Independent medical examiners
Sufficient numbers of independent medical examiners need to be appointed and resourced to ensure that they can give proper attention to the workload.
- The statutory medical examiner system, which commenced on 9 September 2024, requires sufficient medical examiners to be appointed across England and Wales to scrutinise all non-coronial deaths. NHS England funded the establishment of Medical Examiner Offices across all acute trusts during the non-statutory rollout from April 2019 (NHS England, Medical Examiner System).
- Central funding was established in March 2022 to support medical examiner resourcing, replacing the earlier cremation fee funding model. The Medical Examiners (England) Regulations 2024, laid before Parliament on 15 April 2024, set out the statutory requirements for the system including resourcing obligations.
- The National Medical Examiner oversees workforce planning and quality assurance for the medical examiner system nationally. The Royal College of Pathologists leads medical examiner education, providing 24 e-learning modules plus face-to-face training.
- The system now covers deaths in all settings, not just acute hospitals, following the September 2024 statutory commencement. This required expansion of the medical examiner workforce to manage the increased workload.
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
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.