9 March 2016

The College welcomes the Secretary of State’s announcement that from April 2018 medical examiners will independently review all deaths that have not been referred to the coroner.

President of The Royal College of Pathologists, Dr Suzy Lishman said: “No other patient safety initiative can provide these benefits in such a timely and truly independent way.

"Medical examiners will work closely with families to answer questions they may have and address any concerns - helping to help avoid unnecessary distress that can arise from unanswered questions about the cause of death of a loved one.

Crucially they will be uniquely placed to be able to identify sub-standard care in hospitals, care homes or in the community enabling action to be taken at the earliest opportunity.

The Royal College of Pathologists has long campaigned for the establishment of a national network of medical examiners. We believe that if an independent medical examiner had been in post, cases of poor care and neglect at Mid Staffordshire would have been spotted earlier, avoiding the needless suffering of hundreds of patients.”

Medical examiners were first proposed in 2005 by the inquiry into the crimes of Harold Shipman. Provision was made for their introduction in the Coroners and Justice Act 2009. Medical examiners were subsequently recommended by investigations into Mid Staffordshire (2013) and Morecambe Bay (2015).

Seven pilot sites which scrutinised over 23,000 deaths have demonstrated a number of benefits including:

  • detecting unexpected cases that were brought to the immediate attention of the relevant authorities. For example, problems with post-operative infections
  • providing reassurance to next of kin
  • ensuring referrals to the coroner are more appropriate
  • improving the accuracy of death certification
  • fostering openness as health professionals raising concerns feel supported by the independence and authority of the medical examiner
  • reducing litigation against the NHS.
  • providing statistical information on causes of deaths to those responsible for the overview of care, helping to direct health resources to improve patient care.




For more information or to arrange an interview, please contact Samantha Jayaram, Press and Communications Manager. Tel 020 7451 6752/0757 834 9018. E: samantha.jayaram@rcpath.org

Notes for editors


  • Medical examiners will be part of a national network of specifically trained independent senior doctors. Overseen by a National Medical Examiner, they will scrutinise all deaths across a local area that have not been taken by the coroner for investigation. This would include all deaths in hospital and in the community, for example the death of a person under the care of a GP or in a care home.
  • The Royal College of Pathologists is the lead medical royal college for medical examiners. It has established a committee which will help oversee the implementation of medical examiners. It has also developed a job description and person specification for the role.
  • Seven medical examiner pilot schemes were established in Sheffield, Gloucester, Powys, Leicester, north London, Brighton and Hove and Mid-Essex.