Skip to main content

Introduction of Medical Examiners expected to lead to more inquests

An impact assessment has indicated that, following the introduction of Medical Examiners in April 2019, there may be an increased number of inquests.


A recent impact assessment undertaken by the Department of Health and Social Care (“DHSC”) has indicated that, following the introduction of Medical Examiners in April 2019, there may be an increase seen in the number of coroners’ inquests. The impact of the new system on coroners and inquests will be reviewed 18 months following its introduction. The true impact of this service on the number of inquests and any increases in inquests being opened will become more apparent then.


Medical Examiners were a key recommendation of a number of important public inquiries, including the Luce Review (2003), the Shipman Inquiry (2003), the Morecambe Bay Maternity Inquiry (2011) and the Francis Inquiry (2013). A number of successive governments did not implement the recommendations to introduce a system of Medical Examiners until 2016, when Health secretary Jeremy Hunt announced plans to launch a Medical Examiners service, to review all deaths from 2018.

The introduction came following a successful pilot of the Medical Examiners system in Sheffield (the flagship) and six other areas around England and Wales, representing a cross-section of society. A review of the cases referred to the Yorkshire coroner from the Sheffield pilot, conducted in the first three months, found an overall reduction in the

numbers of unnecessary referrals being made to the coroner, with a preservation of appropriate referrals.


The arrangements for scrutinising Medical Certificates for Cause of Death (‘MCCD’) have remained unchanged for 50 years; however there remain concerns over the efficacy of this, particularly for cases that have not been referred to the coroner.

The main policy objectives and benefits of a Medical Examiner System are that it:

  • Improves the quality and accuracy of MCCD’s.
  • Provides better scrutiny to identify and deter criminal activity or poor practice.
  • Helps improve clinical governance and protects patients.
  • Provides an improved level of reassurance for the bereaved.

Increase in cases referred to the coroner

The introduction of the Medical Examiners system seeks to scrutinise all non-coronial deaths. This is expected to lead to a reduction in the number of problems, as well as detection of any issues which would require a referral to the coroner.

The involvement of Medical Examiners is likely to lead to the detection of deaths that meet the coroner’s investigative duty, which otherwise may have gone unreported. The Sheffield pilot found that there was a fall in the proportion of registered deaths that are reported to the coroner, but at the same time, an increase in the proportion of registered deaths that result in an inquest. It is expected that Medical Examiners will be better able to determine whether or not cases meet the coroner’s duty to investigate and, whilst fewer cases may be referred to the coroner, of those that are referred, they will require an inquest more often than under the current system.

The impact assessment revealed that the introduction of the Medical Examiner service could result in an extra 141 cases being referred to the coroner, which would not have been referred under the current system. It was found that if the number of cases not referred in one area was representative of the country as a whole, it would result in this number of further cases per year. An analysis of the Sheffield pilot found that more cases would be referred to the coroner that would result in “critical” conclusions.


Although the figure of 141 additional inquests being suggested is based on ‘expert opinion’, this is perhaps somewhat speculative, as it might assume that every geographical area would have unreported cases. This may not be the case for all areas and some may have more unreported cases than others, which makes the accuracy of the statistic difficult to rely on.

The changes to the Deprivation of Liberty Safeguards (“DoLS”) legislation, introduced through the Crime and Policing Act 2017 will have seen a large reduction in the number of cases requiring an inquest, as coroners no longer have to hold an inquest if a person dies while the subject of a DoLS. This has likely had the effect of reducing the large administrative burden which was previously on the coroner’s court and may allow for additional capacity to hear any additional cases arising from the new Medical Examiners service.

The full impact assessment has been published.

If you have any questions or would like more information about our update, please get in touch with your usual Weightmans contact or the author of this update, David Reddington (Employed Barrister) on 0207 822 1925, or

Sectors and Services featured in this article

Share on Twitter