Recommendation F280: Appropriate and sensitive contact with bereaved families
From Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, published 6 February 2013.
Recommendation
Both the bereaved family and the certifying doctor should be asked whether they have any concerns about the death or the circumstances surrounding it, and guidance should be given to hospital staff encouraging them to raise any concerns they may have with the independent medical examiner.
In brief (written by this site)
In September 2024, the Department of Health and Social Care and NHS England stated that medical examiners had now been introduced, noting that a key function is to give bereaved families greater transparency and opportunities to raise concerns (DHSC and NHS England, Feb 2026). In a review published in February 2026, the Thirlwall Inquiry legal team found that earlier draft death certification regulations had not been implemented, though primary legislation establishing the framework for a statutory medical examiner system came into force in October 2023 (The Thirlwall Inquiry legal team, Feb 2026).
AI-generated summary of the record on this page, checked by a second model and automatic checks, 26 Sep 2026. The record below is the sources' own words.
About this summary
This recommendation applies across many organisations. The record reflects central policy activity; adoption in individual organisations may vary.
Government response
Accepted.
The Department of Health intends to publish draft death certification regulations that requires medical examiners to make arrangements to speak to anyone they consider necessary to discuss the circumstances and causes of death and to provide them with the opportunity to mention any matter that might cause a senior coroner to think that the death should be investigated. This includes the family of the deceased and/or the provider of care services.
In addition, the certifying doctor can provide any information necessary in establishing the cause of death or to protect individuals health and safety along with his/her certificate for scrutiny.
How this response relates to the recommendation
Site note: This is volume two of "Hard Truths: The Journey to Putting Patients First" (Cm 8777-II), the government's response to the Inquiry's 290 recommendations, published by the Department of Health on GOV.UK on 19 November 2013 and dated to that day here. The PDF the row links to is the accessible edition, whose title page reads "January 2014". The Department of Health has been the Department of Health and Social Care since January 2018. The volume says it includes accounts from each of the national organisations the recommendations name, but it does not mark which passage each organisation wrote, so every row is filed under the Department that published it.
Blanket government agreement does not establish acceptance or delivery by each addressee. Some response passages cover groups of recommendations.
Scope of the government response
Government responded via "Hard Truths: The Journey to Putting Patients First" (2014), a single document covering all 290 recommendations with a blanket acceptance. Individual recommendation responses were not broken out.
Delivery
DHSC and NHS England say in progress (27 February 2026)
Medical examiners have now been introduced as set out in Recommendation 45.
A key function of medical examiners is to provide bereaved families with greater transparency and opportunities to raise concerns.
Site note: DHSC and NHS England's own account of progress, supplied to the Thirlwall Inquiry in September 2024 and printed in the Inquiry legal team's Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version dated April 2025, published 27 February 2026). It is not a finding of the Inquiry. Their reviewed extent of implementation reads “Implemented - Ongoing”. Table row: section 18.2 No. 280, PDF page 574.
Department of Health and Social Care says in progress (11 February 2015)
A number of the recommendations in Sir Robert’s Mid Staffordshire Inquiry report refer to our planned reform of the death certification system and the introduction of the role of medical examiner in England and Wales. A new system of medical examiners has been trialled successfully in a number of areas across the country. The work of the two flagship sites in Gloucestershire and Sheffield has been continued and extended to operate a medical examiner service on a city and countywide basis at a scale that will be required for implementation by local authorities when legislation is introduced. We will publish shortly a report from the interim National Medical Examiner setting out the lessons learned from the pilot sites.
The government remains totally committed to the principle of these reforms. Further progress will be informed by a reconsideration of the detail of the new system in the light of other positive developments on patient safety since 2010 and by a subsequent public consultation exercise.
Site note: This is the supporting annex published on 11 February 2015 with "Culture change in the NHS: applying the lessons of the Francis Inquiries" (Cm 9009), attached to the GOV.UK page as "Culture change in the NHS supporting annex". The annex has no title page; that title is GOV.UK's and the PDF's own. Its table has four columns (No., Recommendation, Hard Truths Government response, Progress update), and the row carries the Progress update cell. No column says which organisation wrote an update, so the row is filed under the Department of Health (now the Department of Health and Social Care), which published it.
Site note: The Inquiry addressed this recommendation to healthcare providers, not to the Department of Health. The annex gives this update in the Department's publication and does not say who wrote it, so the row is the Department's report of the progress made on it.
What other bodies have found
In their own words. These do not change the delivery statement above.
Thirlwall Inquiry legal team (27 February 2026)
This recommendation was accepted by the Government. The Government published draft death certification regulations requiring medical examiners to make arrangements to speak to anyone they consider necessary to discuss the circumstances and causes of death and to provide them with the opportunity to mention any matter that might cause a senior coroner to think that the death should be investigated. Thes regulations were not implemented. In April 2023, the Government announced it intended to introduce a statutory medical examiner system from April 2024. Primary legislation by way of amendment of the Coroners and Justice Act 2009 to provide the framework for this came into force in October 2023.
Site note: The Thirlwall Inquiry legal team's own notes on implementation, from its Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version dated April 2025, published 27 February 2026). The review does not colour its Extent of Implementation cell for this recommendation green; it leaves the cell uncoloured where a recommendation was rejected, where evidence of implementation was insufficient, or where steps had been taken but implementation was not yet complete. Table row: section 18.2 No. 280, PDF page 574.
Earlier findings (1)
Thirlwall Inquiry legal team (15 May 2024)
This recommendation was accepted by the Government.
The Government published draft death certification regulations requiring medical examiners to make arrangements to speak to anyone they consider necessary to discuss the circumstances and causes of death and to provide them with the opportunity to mention any matter that might cause a senior coroner to think that the death should be investigated. These regulations were not implemented.
In April 2023, the Government announced it intended to introduce a statutory medical examiner system from April 2024. Primary legislation by way of amendment of the Coroners and Justice Act 2009 to provide the framework for this came into force in October 2023.
Site note: The Thirlwall Inquiry legal team's own notes on implementation, from its Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version of 15 May 2024). The review does not colour its Extent of Implementation cell for this recommendation green; it leaves the cell uncoloured where a recommendation was rejected, where evidence of implementation was insufficient, or where steps had been taken but implementation was not yet complete. Table row: section 16.2 No. 280, PDF page 527.
Source
Responsible bodies
Themes and tags
Who has spoken
- Department of Health and Social Care
Response, delivery statement - DHSC and NHS England
Delivery statement - Thirlwall Inquiry legal team
Finding