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About Medical Examiner Service

about Medical Examiner Service

 What is the Medical Examiner Service?

The Medical Examiner Service for Wales provides independent scrutiny of all deaths that occur in Wales that are not referred directly for investigation to Her Majesty’s Coroner. The aims of the Service are to:

  • Strengthen safeguards for the public. By:
    • Providing robust, systematic and independent scrutiny of all deaths not referred directly to the Coroner (cause of death and circumstances surrounding it)
    • Ensuring that the right deaths are referred to a Coroner and to individual care organisations for further investigation where appropriate, and
    • Providing intelligent analysis and system level reporting of concerns found during scrutiny
  • Improve the quality of death certification. By:
    • Completing the Medical Certificate of the Cause of Death directly where appropriate, or providing expert advice to doctors (usually the Qualified Attending Practitioner on behalf of the clinical team that provided the last episode of care to the deceased) based on discussion and a review of relevant clinical records
  • Avoid unnecessary distress for the bereaved. By:
    • Giving an explanation regarding the cause of death and answering questions about the circumstances of death; answering questions or concerns about care given; and notifying appropriate parties where further investigation is required,


The scrutiny is undertaken by an independent Medical Examiner, who is also an experienced medical doctor, supported by dedicated and trained Medical Examiner Officers. They follow a systematic process of enquiry based on the following three key sources of information:

  • Clinical Notes
  • The Qualified Attending Practitioner (a doctor on behalf of the clinical team that last treated the deceased before they died), and
  • The bereaved


It is important to understand that the service aims to scrutinise all deaths and so scrutiny is not undertaken because there are any concerns about the care given to the person before they died.

Roles within the Medical Examiner Service 

The Medical Examiner Service for Wales reviews clinical records and interacts with qualified attending practitioners and the bereaved to address three key questions:

  • What did the person die from? (Ensuring accuracy of the medical certificate of cause of death)
  • Does the death need to be reported to a coroner? (Ensuring timely and accurate referral – there are national requirements)
  • Are there any clinical governance concerns? (Ensuring the relevant notification is made where appropriate)

In undertaking this function, the Service employs two main roles:


Royal College of Pathologists

Royal College of Pathologists website