Recommendation 280

Raising concerns around deaths

Both the bereaved family and the certifying doctor should be asked whether they have any concerns about the death or the circumstances surrounding it, and guidance should be given to hospital staff encouraging them to raise any concerns they may have with the independent medical examiner.

The Department of Health intends to publish draft death certification regulations that requires medical examiners to make arrangements to speak to anyone they consider necessary to discuss the circumstances and causes of death and to provide them with the opportunity to mention any matter that might cause a senior coroner to think that the death should be investigated.  This includes the family of the deceased and/or the provider of care services.

In addition, the certifying doctor can provide any information necessary in establishing the cause of death or to protect individuals health and safety along with his/her certificate for scrutiny.


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.