Deaths in England and Wales must be reviewed by a senior medical examiner if they are not referred to the coroner | Death and dying

The death certificate system in England and Wales will undergo its biggest overhaul in decades next month, with changes designed to improve protection for the public.

Any death not reported to a coroner must be reported to a medical examiner from September 9, under a regulation introduced to Parliament in April.

The new system will provide independent oversight and give bereaved families the opportunity to discuss care and treatment in advance of a death. The overhaul is designed to give reassurance to relatives and reduce the risk of scandals in the NHS or malicious actions by doctors.

The serial killer and family doctor, Dr. Harold Shipman, remained undetected for years because he was able to issue death certificates for his victims in which he stated “natural causes” as the cause of death.

Dr Alan Fletcher, the national coroner for England and Wales, said: “I am pleased that coroners will soon be reviewing every death in England and Wales that has not been investigated by a coroner. The reforms to death certification are an important step in ensuring that serious problems are identified quickly and referred for further action.”

Coroners will be part of a national network of trained, independent senior medical examiners who will investigate all deaths that do not fall within the jurisdiction of a coroner. They will ensure the accuracy of the death certificate and determine whether the death should be referred to a coroner and whether there are any concerns about clinical supervision.

The inspectors are employed by NHS bodies. The new national system was proposed in 2005 following the Shipman inquiry, into which the once-trusted GP killed around 250 patients between 1971 and 1998.

Other inquiries into NHS failings have also recommended the use of coroners. The investigation into the Stafford Hospital failings scandal between 2005 and 2008 found evidence that information on death certificates was often inaccurate or incomplete.

Since 2019, NHS trusts have appointed coroners to investigate most deaths in acute care settings. By June 2024, coroners will have investigated more than 900,000 deaths in England and Wales on a non-statutory basis. Scotland has its own death investigation service with coroners.

Fletcher said: “The introduction of the medical review system has enabled us to improve the experience of bereaved families. They have been consistently positive about the support they have received. Many have said they have been relieved of doubts and worries that they could have done more for a loved one in their final days. Now thousands more people will be supported by senior doctors in these roles.

“In most cases there are no serious concerns and we often receive positive feedback from families which is passed on to nursing staff. However, when there are problems, the statutory independent role of coroners provides a new opportunity for bereaved families and NHS staff to communicate their concerns and for healthcare providers to learn and improve care for future patients.”