On the 12th of September, the Medical Examiner released the following report, assessing the impact of the Medical Examiner system since its implementation in September 2024. The full report can be found here: NHS England » National Medical Examiner report 2024.
In summary, the following key takeaways are reported as:
- Successful implementation of reforms: The statutory requirement for independent medical examiner scrutiny of all non-coronial deaths was introduced across England and Wales, marking the most significant change to death certification in decades.
- Enhanced safeguards and support for bereaved families: Every non-coronial death now undergoes independent review, giving bereaved families the chance to ask questions and raise concerns. Feedback has been overwhelmingly positive, highlighting the compassion and reassurance provided.
- Impact on processes and system performance: While some local delays are noted, overall registration times have increased by 1–2 days. Most cases are processed within 5 days (England) and 8–9 days (Wales).
- Quality, safety, and learning improvements: In 2024, over 400,000 deaths were scrutinised. Thousands of concerns were referred for clinical review, including patient safety incidents, and referrals to coroners fell by 10%.
- Future priorities and challenges: The system is still developing and requires sustained support, digital tools (such as a long-awaited digital Medical Certificate of Cause of Death), adequate staffing, and collaboration across healthcare, coroners, and registrars’ services to meet rising death numbers and ensure resilience.