The Notification of Deaths Regulations 2019 came into force on 1 October 2019. The new Regulations place a duty on registered medical practitioners to notify the Coroner of a death if one or more of the circumstances set out in Regulation 3(1) apply.

Until now, there was no clear statutory duty on doctors to report particular deaths to the Coroner and so these Regulations will provide much-needed clarity. They were drafted as a result of recommendations made by Dame Janet Smith who chaired the Shipman Inquiry. She was concerned at how Dr Harold Shipman was able to exploit weaknesses in the death certification system to cover up his crimes.

So when does the duty to report a death arise? A death under the circumstances set out below should always be notified to the Coroner, regardless of how much time has passed since the death:

  • The death was due to poisoning, including by an otherwise benign substance (e.g. sodium/salt).
  • The death was due to exposure to, or contact with a toxic substance (e.g. toxic material/solids/liquids/gases/radioactive material).
  • The death was due to the use of a medicinal product, the use of a controlled drug or psychoactive substance (illicit/recreational drugs/prescribed or non-prescribed medication/self-administered overdose/excessive deliberate dose /given in error/psychoactive substances/legal highs/designer drugs/herbal highs).
  • The death was due to violence, trauma or injury.
  • The death was due to self-harm.
  • The death was due to neglect, including self-neglect. (This does not include where the self-neglect was caused due to dementia, or, where caused by lifestyle choices such as: smoking, excessive eating or chronic alcoholism).
  • The death was due to a person undergoing any treatment or procedure of a medical or similar nature.
  • The death was due to an injury or disease attributable to any employment held by the person during the person’s lifetime.
  • The person’s death was unnatural but does not fall within any of the above circumstances.
  • The cause of death is unknown.
  • The registered medical practitioner suspects that the person died while in custody or otherwise in state detention.
  • There was no attending registered medical practitioner required to sign a medical certificate cause of death (“MCCD”) in relation to the deceased person.
  • The attending medical practitioner is not available within a reasonable time of the person’s death to sign the certificate of cause of death.
  • The identity of the deceased person is unknown.

A Coroner’s investigation may not be necessary in all notifiable cases but it is heartening that there will now be consistency in deaths reported to the Coroner and Inquests carried out where there is a need.


Caption: Claire Kirwan, Partner & Head of Medical Negligence and Personal Injury

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