Recommendation 276

Number of independent medical examiners

Sufficient numbers of independent medical examiners need to be appointed and resourced to ensure that they can give proper attention to the workload.

The Coroners and Justice Act 2009 requires the appointment of enough medical examiners, and the availability of sufficient funds and resources, to ensure the functions of medical examiners are discharged within the appointing area.

It is the responsibility of local authorities, who will appoint medical examiners, to ensure that this is the case.  However, to support local authorities in this task, the Department of Health will provide each local authority with estimated numbers of medical examiners that may be required locally based on expected levels of death and workload and match resourcing for medical examiners to that estimation.


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.