Information to coroners
There is an urgent need for unequivocal guidance to be given to trusts and their legal advisers and those handling disclosure of information to coroners, patients and families, as to the priority to be given to openness over any perceived material interest.
- The Medical Examiner system became statutory on 9 September 2024, implementing independent scrutiny of deaths to refer concerns as appropriate (Medical Examiner System, UK Government, September 2024).
- A review of the statutory duty of candour published in November 2024 found that 52% of respondents believed the Care Quality Commission had not adequately enforced the duty (Duty of Candour Review, DHSC, November 2024).
- Phase 2 of Martha's Rule was expanded to all acute trusts in April 2025, allowing patients and families to access rapid reviews from critical care outreach teams (Martha's Rule, NHS England, April 2025).
How was this evidence gathered?
Response
Accepted
Response
AcceptedThe government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" in March 2013. Key reforms included a new Chief Inspector of Hospitals, strengthened Care Quality Commission inspection regime, a statutory duty of candour, and the fit and proper person test for NHS directors. Volume 2 (Cm 8754) contains the government's detailed responses to each of the 290 recommendations. See: https://assets.publishing.service.gov.uk/media/5a7cd486ed915d63cc65d167/34658_Cm_8777_Vol_1_accessible.pdf
Progress Timeline
DHSC and NHS England implementation update provided to the Thirlwall Inquiry (April 2025). This is the government's own account of progress, submitted to the inquiry. Reviewed extent of implementation: Implemented - Ongoing. All medical practitioners must adhere to the GMC Good medical practice and to applicable information governance law and policies. It is not anticipated that such requirements will impede medical examiners passing on feedback and referring concerns as appropriate, but if in doubt in a given case, advice should be sought (for example, from the appointing NHS body's Caldicott Guardian) where appropriate. Medical examiners have now been introduced as set out in Recommendation 45. The National Medical Examiner favours an assumption of transparency and openness to empower bereaved families. When a bereaved person who spoke with the medical examiner office about causes of death makes a reasonable request to see records of medical examiner scrutiny, these records should be shared where possible. Medical Examiners are subject to statutory Duty of Candour as set out in Recommendation 21.
Published Evidence
Published assessments of progress from inspectorates, select committees, official progress reports, and other sources. Source type badge indicates whether each assessment is independent or government self-reported.
Martha's Rule ensures patients, families and staff can access rapid review from critical care outreach team when concerned about deterioration. Phase 1 launched May 2024 at 143 pilot sites. Phase 2 expanded to all acute trusts April 2025. Early data: 9,135 calls Sep 2024-Nov 2025; 286 led to urgent critical care review.
DHSC published findings of call for evidence on statutory duty of candour. 261 responses received. Key finding: 52% of respondents said CQC had not adequately enforced the duty. Many reported it had become a "tick-box exercise". Only 40% thought the purpose was clear and well understood. Final government response still pending.
Medical Examiner system became statutory from 9 September 2024 under Coroners and Justice Act 2009 (as amended by Health and Care Act 2022). Independent medical examiners must scrutinise all deaths not referred to a coroner. Full national rollout achieved, implementing Francis recommendations on death certification.
Research published 2023 marking ten years since the Francis Report found mixed results. Structural and legislative changes largely delivered (duty of candour, FPPR, CQC overhaul, revalidation, Freedom to Speak Up Guardians). However, cultural change not fully embedded; understaffing, fear of speaking up, and poor complaint handling persist in parts of the NHS.
Government published "Culture Change in the NHS" (Cm 9009) reporting progress on all 290 recommendations. Key achievements: 19 hospitals placed in special measures; those trusts recruited 109 additional doctors and 1,805 additional nurses; 129 board-level changes made; excess avoidable deaths fell by 450 in less than a year.
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 20: statutory duty of candour came into force for NHS trusts November 2014, extended to all CQC-registered providers April 2015. Requires providers to notify patients/families of notifiable safety incidents and apologise.
Government published "Hard Truths: The Journey to Putting Patients First" (Cm 8777) in two volumes. Vol 1 set out new actions; Vol 2 provided detailed response to each of the 290 recommendations. Approximately 204 of 290 recommendations were fully accepted.