National Medical Examiner's report 2022

This report covers 2022 and was published on 17 May 2023. It describes a medical examiner system that was still in a "non-statutory period": medical examiners were being rolled out in England and Wales, and the Health and Care Act 2022, which received royal assent in May 2022, paved the way for a statutory system. The National Medical Examiner wrote the report; it refers to a statutory system from April 2024.

What the report says the system achieved in 2022

• Medical examiners provided independent scrutiny of more than half a million deaths in England and Wales since the programme began in 2019. The foreword says more than 250,000 of these were in 2022.
• In England, medical examiner offices reported referring 24,095 deaths for case record review or other clinical governance review, and identifying 2,267 patient safety incidents.
• Medical examiners and officers gave bereaved people the chance to ask questions and raise concerns in what the report calls "the overwhelming majority of cases".
• The report says feedback from bereaved families and stakeholders in England and Wales was positive, and that scrutiny was extending from hospitals into community settings, with some GP practices not yet engaged in England.
• The report says 1,800 medical examiners had completed training by the end of 2022.

What the report says comes next

• Full rollout is described as a complex task, with more progress needed in many areas in the coming months.
• A ministerial statement sets out the pathway to the full statutory system from April 2024.
• Work started towards the end of 2022 on a national solution, supported by the NHS e-Referral Service, for sharing patient records in areas that had yet to make progress.
• Further steps are planned to link intelligence from medical examiners to other national quality and surveillance processes.
• Further good practice guidance is planned on dementia, major incidents and palliative care.