PRESS RELEASE : Causes of death to be scrutinised in revamp of death certificates [April 2024]

The press release issued by the Department of Health and Social Care on 15 April 2024.

To strengthen safeguards, medical examiners will look at the cause of death in all cases that have not been referred to the coroner.

• Widely welcomed reforms to the system will provide greater transparency to the bereaved and help protect the public
• All deaths not investigated by a coroner will be reviewed by medical examiners, from 9 September 2024
• Cases such as those involving Harold Shipman and Lucy Letby highlighted the need for an extra layer of scrutiny

Public protection and support for bereaved families are at the heart of a government overhaul of how deaths are certified.

From September, medical examiners will look at the cause of death in all cases that have not been referred to the coroner in a move designed to help strengthen safeguards and prevent criminal activity.

They will also consult with families or representatives of the deceased, providing an opportunity for them to raise questions or concerns with a senior doctor not involved in the care of the person who died.

The changes demonstrate the government’s commitment to providing greater transparency after a death and will ensure the right deaths are referred to coroners for further investigation.

Health Minister, Maria Caulfield, said:

Reforming death certification is a highly complex and sensitive process, so it was important for us to make sure we got these changes right.

At such a difficult time, it’s vital that bereaved families have full faith in how the death of their loved one is certified and have their voices heard if they are concerned in any way.

The measures I’m introducing today will ensure all deaths are reviewed and the bereaved are fully informed, making the system safer by improving protections against rare abuses.

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 9 September 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.

Welcoming the announcement today, Dr Suzy Lishman CBE, Senior Advisor on Medical Examiners for the Royal College of Pathologists, said:

As the lead college for medical examiners, the Royal College of Pathologists welcomes the announcement of the statutory implementation date for these important death certification reforms.

Medical examiners are already scrutinising the majority of deaths in England and Wales, identifying concerns, improving care for patients and supporting bereaved people. The move to a statutory system in September will further strengthen those safeguards, ensuring that all deaths are reviewed and that the voices of all bereaved people are heard.

National Medical Examiner, Dr Alan Fletcher, said:

I am delighted that the statutory basis for independent medical examiners is confirmed. This will ensure all bereaved people have a voice, supporting patient safety learning and improvement, including through accurate coroner referrals.

Welsh Government Cabinet Secretary for Health and Social Care, Eluned Morgan, said:

I am pleased to see death certification reforms are taking a long-awaited step forward today.

The legislative framework I have laid for Wales will pave the way for greater public protection and an improved service for the bereaved.

Moving the current medical examiner service onto a statutory basis will also introduce independent scrutiny of all deaths and an increased opportunity for learning and improvement across the health sector.

Laying the regulations before Parliament today and setting out a timeline for the new system to be implemented means all those involved in the death certification process have the chance to prepare before it comes into force.

Work is already ongoing across government and the health service to ensure that the appropriate operational processes are in place to deliver the changes, which have the backing of all key stakeholders.

There will be further communication regarding legislative changes and operational guidance between now and September.