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Medical Examiner and Death Certification Reforms

Volume 742: debated on Thursday 14 December 2023

I wish to update the House on the Government plan to introduce secondary legislation to reform death certification in England and Wales, from April 2024. Under the reforms, all deaths will become legally subject to either a medical examiner’s scrutiny or a coroner’s investigation. Medical examiners are senior medical doctors that independently scrutinise the causes of death. Since 2019, NHS trusts have appointed medical examiners to scrutinise most deaths in acute healthcare settings and some community settings on a non-statutory basis. From April 2024, it will become a requirement that all deaths in any health setting that are not referred to the coroner in the first instance are subject to medical examiner scrutiny.

The changes will mean that families will have greater transparency on the circumstances surrounding the death of a loved one. Medical examiners will always offer a conversation to the bereaved, providing an opportunity for them to raise questions or concerns with a senior doctor not involved in the care of the deceased. This will help deter criminal activity, improve poor practice and ensure the right deaths are referred to coroners for further investigation.

The relevant primary legislation for these reforms was commenced on 1 October 2023 and today the Government are publishing three sets of draft regulations under powers in the Coroners and Justice Act 2009 that will be laid shortly when parliamentary time allows. These will be published on

The introduction of medical examiners is part of a broader set of reforms to death certification, coronial and registration processes which will allow for the efficient flow of information between doctors, medical examiners, coroners and registrars in the new system. We are working closely with our partners in Government and the health service to ensure that the appropriate operational processes are in place to deliver these changes from April 2024.