The role of medical examiner (ME) was introduced in response to a series of medical scandals ranging from the criminal activities of Harold Shipman to the negligent care provided in Mid-Staffordshire. The need for a robust method of monitoring clinical care has been further strengthened by ongoing issues with sub-standard maternity care and the overall management of perinatal care in the Countess of Chester Hospital and the role of Lucy Letby. A central feature in all of these cases was the failure to identify sub-standard care and aberrant mortality patterns at an early stage and initiate appropriate investigations. Clearly, risk management information systems for reporting of adverse events and internal root cause analysis had failed to deliver effective results, identify trends and promote better clinical practice.
The concept behind the original proposal was that an independent ME would examine the circumstances surrounding a death and reach a decision
