for the Health and Care Bill "clears the way for the medical examiner system to become a statutory part of death certification processes".

What the report says was achieved in 2021

• All acute trusts in England had established medical examiner offices by June 2021. In Wales, four hub sites covering all health board areas were established.
• Medical examiner offices in England reported independent scrutiny of 194,074 deaths in 2021, and that 19,807 deaths were referred for case record review or other clinical governance review because of concerns about care. They also reported notifying 498 patient safety incidents.
• Medical examiners contacted the bereaved in the majority (92.3%) of cases, giving them an opportunity to ask questions and raise concerns.
• In June 2021 NHS England and NHS Improvement asked all NHS organisations in England to prepare for independent scrutiny of all non-coronial deaths wherever they occur. The report says the Confidentiality Advisory Group supported an application that enabled confidential patient information to be shared for this purpose in the non-statutory phase.
• The report says "the overwhelming majority of feedback was positive". It lists common issues identified by medical examiners, including hydration and end-of-life care pathways.
• The Royal College of Pathologists continued virtual training, and four good practice papers were produced.

What the report says comes next

• The foreword sets out two areas of focus. The first is for all non-coronial deaths, not only those in acute hospitals, to receive independent scrutiny, with all offices fully implementing the three elements of scrutiny in the good practice guidelines.
• The second is to be ready for the statutory system, so that all bereaved people can benefit from independent scrutiny.
• NHS Business Services Authority began rolling out the case management system in England in January 2022. It has also been commissioned to deliver a digital medical certificate of cause of death, and both products are intended to be available when the system becomes statutory.
• The report says more needs to be done to capture wider themes and learning, which depends on scrutiny of all non-coronial deaths.