A new statutory medical examiner system is has been rolled out across England and Wales to provide independent scrutiny of deaths, and to give bereaved people a voice. From 9 September 2024 all deaths in any health setting that are not investigated by a coroner will be reviewed by NHS medical examiners. The changes, which form part of the Department of Health’s Death Certification Reforms, were announced by the government on 15 April 2024, and come into force on 9 September 2024. As part of the changes, there will be a new medical certificate of cause of death (MCCD). From 9 September 2024, medical practitioners will be able to complete an MCCD if they attended the deceased in their lifetime. This represents a simplification of the current rules, which before 9 September require referral of the case to a coroner for review if the medical practitioner had not seen the patient within the 28 days prior to death or had not seen in person the patient after death.

The role of these offices is to examine deaths to:

• agree the proposed cause of death and the overall accuracy of the medical certificate of cause of death (MCCD) with the doctor completing it

• discuss the cause of death with bereaved people and establish if they have questions or any concerns with care before death

• act as a medical advice resource for the local coroner

• identify cases for further review under local mortality arrangements and contribute to other clinical governance processes.

The purpose of the medical examiner system is to:

• provide greater safeguards for the public by ensuring independent scrutiny of all non-coronial deaths

• ensure the appropriate direction of deaths to the coroner

• provide a better service for the bereaved and an opportunity for them to raise any concerns to a doctor not involved in the care of the deceased

• improve the quality of death certification

• improve the quality of mortality data.