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BACK TO INSIGHTS Introduction of Medical Examiners expected to lead to more inquests

An impact assessment has indicated that, following the introduction of Medical Examiners in April 2019, there may be an increased number of inquests.


A recent impact assessment undertaken by the Department of Health and Social Care (“DHSC”) has indicated that, following the introduction of Medical Examiners in April 2019, there may be an increase seen in the number of coroners’ inquests. The impact of the new system on coroners and inquests will be reviewed 18 months following its introduction. The true impact of this service on the number of inquests and any increases in inquests being opened will become more apparent then.


Medical Examiners were a key recommendation of a number of important public inquiries, including the Luce Review (2003), the Shipman Inquiry (2003), the Morecambe Bay Maternity Inquiry (2011) and the Francis Inquiry (2013). A number of successive governments did not implement the recommendations to introduce a system of Medical Examiners until 2016, when Health secretary Jeremy Hunt announced plans to launch a Medical Examiners service, to review all deaths from 2018.

The introduction came following a successful pilot of the Medical Examiners system in Sheffield (the flagship) and six other areas around England and Wales, representing a cross-section of society. A review of the cases referred to the Yorkshire coroner from the Sheffield pilot, conducted in the first three months, found an overall reduction in the

numbers of unnecessary referrals being made to the coroner, with a preservation of appropriate referrals.


The arrangements for scrutinising Medical Certificates for Cause of Death (‘MCCD’) have remained unchanged for 50 years; however there remain concerns over the efficacy of this, particularly for cases that have not been referred to the coroner.

The main policy objectives and benefits of a Medical Examiner System are that it:

  • Improves the quality and accuracy of MCCD’s.
  • Provides better scrutiny to identify and deter criminal activity or poor practice.
  • Helps improve clinical governance and protects patients.
  • Provides an improved level of reassurance for the bereaved.

Increase in cases referred to the coroner

The introduction of the Medical Examiners system seeks to scrutinise all non-coronial deaths. This is expected to lead to a reduction in the number of problems, as well as detection of any issues which would require a referral to the coroner.

The involvement of Medical Examiners is likely to lead to the detection of deaths that meet the coroner’s investigative duty, which otherwise may have gone unreported. The Sheffield pilot found that there was a fall in the proportion of registered deaths that are reported to the coroner, but at the same time, an increase in the proportion of registered deaths that result in an inquest. It is expected that Medical Examiners will be better able to determine whether or not cases meet the coroner’s duty to investigate and, whilst fewer cases may be referred to the coroner, of those that are referred, they will require an inquest more often than under the current system… READ FULL ARTICLE