Provision was made in the Coroners and Justice Act of 2009 for all deaths to be scrutinised by an independent ‘medical examiner’. This had been recommended by multiple inquiries, including in relation to Harold Shipman (2005), Mid Staffordshire (2013) and Morecambe Bay (2015).

In March 2016, following a number of medical examiner pilot schemes, the government held a public consultation. In the House of Lords on 18 October 2017 the Government was asked when the outcome of that consultation would be published. The Government responded with a commitment to introduce "a system of effective medical scrutiny, applicable to all deaths that do not require a coroner’s investigation" no later than April 2019. The Government’s response to the consultation will be published 'shortly', along with the regulations for the system. The intention is for the service to cover the entire country from April 2019, starting in secondary care and then moving into primary care.

Lord O'Shaughnessy noted that this would mean a greater workload but was reassured that "the pilots and the early adopters have demonstrated that it is possible to do this with existing staff loads".

It has been reported that the pilot studies have demonstrated that medical examiners ensure that death certificates are accurate and that cases are referred appropriately to the coroner. Whilst the number of referrals to a coroner resulting in an inquest increased, there was a reduction in the number of inappropriate referrals (where the doctor was satisfied that there was a natural cause of death but wasn’t sure how to complete the medical certificate as to the cause of death). In addition, bereaved relatives are able to ask questions and raise concerns.

More details and lessons published from the medical examiner pilot schemes can be found here.

NHS Improvement and the Department of Health are commissioning research to explore whether medical examiners will be best placed to select which deaths require a 'case record review' in accordance with the National Guidance on Learning from Deaths (March 2017).