The medical examiner (ME) system was introduced in England and Wales in May 2019. Subsequently, the Health and Care Act of 2022 laid the foundations for a statutory system which was implemented on 9 September 2024. All deaths in England and Wales not investigated by a coroner are now being reviewed by a National Health Service (NHS) ME. By the end of 2023, some 2167 MEs had been trained, the majority of these are hospital consultants and general practitioners (GPs) who are supported by ME officers (MEOs) in 126 offices within NHS trusts. MEs and MEOs have undertaken specialist training for their roles facilitated by the Royal College of Pathology.

The purpose of the ME system is to provide greater safeguards for the public by ensuring independent scrutiny of all non-coronial deaths, to ensure appropriate referral of deaths to the coroner, to provide a better service for the bereaved with an opportunity for them to raise any concerns to a doctor independent of the case, to improve the quality of death certification and the quality of mortality data.

There were 581 363 deaths registered in England and Wales in 2023 and the recently published national ME annual report for 2023 demonstrated that MEs reviewed more deaths than in any previous year; a total of 311 249. It was reported that 8.1% of cases (23 934) were referred to a coroner after ME scrutiny, 8.8% (26 003) were referred for some form of clinical governance review …