National Medical Examiner report 2024

This is the first annual report since the statutory medical examiner system began on 9 September 2024, so it covers only part of the year under the new rules. It is the last report by the outgoing National Medical Examiner, who makes it to the Secretary of State and Welsh Ministers under the National Medical Examiner (Additional Functions) Regulations 2024.

What the report says the system achieved in 2024

• Medical examiners independently scrutinised over 403,696 deaths in 2024 across England and Wales. The report gives separate totals for each country.
• The Foreword says the author was "impressed by how smooth the transition has generally been". It also acknowledges that in a minority of areas it took longer for deaths to be registered, and the distress this may have added to bereaved families.
• Medical examiner offices in England reported an interaction with bereaved people for over 95% of the deaths scrutinised there in 2024. The report notes that taking part is voluntary.
• The report cites Ministry of Justice figures showing a 10% fall in deaths reported to coroners in England and Wales in 2024 compared with 2023. It notes the reforms were in force for only the final third of the year.
• The estimated share of scrutinised non-acute deaths in England rose to around 70% in July to September 2024, the quarter in which the statutory system began. The report says these figures may not be directly comparable with earlier quarters.

What the report says comes next

• The report states that "NHS trusts and ICBs must adequately resource medical examiner offices" to carry out their statutory function.
• It says the new National Medical Examiner "will need to better understand the difference medical examiners are making" on probity, patient safety incidents and inadequate care, and may be helped by the independent review commissioned by the Department of Health and Social Care.
• It calls for a national focus on digital technology, including a digital Medical Certificate of Cause of Death and a case management system for reporting.
• It says that giving medical examiners fuller access to social care records may need a change to regulations, and that the national framework on implantable medical devices may need further consideration.
• It asks medical examiners and partners to review how things went and to plan for winter 2025/26.