25 September 2019

A New Legal Obligation On Doctors To Notify Particular Deaths To A Coroner

Clyde & Co


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The Notifications of Deaths Regulations 2019 come into force on 1 October 2019 and the Ministry of Justice (MoJ)
UK Food, Drugs, Healthcare, Life Sciences
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The Notifications of Deaths Regulations 2019 come into force on 1 October 2019 and the Ministry of Justice (MoJ) has issued a guidance document for doctors. The Chief Coroner is expected to publish a guidance note, requiring the legislation to be followed by coroners immediately. The purpose of the regulations is to ensure that medical practitioners consistently refer deaths to coroners where there might be a need for investigation or an inquest. Currently doctors refer deaths to the coroner in accordance with locally-agreed criteria. As an example, in some regions doctors are expected to refer every death of a child, or every death occurring within 24 hours of admission to A&E, regardless of whether the cause of death was known, or considered to be wholly natural.

The deaths that must be referred to a Coroner

The list of circumstances (in paragraph 3 of the Regulations) includes where 'a doctor suspects' that a death has been caused or more than minimally contributed to, by violence, trauma, injury, self-harm, self-neglect, neglect, industrial disease, drug toxicity, poisoning or a medical procedure or treatment. Any death occurring in state custody or detention must be notified, irrespective of the cause of death. If none of the above circumstances are relevant, but a doctor still suspects that a death was unnatural, or the cause is unknown, notification is required.

Deciding on a natural or unnatural death

A description of a 'natural death' can be understood from paragraph 24 of the MoJ guidance: where the death results entirely from a naturally occurring disease process running its natural course, where nothing else is implicated. However, it is still common for a pathologist to conclude that the death was due to a 'natural cause' when a significant disease process causing death has been identified e.g. cancer or ischaemic heart disease. However, the MoJ guidance makes clear, at paragraph 16, that a notification must be made where a death, 'albeit from natural causes', is reasonably suspected to have resulted from 'some human failure, including any acts or omissions'. Therefore, if a doctor has a reasonable suspicion about a death that was caused by a natural cause (or disease process), but there was a delay in care or a missed diagnosis is implicated, a notification to the Coroner must be made. It will be interesting to see how the assessment of the medically natural cause, and legally natural cause develops.

When to make the notification

Notification must take place as soon as is reasonably practicable after the duty arises. This is likely to be on the same day as death, or the day after. Notification must be in writing, unless there are exceptional circumstances which justify an initial oral notification. If an oral notification is made, written confirmation must be give as soon as reasonably practicable thereafter. Paragraph 4(3) of the regulations specifies the details which must be included. Doctors should discuss all hospital deaths with their local Medical Examiner (if/when they have been appointed), to discuss whether an MCCD can be issued to the Registrar in order to register a natural death, or alternatively whether the notification duty arises. Medical Examiners (as registered medical practitioners) will also be under a duty to notify relevant deaths (if it has not already been notified by a doctor).


These Regulations create, for the first time, a specific legal duty on all doctors to report a particular death to the relevant coroner, and to actively consider whether the death was more than minimally contributed to by an act or omission in medical care or treatment. We recommend that all practising doctors are urgently taught about the notification criteria and the procedural requirements now upon them. In some regions, there will be little change as the deaths to be notified are the same as current practice, and in some areas it will be the case that some types of deaths should not be reported to the Coroner from now on.

There are no specific sanctions in place for non-compliance with these new regulations. However, the usual risks arise: there could be regulatory consequences if a doctor is referred to the General Medical Council, and the offences of perverting the course of justice, misleading a coroner or withholding a relevant document, could apply to a failure to notify. The issue may also be the subject of a Report to Prevent Future Deaths, to the chief executive of the healthcare organisation.

If your organisation or individual clinicians would like to discuss these new regulations, or require training on the death reporting process to coroners, then please do not hesitate to contact one of the advocates in our Inquests & Advocacy team.

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.

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