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Coal miners in Queensland Australia have a pre-employment medical and then medical every five years. In 2015, cases of coal workers’ pneumoconiosis (CWP) were identified among miners/ex-miners, outside the medical scheme.We reviewed the respiratory component of the medical scheme and evaluated its design and implementation. We reviewed 91 completed medical forms, 257 chest x-rays (CXRs) and 260 spirograms and surveyed the spirometry equipment and training of providers. We interviewed employer and trades union representatives.Medicals had become focussed on fitness for work rather than surveillance. Some forms were poorly completed and the questions were inadequate to evaluate respiratory health.The criteria to trigger a CXR were unclear. Only 25% of the CXRs ‘good’ under the ILO classification scheme. 18 of the CXRs showed Category 1 simple pneumoconiosis, only two were identified in the original radiology reports.40% of the spirograms had not been performed to ATS/ERS standards and were uninterpretable. We identified 30 abnormal spirograms of which only 1 had been identified in the medical report. The survey of spirometry providers identified poor knowledge of the equipment, poor quality control processes and inadequate training.An effective scheme needed to more clearly articulated its surveillance purpose and to be reviewed on a regular basis.We recommended that a smaller number of experienced doctors trained and approved to undertake these assessments. The scheme needed better spirometry testing and interpretation, a better CXR referral process, improved CXR interpretation and reporting using the ILO criteria. Clinical guidelines were needed to inform diagnosis and management of CMDLD. Medical screening and surveillance is not a substitute for effective dust control, which is the primary protection against CWP. This is particularly important because it can progress even after dust exposure has ceased. These findings have implications for medical screening in other industries.