The role of medical examiners and medical examiner officers

Medical examiners

Medical examiners are senior medical doctors who are trained in the legal and clinical elements of death certification processes. Their role includes: 

  • speaking to the doctor who treated the patient on their final illness
  • reviewing the medical records and any supporting diagnostic information 
  • agreeing the proposed cause of death and the overall accuracy of the medical certificate cause of death 
  • discussing the cause of death with the next of kin/informant and establishing if they have any concerns with care that could have impacted/led to death
  • acting as a medical advice resource for the local coroner
  • informing clinical governance systems to highlight deceased patients who require a mortality case record review so any formal learning can be gained by the provider organisation
  • ensuring that patterns and concerns about care are raised appropriately
  • enabling a medical examiner officer to conduct component parts of the role under delegated authority.

Medical examiner officers

Medical examiner officers support medical examiners and their role includes:

  • managing cases from initial notification through to completion
  • obtaining relevant medical records
  • communication with the registrar and bereaved families. 

The independence of medical examiners

A medical examiner must always be independent of the case and cannot know, or have treated, the deceased patient on which they are carrying out scrutiny of the circumstances of death. They are responsible for completing the following steps to arrive at their decision:

  • a proportionate review of medical records
  • interaction with the attending doctor
  • interaction with the bereaved. 

The above should be completed within 24 hours of the medical notes being received (for cases not investigated by the Coroner). The interaction with the attending doctor and the bereaved may be undertaken in collaboration with medical examiner officers.

In England, medical examiners are employed by NHS trusts and have a separate reporting line to the regional lead medical examiner. Those who work in medical roles within the NHS are accustomed to having different roles and different lines of accountability and to making this work, and it is expected that employing organisations will respect this distinction. Appraisal and revalidation processes will support independence. Engagement with senior coroners is encouraged at the outset and specifically to support appointment committees. In Wales, medical examiners are employed by the NHS Wales Shared Services Partnership, supporting their independence.

Background to the service

A national network of medical examiners was recommended by the Shipman, Mid-Staffordshire and Morecambe Bay public inquiries. The College campaigned for their implementation and continues to play a key role in influencing government’s work around implementation of the service. 

Acute trusts in England and local health boards in Wales were asked to set up medical examiner offices to focus initially on the certification of all deaths that occur in their own organisation on a non-statutory basis.

  • In June 2021, NHS England sent a system wide letter setting out what local health systems needed to do to extend the role of these offices, to include all non-coronial deaths, wherever they occur
  • In July 2022, NHS England wrote to NHS healthcare providers and integrated care boards, setting out what local health systems need to do to prepare for the statutory medical examiner system.
  • In April 2023, the Government confirmed the next steps towards the statutory medical examiner system, and that work would take place for full introduction of the statutory system from April 2024. Relevant provisions of the Coroners and Justice Act 2009 and the Health and Care Act 2022 were to commence by autumn 2023. 
  • In December 2023, the Department of Health and Social Care published the draft regulations for the statutory medical examiner system planned from 2024

Further information on medical examiners, the medical examiner system and the introduction of the non-statutory system from April 2019 may be found in this video resource.