National medical examiner annual report 2023

This report covers 2023 and was published on the NHS England website on 6 September 2024. The report says independent scrutiny by a medical examiner becomes a statutory requirement for registration of all deaths in England and Wales not investigated by a coroner from 9 September 2024. During 2023, it says, medical examiners worked to extend independent scrutiny to non-coronial deaths in all healthcare settings and continued to prepare for the Death Certification Reforms.

What the report says the system achieved in 2023

• The foreword says medical examiners reviewed 311,249 deaths in England and Wales in 2023, more than in any previous year.
• In England, medical examiner offices reported referring 26,003 deaths for case record review or other clinical governance review, and identifying 2,242 patient safety incidents.
• The report says scrutiny of deaths in community settings in England increased steadily, and that Wales saw substantial growth in scrutinising deaths in non-acute healthcare settings.
• The report says feedback from bereaved families and stakeholders in England and Wales was positive, and that coroners and registrars find the involvement of medical examiners improves the accuracy of notifications and medical certificates of cause of death.
• By the end of December 2023, 2,167 medical examiners had been trained, according to the report.

What the report says comes next

• The National Medical Examiner's team continues to work with medical examiners and officers towards implementing the Death Certification Reforms from 9 September 2024.
• The report says there will be opportunities for surveillance and review of the effect of the statutory system on coroners, cause of death statistics, time to registration, and urgent release requirements.
• The National Medical Examiner's office will continue to monitor demand for, and delivery of, weekend and public holiday cover.
• The report says key objectives will focus on addressing concerns and identifying constructive learning to improve care for patients, as well as giving the bereaved a voice.