Independent medical examiners
It is of considerable importance that independent medical examiners are independent of the organisation whose patients' deaths are being scrutinised.
- The National Medical Examiner's good practice guidelines, produced in 2020, set out requirements to maintain the independence of the medical examiner role (National Medical Examiner Good Practice Guidelines, NHS England, 2020).
- The Medical Examiner system became statutory on 9 September 2024, requiring independent medical examiners to scrutinise all deaths not referred to a coroner (Medical Examiner System, UK Government, September 2024).
- An academic review in February 2023 confirmed that structural changes, including the introduction of Freedom to Speak Up Guardians and revalidation, had been delivered (Ten Years After Francis, Academic Review, February 2023).
How was this evidence gathered?
Response
Accepted in Part
Response
Accepted in PartThe 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. Medical examiners have now been introduced as set out in recommendation 45. The National Medical Examiner's good practice guidelines were produced in 2020 setting out how the National Medical Examiner expects medical examiner offices to operate. This covers requirements to maintain the independence of the Medical Examiner role. Some NHS trusts have considered combining medical examiner officer duties with other roles. This is not supported. Resources are provided to NHS bodies on the basis that they facilitate medical examiner activity, and operational arrangements at NHS bodies employing medical examiners must support their independent role.
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.
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.
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.