Independent medical examiners
It is of considerable importance that independent medical examiners are independent of the organisation whose patients' deaths are being scrutinised.
- The statutory medical examiner system commenced on 9 September 2024 under the Coroners and Justice Act 2009 (as amended by the Health and Care Act 2022). From this date, all deaths in England and Wales not investigated by a coroner must be reviewed by an NHS medical examiner (Death Certification Reform, DHSC).
- Medical examiners are independent of the clinical teams whose patients' deaths they scrutinise. They are senior doctors (with at least five years post-registration experience) employed by NHS trusts but exercising their medical examiner function independently of the trust's management. The National Medical Examiner's guidance emphasises this independence as a core principle of the role.
- Dr Alan Fletcher was appointed as the first National Medical Examiner for England and Wales in March 2019, overseeing the non-statutory rollout from April 2019 and the subsequent statutory implementation (NHS England, Medical Examiner System).
- The system was initially rolled out non-statutorily from April 2019, with NHS England asking all trusts to establish Medical Examiner Offices. The move to statutory footing in September 2024 completed the implementation, directly fulfilling Francis's recommendation that medical examiners should be independent of the organisations being scrutinised.
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
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.