New guidance for doctors on referring deaths to the coroner

New rules for the notification of deaths come into force on 1 October 2019.

The Notification of Deaths Regulations 2019 are designed to clarify the circumstances when a death needs to be notified to the coroner. They will affect the reporting of all deaths in England and Wales which occur on or after that date.

The new regulations follow a number of reforms to the death certification process and are designed to address concerns about inconsistent reporting of deaths. Previously, doctors were not under a statutory duty to report deaths to the coroner, but voluntarily notified unnatural deaths in accordance with normal custom and practice.

The regulations require a medical practitioner (who is registered with the GMC and has a licence to practice) to make a notification to the senior coroner in the area where the deceased's body lies, under certain circumstances.

The guidance accompanying the regulations sets out what these circumstances are and what information needs to be included in a notification.

It's important to emphasise what the guidance says about how a medical practitioner should assess the threshold for referral. It states that a death must be notified to the senior coroner, 'where there is reasonable cause to suspect that the death was due to (that is, more than minimally, negligibly or trivially), caused or contributed to' by the defined, relevant circumstances (paragraph 7).

Some of the relevant circumstances surrounding death which need to be reported to the coroner include:

  • poisoning, including by an otherwise benign substance (such as salt/sodium) and refers to either deliberate or accidental intake of poison
  • the use of a medical product, controlled drug or psychoactive substance
  • violence, trauma or injury (including those that are self-inflicted as well as assaults and accidents)
  • self-harm
  • neglect, including self-neglect
  • death due to a person undergoing a treatment or procedure of a medical or similar nature
  • an injury or disease attributable to a person's employment
  • where the practitioner suspects the person's death was unnatural
  • deaths in custody or state detention
  • cause of death or identity of the deceased is unknown.

Notifying a death

Even if you are aware that a death has already been reported to the coroner - for example, by the deceased person's family or the police - the regulations make clear you must still report the death, to make sure all the relevant information is given to the coroner. This is regardless of how much time has passed since the death occurred.

Where the death is suspicious, it is important to inform the police straight away. For deaths that are not suspicious, but need to be reported to the coroner, the expectation is that this will be done as soon as reasonably practicable. The guidance also recommends that doctors making a notification to the coroner include their GMC number as part of the 'further information that they consider to be relevant to the coroner'.

The new regulations relate to notification of deaths and don't impact rules around the Registration of Births and Deaths Regulations 1987. As was previously the case, any medical certificate of the cause of death (MCCD) must be completed by an attending medical practitioner who has seen the deceased either in the 14 days before the date of death, or after death. If this is not possible, the death must be reported to the coroner by the registrar.

This guidance was correct at publication 27/09/2019. It is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.

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