Dear Member,
NHS England has published the National Medical Examiner Report 2025, providing an overview of the first full year of the statutory medical examiner system across England and Wales.
The report highlights the impact of the reforms introduced in September 2024 and demonstrates how the medical examiner system is strengthening public safeguards, improving the experience of bereaved people, supporting better quality death certification and ensuring more appropriate referrals to coroners.
Among the key findings are:
- More than 500,000 deaths received independent scrutiny by medical examiners during 2025
- Half a million bereaved families every year are now being given an opportunity to raise concerns about care and to ask questions about what caused the death of their loved ones, with 97% taking up this opportunity
- Coroners ordered 10,000 fewer post-mortems in 2025 than in 2023
- In 2025, medical examiners referred 9,134 deaths in Wales for review under the Welsh Health and Care Quality Standards (HCQS). In the same year, in England, medical examiners referred 27,158 deaths for further clinical governance review and identified more than 2,000 patient safety incidents
- The report also identifies recurring themes that can support learning and improvements across health and care services.
For ICCM members, the report offers valuable insight into the continuing development of the death certification process and the wider benefits of independent scrutiny for bereaved families and public confidence.
You can read the full report here:
National Medical Examiner Report 2025
Kind regards,
The ICCM Team