Abstract
This chapter discusses the development of, and the history behind, the new Medical Examiner system in England and Wales. It describes the background to concerns about medicolegal investigation of death and the need for appropriate, independent review of deaths that fall outside the coronial system. It identifies relevant reports, inquiries and government actions that led to the introduction of this system in 2019, in particular the case of the GP Harold Shipman, and a series of hospital-based scandals in which the concerns of whistleblowers (frequently healthcare professionals) and families of the deceased were ignored by those who should have responded to, and acted on, their findings. The chapter identifies that the new Medical Examiner system has the potential to be the most significant advance in the medicolegal investigation of death worldwide in living memory.
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