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Dear Norman

I am afraid I have to point out some important omissions and inaccuracies in you description of the medical examiner service. I am lead medical examiner in Sheffield.

First, Sheffield is one of several other pilots and early adopter sites in England and Wales (Gloucestershire, Powys, Essex, Brighton and Hove, Inner North London, Leicester, Birmingham).

Second, medical examiners do not decide which cases are referred to a coroner but give advice where it is needed.

Third, and very importantly, medical examiners always have the time and opportunity to scrutinise the notes. This is the very essence of scrutiny and also includes a discussion with the bereaved to determine if they have concerns.

M&M meetings have an important place after registration of death or whilst coroners investigate. You have nevertheless not included two important considerations if your M&M meeting identifies 'avoidability': the case should be referred or information passed to a coroner and the relatives should be informed. I'll wager neither of these steps follow M&M meetings in the great majority of cases. The medical examiner system fills this gap and achieves the openness and transparency missing for so long.

With kind regards

Dr Alan Fletcher