Chapter 32. Medical examiners

Introduction

The statutory system of medical examiners came into effect on 9 September 2024. The system could and should have been introduced at least a decade earlier, as I shall explain.
Dr Alan Fletcher was the National Medical Examiner for England and Wales until September 2025. He was involved for decades in the effort to introduce medical examiners into the NHS. He provided the Inquiry with detailed evidence about the purpose of medical examiners and the circumstances in which they came to be introduced as well as a review of their efficacy. During his career as a medical examiner from 2008 to 2025, he reviewed more than 22,000 deaths. Dr Fletcher had very extensive experience as a working clinician, as a medical examiner, and latterly as National Medical Examiner.
Dr Fletcher explained that the purpose of the medical examiner system is to “ensure that an independent person reviews the documents and circumstances of every person who has died in England and Wales whose death is not subject to coronial investigation”.¹

History

In July 2003, Dame Janet Smith published her third report of the Shipman Inquiry.² She identified a number of flaws in the system in England and Wales for certifying deaths, a system which had remained unchanged since its introduction in 1926. It depended on the accuracy and integrity of a single doctor who certified the cause of death. As a result, Harold Shipman was able to murder approximately 250 patients and certify the cause of death without fear of contradiction. Dame Janet recommended a system which operated an effective cross-check of the account given by a doctor who had treated the patient and who had given a cause of death. The government of the day proposed a medical examiner system in the UK which would provide an independent medical review of all deaths that were not reviewed by the coroner. As Sir Robert Francis explained, the system has a much wider effect than potentially identifying a doctor who kills, although it does of course do that. It operates as an early warning system when a person or several people die.³ It is the role of medical examiners to identify patterns of poor care, including care which is negligent or deliberately harmful. As intended, they review deaths which a coroner has not taken for investigation. In some cases, where appropriate, they refer a case to the coroner.
The system of medical examiners was implemented 22 years after it was recommended. Mr Hunt, Secretary of State for Health between 2012 and 2018, said in evidence: “I think of all the things that could have potentially meant that what happened at the Countess of Chester was spotted earlier and the dots were joined up would have been having Medical Examiners.”⁴
In 2008, pilot schemes of medical examiners were set up in several cities. The most comprehensive and long-running pilots were in Sheffield and Gloucester, which tested the operation of medical examiners in Primary Care Trusts for many years, from 2008 to 2019.^* ⁵
The Coroners and Justice Act 2009 was passed six years after the publication of Dame Janet’s recommendations. Section 19 of the Act placed upon Primary Care Trusts (in England) and Local Health Boards (in Wales) an obligation to appoint medical examiners.⁶ It also gave the government the power to appoint a National Medical Examiner.⁷ In 2009, it was assumed, reasonably, that funding for medical examiners would come from the NHS budget.⁸ The sections in the Act dealing with funding were not brought into force and for some years no progress was made on the national scheme.
As part of the reforms to the NHS introduced by the Rt Hon. Andrew Lansley CBE, Secretary of State for Health between 2010 and 2012, the sections of the Coroners and Justice Act 2009 dealing with funding (which are still not in force) were amended so as to shift the cost burden of medical examiners onto local authorities.⁹ The pilot programmes continued to run during this time, with funding coming from local authority budgets.
Sir Robert Francis’s inquiry into the failings at Mid Staffordshire NHS Foundation Trust published its report in February 2013.¹⁰ Sir Robert Francis supported the use of independent medical examiners. This and many other recommendations were accepted by the government in 2014.¹¹
Another ten years passed before the statutory scheme was set up. In the meantime, various approaches to funding were considered and the pilot schemes continued. In response to a consultation in 2016, the then Department of Health decided that medical examiners would be better funded through central NHS funding (rather than via local authorities).¹² This approach should have been taken in the first place. It is regrettable that even after the decision had been taken that funding should come from the central NHS budget, that did not happen. Instead, the Department of Health decided to devote some of the NHS budget to a non-statutory scheme.¹³ It also changed the process for the completion of Cremation Form 5, which until then could be completed only by a GP. The change moved responsibility for completing the form from GPs to medical examiners. The money saved by not paying GPs to fill in the form was diverted to fund the position of medical examiners.¹⁴ One can only admire the ingenuity deployed by those in the Department of Health who were endeavouring to bring in medical examiners by finding ways around the failure to fund a system that had been agreed by government. This was a waste of the time of civil servants and of public money.
In 2019, the UK government laid primary legislation before Parliament to place medical examiners under the control of the NHS. The Bill received a second reading but was overtaken by a general election and the onset of the Covid-19 pandemic.¹⁵ As a result, the ad hoc arrangements which had become referred to as ‘non-statutory arrangements’ continued. Medical examiners reviewed deaths across the UK but there was no statutory requirement for a medical examiner to be involved in the certification of death. Trusts were asked by NHS England to appoint medical examiners who would review deaths in hospitals. Many did, but there was no requirement to do so.
In 2022, after a government spending review, NHS England advocated for the statutory medical examiner scheme to be centrally funded.¹⁶ It was Mr Hunt’s evidence that having been Secretary of State for Health and now Chancellor, he was motivated to ensure that the scheme was properly funded and worked to ensure that the scheme was allocated central government funding.¹⁷ He had been Secretary of State for Health from 2012 to 2018, during which time there was a failure to fund a statutory system of medical examiners. He conceded that the medical examiner system “is something that I look at as being one of the things that we took too long to implement”.¹⁸ He spoke about the “NHS’s reluctance to implement Medical Examiners”.¹⁹ He explained that “what lay behind the institutional reluctance” was: (a) the cost associated with implementation; (b) that it was not initially clear who the medical examiners would be; and (c) that there was a shortage of doctors in the NHS and the focus was on using doctor time to treat patients as opposed to examining deaths.²⁰ That latter point rather overlooks that one of the purposes of examining a death is to understand what happened while the patient was alive and whether, had something different been done, the outcome may have been different. This is essential learning for the effective treatment of live patients. In its closing submissions, DHSC accepted that it had taken a long time to implement the statutory scheme.²¹
Coinciding with the effort to ensure the scheme was centrally funded was the passage of the Health and Care Act 2022, section 169 of which re-established medical examiners as funded and appointed by NHS bodies.²² It placed a duty on the Secretary of State to ensure that there were sufficient medical examiners to discharge their responsibilities across England, with a similar provision placing responsibility on Welsh ministers.²³
It was not, however, until 9 September 2024 that the full statutory scheme of medical examiners was fully operational. That it was rolled out just before this Inquiry started hearing evidence was, I was told, a coincidence. DHSC gave three reasons for the further delay to the full scheme: first, to get the scheme to “bed down”;²⁴ second, to try to get more engagement from GPs, who at that point had not been asked to engage with the medical examiner system;²⁵ and third, because NHS England needed time to introduce the system and embed the logistical arrangements.²⁶ In other words, more preparation was needed.
In my view, it took far too long to implement this system. It should have been in place at the latest by mid-2014. This would have been 11 years after the recommendation was made, 10 years after it was accepted, 5 years after the Coroners and Justice Act 2009 was passed, and shortly after the reinforcement by the Francis Inquiry of the need for medical examiners. The system of 129 medical examiners’ offices in England and Wales currently costs approximately £50 million to run each year, alongside £7 million of central administrative costs,²⁷ out of an NHS England annual budget of £179 billion in 2024/25.²⁸ Given the efforts of DHSC to find ways to put some sort of system into place, the absence of funding for this necessary measure was the result of a failure of political will. The most recently available (September 2025) information is that the funding for medical examiners is no longer ring-fenced but ICBs are funded on the basis that they will provide the medical examiner service.²⁹ I need hardly say that there should be no question of a failure to fund this important service. Ring-fenced funding makes sure of that. When, as I recommend later in this chapter, the operation of medical examiners is next reviewed, the question of the adequacy of funding must be addressed.

Current system

There are 129 medical examiners’ offices in England and Wales, each of which serves about two NHS Trusts.³⁰ Typically, each office employs a number of senior doctors as part-time medical examiners, one of whom will be the Lead Medical Examiner, with a team of medical examiner officers.³¹
All medical examiners receive training. Importantly, the possibility of deliberate harm comes at the beginning of the training. Dr Fletcher said: “[I]n the first line of the e-learning, Medical Examiners are reminded that their role had the germination from the murders committed by Harold Shipman, the issues at Morecambe Bay, [and] Gosport War Memorial Hospital.”³² The report into the events at Morecambe Bay by Dr Kirkup was published in 2015.³³ I am satisfied that had the system been up and running in 2015, it would have included this same information.
Mandatory training includes the safeguarding of children and young people.³⁴ Dr Fletcher said, however, that he would normally expect safeguarding to be raised as an issue by the treating clinician, but he recognised that safeguarding is everyone’s responsibility. He stated that he would prefer medical examiners to engage in a conversation with the clinical team and ask whether they have raised a safeguarding concern. If the response is no and the medical examiner considers it needs to be done, they should then do it themselves.^†³⁵
The role of the medical examiner officer is to help the medical examiners discharge their statutory functions effectively.³⁶ As permanent members of staff, officers run the office and keep records so that there is an institutional memory and oversight of the work of the examiners. Most importantly, they are often the first contact with the bereaved and need the skills to communicate appropriately. Whilst responsibility to discharge the duty to take reasonable steps to speak to the family rests with the medical examiner, in most cases this is done by the medical examiner officer.³⁷ Most families do speak to either the medical examiner or the medical examiner officer.³⁸
Fundamental to the system is that the doctors carrying out the reviews are independent from the primary, treating physician. This removes the risk of the treating doctor’s professional and emotional investment in the treatment, life and death of the patient affecting their judgement as to the cause of death. For the same reason, medical examiners cannot review a patient whom they have treated or where there is a conflict of interest – for example, where a death has occurred in the unit in which they work.³⁹
Medical examiners have the power to access the medical records of the deceased under the Access to Health Records Act 1990 and must review them within five days of the death.⁴⁰ The review should be “proportionate”.⁴¹ As a matter of course, the medical examiner discusses the case with the attending practitioner, who is responsible for completing the medical certificate of cause of death.⁴² They will also speak to the relatives of the deceased to establish whether they have any particular concerns about the quality of the care that was provided.⁴³ It was plain from the evidence given during the Inquiry that parents and relatives can provide important information to clinicians – and, it follows, to medical examiners – about the condition and care of their babies.⁴⁴
In the case of neonates, the medical notes are usually very much shorter than those of older children and adults. It is likely, therefore, that a medical examiner would look at all the medical records when examining the death of a neonate. This would be proportionate to the task.
Dr Fletcher said that medical examiners should answer three questions:
- What is the cause of death and has it been accurately recorded?
- Does the case need to be referred to the coroner?
- Are there any clinical governance concerns that need further review?⁴⁵
The guidance to medical examiners makes it clear that they are not expected to carry out in-depth reviews or investigations.⁴⁶ They have neither the resources nor the expertise to do so. Their role is to identify any issues and pass them on to the coroner, where appropriate, or, if the issues are about clinical governance, refer them either to established clinical governance processes⁴⁷ or to the National Medical Examiner.⁴⁸ Where the concerns require immediate action, they should be passed on to the Executive Team of the Trust concerned.⁴⁹ It goes without saying that, from that point on, the quality of the work done depends on the expertise and judgement of the Executive Team.
A decision to involve the police would occur after multi-agency discussions, probably involving the medical examiner, the coroner and the Trust’s executives, after a concern had been identified and raised by the medical examiner.⁵⁰

Developments in medical examiners’ guidance on neonatal deaths

In the spring of 2024, Dr Fletcher commissioned three medical examiners, two of whom are neonatologists and one a paediatric pathologist, to work with BAPM to develop updated guidance on neonatal and child deaths for medical examiners. The resulting guidance was published in March 2025 and I was grateful to receive it, as promised by Dr Fletcher.⁵¹ The same group is creating an e-learning module that informs neonatologists and paediatricians about the medical examiner system and vice versa.
The recent guidance (2025 update) makes clear that where there is a sudden unexpected death of a child or neonate and there is “no immediately apparent medical cause”, the medical examiner should “actively consider whether unnatural events … may have caused or contributed to the death”.⁵²

Medical examiners’ areas of expertise

Whilst medical examiners are senior doctors, there is currently no requirement for the medical examiner to have knowledge or experience in the area of medicine relevant or potentially relevant to the death. For instance, neonatal deaths can be reviewed by medical examiners who have no experience of neonatal or paediatric care. Dr Kingdon, who gave evidence in her capacity as a past President of the RCPCH, explained the limitations of the system from the perspective of neonatology, which is now very specialised: “[W]hen I am really troubled about what could have happened that triggered this child’s death I think [it] is expecting quite a lot of [adult trained] clinicians who are dealing with all deaths in a busy … general hospital.”⁵³ Dr Fletcher considered that the absence of specialist knowledge is not a barrier to effective review and suggested it may be a strength.⁵⁴
I asked Dr Fletcher about a situation where a baby dies suddenly and unexpectedly and a medical examiner, who is not trained in paediatrics or neonatology, approaches the paediatrician to discuss the case. The paediatrician states that they have a cause of death, but without the appropriate expertise the medical examiner cannot challenge the paediatrician’s view. Dr Fletcher agreed that this scenario could arise, but he emphasised that if a medical examiner has doubts they are encouraged to challenge the practitioner. Dr Fletcher stated that, whilst he accepted a medical examiner may accept a paediatrician’s diagnosis on the first occasion, if there is another sudden and unexpected death, the situation would be very different.⁵⁵ He also said – and I accept – that there is support and accessible expertise in the local and regional structure for medical examiners to obtain advice regarding neonatal cases.⁵⁶ However, at present there is no funding or the resources to provide a full network of neonatal experts. I shall return to this later.
Dr Fletcher made the point that “the Sudden and Unexpected Death of a baby in a neonatal unit is an outstanding and remarkable matter. So in [and] of itself I would expect that occurrence to generate a level, a heightened sense of concern about what happened.”⁵⁷ He also said that, in these circumstances, there is an “extremely low threshold for notifying the Coroner”.⁵⁸ In addition to contacting the coroner, he thought the JAR and Child Death Review process would also be followed. He explained that the medical examiner would review the records, speak to the attending practitioner about the case and ask the family questions. He said that, where a family member raised concerns, such as “I don’t understand what happened … we were told everything was fine”, these comments would be a trigger to review and escalate the case further.⁵⁹ The importance of speaking to the parents cannot be overestimated. The evidence of Mother E and F makes that clear.

Had the medical examiner system been in place in 2015 and 2016, would any deaths have been avoided?

The deaths of Baby A, Baby C and Baby D were reported to the coroner, so the medical examiner would almost certainly not have been involved. Although Dr Newby, when reporting the death of Baby D, alerted the coroner’s office to the fact that there had been three deaths within a short period and a collapse of a twin, Dr McPartland did not recommend a forensic post-mortem. Given Dr Fletcher’s view of the significance of the unexpected death of a neonate, it may well be that, had the medical examiner been informed of the death and the nature of the referral, they would have suggested that there should be a forensic post-mortem. However, I do not have the evidence to make a finding that this would have happened, nor can I say what the consequences would have been.
Baby E died at the beginning of August and his brother, Baby F, was poisoned with insulin shortly afterwards. Although not examined, Baby E’s death was also reported to the coroner. I have set out the facts in Chapter 5. Had the medical examiner system been in place, it may be that Dr ZA would have turned first to the medical examiner, although at that time the Senior Coroner, Mr Rheinberg, had in place a rule that all deaths of babies should be reported to the coroner (a policy that Dr Fletcher felt was likely to lead to overloading of the coroner’s office and was probably unnecessary).
Had the medical examiner been involved, they may have held discussions with Dr ZA and, if appropriately experienced, may have challenged her view of the cause of death (see Chapter 5). However, I bear in mind that Dr Brearey, the lead for neonatology at the Countess, accepted her view at the time. Whether the medical examiner would have understood the significance of the X-ray findings I cannot tell. The medical examiner may have spoken to Mother E and F.  Had she been asked about her experiences on the evening of E’s death, it is likely that she would have told him. I cannot say whether the significance of her information would have been understood at that time but it may have been.
In October 2015, Baby I was the fifth baby to die suddenly and unexpectedly on the neonatal unit. Dr Gibbs referred the case to the coroner. The involvement of the coroner would have precluded the involvement of a medical examiner. The post-mortem returned a natural cause of death.
Had there been in place a hospital-based record of all deaths on the neonatal unit which was accessed as a matter of course by the medical examiner whenever a death on the unit was referred to them, that would have enabled the medical examiner to identify or at least ask about, for example, an unusual rise in the number of deaths. It would also have allowed the clinicians to talk about their concerns to someone external to the Trust. The results of the Inquiry questionnaire sent to 120 Trusts show that, by December 2023, most (112) had in place processes for medical examiners to identify trends or patterns in deaths across the Trust.⁶⁰ Had this been in place at the Countess in 2015 and 2016, as it should have been, the discussions should have led to action to protect babies by May 2016. By that stage, a baby had died each month from December 2015 to March 2016 (deaths not on the indictment). In respect of two, there was no post-mortem. In April 2016, Ms Powell had moved Letby to day shifts, as set out in Chapter 8. Whether other action to protect babies would have occurred would have depended on whether the medical examiner’s external voice persuaded the senior managers that the time had come to take action.

Conclusions

The introduction of medical examiners is a very positive development. For the first time, bereaved families have a voice in establishing what happened to their child or other family member. This is emphasised in the version of the ‘Medical examiners’ pages on the NHS website.⁶¹ Importantly, there is a hospital-based record of all deaths on a neonatal unit which should be accessed by any medical examiner tasked with reviewing the death of a new baby. In most hospitals, the record is held on BadgerNet. I say more about that in Chapter 35. I would just add that all 120 Trusts that completed the Inquiry questionnaire confirmed that they had access to a medical examiner.⁶²

Recommendations

Dr Fletcher made and agreed with a number of suggestions on how to improve the medical examiner system, including the following:
1. There should be a checklist of steps that medical examiners must take when dealing with the death of a neonate. It should include consideration of whether they should make a safeguarding referral to the LADO.⁶³ I agree. When a medical examiner or any other doctor or nurse is dealing with the death of a neonate, what to do should be set out clearly and simply, in no more than one page.
2. The SUDIC guidelines should be set out within the Good Practice Series for medical examiners, not merely signposted.⁶⁴ I agree. Simplicity of process is imperative.
3. Medical examiners should ask direct questions of the attending practitioner as to whether there is a concern that a child has been harmed or if there is a safeguarding concern.⁶⁵ I would add that, where there may be such a concern, the medical examiner should ensure that there is a record made immediately of the contact details of every doctor or nurse who attended the baby during their life. This is not too much to ask. Sudden unexpected death on neonatal units is rare. The number of doctors and nurses who will have looked after neonates during their short lives is usually low. The details should be held on the child’s records and by the medical examiners’ office and provided by the medical examiners’ office to the hospital’s safeguarding team. Where deliberate harm is suspected, these steps are proportionate to the risk to patient safety.
Dr Fletcher suggested that consideration should be given to the possibility of medical examiners having unique specialties in the future.⁶⁶ In light of Dr Kingdon’s evidence, I am sure that this should be done at least for paediatrics and neonates. It is too easy to say, as was done for years after the Coroners and Justice Act 2009 came into force, that medical examiners would reduce the number of doctors available for other things. Now that they are in place, if medical examiners are not specialists in the relevant area of medicine, time is wasted while they get up to speed and seek advice from an appropriately skilled expert. It would be quicker to have a medical examiner who is appropriately skilled in the first place. It requires careful organisation. Specialists may be regional or, rarely, national. These are details to be worked out.
I note that NHS England is working on a time-limited survey of medical examiner offices in England to evaluate the impact of medical examiners on causes of death.⁶⁷ I suggest it be reviewed two years after that. It should include a review of the adequacy of funding for medical examiners and their support staff and offices. In particular, the question of whether the funding should be ring-fenced must be addressed. Thereafter, reviews should be as directed by DHSC.

Footnotes

* Primary Care Trusts were abolished under the Health and Social Care Act 2012 and commissioning responsibilities handed over to Clinical Commissioning Groups; as of July 2022, CCGs were dissolved and replaced by Integrated Care Systems.
† Dr Fletcher stated that this aligns with the medical examiners’ approach to a referral to the coroner.