Recommendation 278

Considering previous incidents relating to the deceased

It should be a routine part of an independent medical examiners’s role to seek out and consider any serious untoward incidents or adverse incident reports relating to the deceased, to ensure that all circumstances are taken into account whether or not referred to in the medical records.

The Government intends to publish draft death certification regulations for medical examiners in England that will require that medical examiners obtain and consider information available about patient safety to inform their professional judgement as to the cause of death in a particular case.

The Royal College of Pathologists and e-Learning for Healthcare have produced an online learning module to help those involved in the certification of death.  This will be updated as soon as possible to reflect these recommendations.


A number of the recommendations in Sir Robert’s Mid Staffordshire Inquiry report refer to our planned reform of the death certification system and the introduction of the role of medical examiner in England and Wales. A new system of medical examiners has been trialled successfully in a number of areas across the country. The work of the two flagship sites in Gloucestershire and Sheffield has been continued and extended to operate a medical examiner service on a city and countywide basis at a scale that will be required for implementation by local authorities when legislation is introduced. We will publish shortly a report from the interim National Medical Examiner setting out the lessons learned from the pilot sites.

The government remains totally committed to the principle of these reforms. Further progress will be informed by a reconsideration of the detail of the new system in the light of other positive developments on patient safety since 2010 and by a subsequent public consultation exercise.

The medical examiner e-learning module will be refreshed following any future consultation to ensure it reflects the relevant Francis recommendations.