This Home Office paper sets out the Government's proposals and timetable for reform of the arrangements for death registration, certification and coroners' investigations in England, Wales and Northern Ireland, drawing on the work and recommendations of the Fundamental Review of death certification and coroner services (Cm. 5831, June 2003; ISBN 0101583125) and the third report of the Shipman Inquiry (Cm. 5854, July 2003; ISBN 010158542X). The proposals are put forward within a framework based upon principles of independence, professionalism, medically-skilled staff, sensitivity to the needs of the bereaved, consistency, robustness (including rigorous inspection and performance) and transparency, which are to be used as a basis for developing a reformed system. Changes suggested include a complete overhaul of the death certification system, in order to provide for: verification of the fact of all deaths; certification of the cause of death by the doctor, as now; scrutiny of all certificates by a medical examiner in the coroner's office; and referral to the coroner of all deaths which cannot be certified or which are unnatural. Inquests, when required, should be focused on the need to learn lessons and avoid preventable deaths, with a more clearly defined relationship between the death investigation and public health systems. Comments on the proposals should be sent to Amaryllis Elphick, Coroners Unit, Home Office, Allington Towers, 19 Allington Street, London SWIE 5EB or emailed to