i. The National Medical Examiner should, by 31 March 2027, prepare and distribute a
one-page document setting out all the steps to be taken by a medical examiner when
dealing with the death of a neonate.
ii. The revised SUDIC guidelines (see Recommendation 8 above) should be set out within
the good practice guidelines for medical examiners, not merely signposted.
iii. Medical examiners should ask direct questions of the attending practitioner as to
whether there is a concern that a child has been harmed or some other safeguarding
concern. Where there may be such a concern, the medical examiner should ensure
that there is a record made that day of the contact details of every doctor or nurse
who attended to the baby during life.
iv. There should be a pool of neonatologists who can assist medical examiners with
their work until such time as it is possible to appoint the appropriate number of
regional neonatologist medical examiners. Ring-fenced funding should be provided
for this purpose.
v. The medical examiner system should be reviewed again in 2027 by DHSC. The review
should include the adequacy of funding for medical examiners and their support staff
and offices. In particular, the question of whether the funding should be ring-fenced
must be addressed. Thereafter, reviews should be as directed by DHSC and NHS
England.