Setting up a medical examiner system

The implementation of a medical examiner system has been welcomed as a way to improve patient safety.

The development, construction and staffing of these systems will need to be managed at a local level. Initial implementations will focus on secondary care deaths, with primary care being added later in most cases. It is recommend that new services are implemented gradually and eventually built up to cover all deaths.

Guidance for Organisations

Dr Alan Fletcher, Medical Examiner and Chair of the Royal College of Pathologists Medical Examiners Committee, has created two excellent video resources for organisations looking to establish their local system.

Medical Examiners: An Introduction – In this webinar, Dr Fletcher talks about what a medical examiner does and shares information about the introduction of a non-statutory medical examiners system in 2019. 


Set Up of a Medical Examiners Service – In discussion with Daisy Shale, Medical Examiner Officer at Sheffield Teaching Hospitals NHS Foundation Trust, Dr Fletcher explores lessons learned from pilots across the country, covering staffing, service provision and the organisation of a medical examiner service.

Key learnings from the pilot

Below we list some of the key areas identified by the pilot medical examiner systems across the country, to help providers develop their own medical examiner services.

Planning your system

  • A project manager should be identified to scope the creation of the new service including the appropriate facilities, staff and costings based on the population the service is for.
  • Throughout, involve registration services as important stakeholders.
  • Do not try to include all deaths at the start; learn and refine your system.
  • Recruit a Lead Medical Examiner and Lead Medical Examiner Officer initially and test the system.
  • Appropriate IT infrastructure should be put in place to review patient records and collate data for the national medical examiners records system. The Department of Health and Social Care is developing a national digital system for data entry.
  • The continuity of the service must be considered to allow the service to be delivered to the standard for case conclusion (eg 24hrs from having received a non-coroner case into the office).
  • It is recommended that the medical examiner system is used to identify cases for Structured Judgement Review.
  • Ensure medical examiners and medical examiners officers are provided a quiet and confidential space for discussions with family and attending doctors.

Building your team

  • A working ratio of 10 PAs of medical examiner time and three full time medical examiner officers is required for every 3000 deaths per annum. This must be reflective of the case mix, geography and may necessitate variation based upon the demographics of the population covered.
  • Bereavement service officers and medical examiners officers can be the same person however they are distinct roles and medical examiner officers will require a specific skill set and additional training.
  • Additional staffing/hours should be considered for Mondays as it is the busiest day for the service.
  • Involve the local Coroner when planning and making medical examiner appointments.
Please note: a centralised bereavement service is recommended, if not already in place, and the medical examiners’ office should located close by. The introduction of a medical examiners office does not take away from the need for a bereavement service.