Deaths in England and Wales are assessed by a senior doctor if they are not referred to a coroner

The death certifying system in England and Wales is set to undergo its biggest overhaul in decades next month, in a move designed to improve protection for the public.

From 9 September, any death not already referred to a coroner must be referred to one, according to legislation submitted to parliament in April.

The new system will provide independent oversight and give bereaved families the chance to discuss care and treatment in the run-up to a death. The overhaul is intended to provide certainty for bereaved families and reduce the risk of NHS scandals or malicious actions by medical professionals.

Serial killer and family physician Dr. Harold Shipman managed to evade detection for years because he was able to issue death certificates for his victims, listing the cause of death as “natural causes.”

Dr Alan Fletcher, the National Coroner for England and Wales, said: “I am delighted that coroners will soon be able to review every death in England and Wales that has not been investigated by a coroner. The reforms to the death certificate are an important step towards ensuring that serious problems are quickly identified and reported for action.”

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

Examiners are hired by NHS bodies. The new national system was proposed in 2005 after the Shipman inquiry; the once trusted GP killed around 250 patients between 1971 and 1998.

Other inquiries into the NHS’s failings have also recommended the use of coroners. The inquiry into the scandal of failures at Stafford Hospital between 2005 and 2008 heard evidence that information on death certificates was often incorrect or incomplete.

Since 2019, NHS trusts have appointed coroners to investigate most deaths that have occurred in acute care settings. As of June 2024, coroners, operating on a non-statutory basis, have investigated more than 900,000 deaths in England and Wales. Scotland has its own deaths investigation service using medical assessors.

Fletcher said: “The rollout of the coroner system has allowed us to improve the experience of bereaved families, who are overwhelmingly positive about the support they have received, with many saying they have been freed from doubt and concerns 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 positive feedback from families is often received and passed on to the staff providing care, but where there are concerns, the independent role of medical examiners, supported by law, will provide a new opportunity for relatives and NHS staff to share any concerns they may have, and for healthcare providers to learn and improve care for future patients.”