Death certification reforms and statutory medical examiner system
A Rapid evaluation of the 2024 death certification reforms and medical examiner system
Background
In September 2024, significant changes to the way that deaths are certified and registered came into force in England and Wales. The death certification reforms (DCRs) established a statutory medical examiner system to scrutinise all deaths that are not accepted for investigation by a coroner, in both acute and community settings. The system is intended to identify clinical concerns and future learning opportunities, thereby improving patient safety and deterring against criminal activity and poor practice.
This is a rapid, mixed‑methods evaluation of the 2024 death certification reforms and the statutory medical examiner system across England and Wales, examining how the changes are working in practice for those who deliver and use the system. It explores the experiences of medical examiners, attending practitioners, registrars, and bereaved people to understand whether the reforms are meeting their intended aims, and to generate learning that can support improvement of the death certification process.
Approach
Approach
The evaluation is comprised of three elements:
Qualitative case study research
In-depth qualitative research will be carried out in four purposively selected case study sites across England and Wales. In England, a case study will be defined as a local medical examiner office, and in Wales (which operates a centralised medical examiner system) it will be defined as an acute hospital. At each case study site, we will conduct up to 15 one-to-one and/or small group interviews with a range of participants including bereaved people, staff and professionals working in medical examiner offices and the stakeholders with whom they interact. At least four interviews per site will be with a bereaved person.
National surveys of the medical examiner system workforce and coroner areas
We will carry out two national surveys across England and Wales: i) of the medical examiner system workforce (125 offices in England, four regional hubs in Wales); and ii) of coroner areas (n=77). The surveys will be online and hosted on the Thiscovery platform.
Routine data analysis
This will include analysis of activity data for the medical examiner service, gathered by NHS England and NHS Wales Shared Services Partnership. Working with stakeholders, we will seek to understand quality and variation within and across datasets and use them accordingly. Further data mapping with stakeholders may identify additional data sets that could be used for the evaluation.
Privacy Notice: Information on how we will store, process and manage personal data
Project team
Project team
- Prof Jo Ellins - Principal Investigator
- Dr Alisi Mekatoa – Project Manager
- Dr Kayleigh Sharp
- Dr Rob Romanelli
- Dr Callum Gunn
Project Duration
October 2025 - December 2026