National Medical Examiner’s report for 2025

The report describes 2025 as the first year in which medical examiners reviewed all deaths not investigated by coroners in England and Wales, under the statutory system introduced in September 2024. The National Medical Examiner makes the report 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 2025

• Medical examiners scrutinised every death not investigated by a coroner: 501,427 in England and Wales, as stated in the executive summary.
• Bereaved families were offered the chance to raise concerns with someone not involved in the person's care. The report says 97% took it up.
• Ministry of Justice coroner statistics, quoted in the report, show deaths referred to coroners fell by 24.2% between 2023 and 2025. Coroners ordered 10,000 fewer post-mortems.
• Medical examiners identified 36,302 deaths in England and Wales for further clinical governance review, and 2,018 patient safety incidents in England.
• Deaths that the Office for National Statistics classed as uncertified fell from more than 10,000 a year to 3, which the report says were certified in other jurisdictions.

What the National Medical Examiner wants to do next

• Strengthen the voice of bereaved people and their ability to raise concerns.
• Make how medical examiners carry out their duties more consistent.
• Make greater use of data and research to improve healthcare.
• Understand, when completed, the University of Birmingham's evaluation of the death certification reforms.