By law, where CO is suspected as a cause of death, cases are referred to the coroner, but routine testing for CO exposure is not required. In April 2019 NHS Improvement announced a national program to introduce a new medical examiner role at all hospital trusts to provide independent scrutiny of all deaths.

The new system is currently being rolled-out across England and Wales. Medical examiners are senior medical doctors who are contracted to undertake medical examiner duties, outside of their usual clinical duties. They are trained in the legal and clinical elements of death certification processes.

This research investigates the opportunities offered by the introduction of the medical examiner system and recent scientific developments, which have the potential to improve the consideration of CO exposure as a factor in the investigation of a death.

The goal is to work towards obtaining a more complete estimate of the number of CO deaths by testing at post-mortem. Better data collection and greater awareness of the effect of CO on public health, will help develop strategies to reduce death and harm from exposure to CO in the home.

Final Report

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