Cases such as those involving Harold Shipman and Lucy Letby highlighted the need for an extra layer of scrutiny.

Nick Johnson KC prosecuting R V Lucy Letby

To strengthen safeguards, medical examiners will look at the cause of death in all cases that have not been referred to the coroner.

https://www.gov.uk/government/news/causes-of-death-to-be-scrutinised-in-revamp-of-death-certificates

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