Recurring concern
Unreliable Medical Examiner processes for reviewing deaths and acting on concerns
- Reports that mention this concern
- 2
- Times this concern has been raised
- 2
- Stated actions linked to this concern
- 3
What this concern includes
Includes failures of the dedicated Medical Examiner process for reviewing deaths and following up concerns, including access to relevant clinical records, identification and communication of concerns, tracking of resulting actions, and assurance that concerns are acted upon.
What is not included
- Excludes general coronial inquest disclosure, autopsy or post-mortem-process deficiencies where the Medical Examiner death-review process is not the identified concern.
- Excludes generic governance, records-access or action-tracking failures unless they directly impair Medical Examiner review of deaths or follow-up of Medical Examiner concerns.
- Excludes failures in the underlying clinical care or cause-of-death determination unless they are specifically part of the Medical Examiner review and follow-up process.
- Excludes clinical records or review processes unrelated to Medical Examiner review of deaths.
Trends
Reports over time
Reports mentioning this concern, over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Reports and published responses 2 reports
See individual reports that have raised this concern, and the actions taken in response
-
Concerns raised1
Lack of Medical Examiner access to obstetric records when reviewing deaths
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Chelsea and Westminster Hospital NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
Chelsea and Westminster Hospital NHS Foundation Trust
Ensure Medical Examiners review all neonatal deaths with access to maternal and obstetric records subject to consent and information-governance requirements.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
-
Chelsea and Westminster Hospital NHS Foundation Trust
Existing statutory Medical Examiner reviews, referral criteria and multidisciplinary reviews are considered sufficient to ensure neonatal deaths are appropriately referred.
-
Chelsea and Westminster Hospital NHS Foundation Trust
Current access to maternal and obstetric records within information governance processes is considered sufficient for Medical Examiner reviews; no Trust concern remains.
-
Concerns raised1
Failure to establish awareness and action on Medical Examiner concerns
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Betsi Cadwaladr University LHB
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
Betsi Cadwaladr University LHB
Implement a process for reviewing complaints, medical examiner reports, incidents and other matters, and sharing appropriate lessons.
-
Betsi Cadwaladr University LHB
Triage medical examiner forms, send them to clinical services and upload them to Datix within two weeks, referring potential incident triggers to the Patient Safety Team.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
-
Betsi Cadwaladr University LHB
The Health Board did not receive medical examiner concerns before the inquest because no scrutiny document had been created at the time.
-
Betsi Cadwaladr University LHB
The independent medical examiner service is provided nationally by NHS Wales Shared Services Partnership, to which the issue was reported.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026