A new legal duty on doctors to report deaths to Coroners

The Notification of Deaths Regulations 2019

The Notification of Deaths Regulations 2019[1] come into effect on 1 October 2019 and will place a legal duty on ALL doctors who come to know of a death to ensure it has been reported to a Coroner where any of the circumstances that might trigger the Coroner’s investigatory duties appear to be present.

Although for over half a century, under the Births and Deaths Registration Act 1953[2], the deceased’s ‘attending medical practitioner’ (‘AMP’) has been required to provide the Registrar with a medical certificate of the cause of death (‘MCCD’), until now there has been no statutory obligation upon the AMP, or any other doctor, to either directly notify the Coroner or ensure the Coroner has been informed by another medical colleague of a death falling within the Coroner’s jurisdiction[3].

The circumstances in which the doctor’s notification duty will now arise largely parallel those situations falling under s.1(2) Coroners and Justice Act 2009 which would give rise to the Coroner’s own investigatory duty – i.e. when the doctor suspects the death was violent or unnatural (including from neglect or self-neglect) or that it occurred whilst the deceased was in state detention or where the cause of death is unknown or the identity of the deceased is not established.

“Better safeguards with the additional scrutiny of deaths”

Previously it would often be the Registrar or a Police Officer who would notify the Coroner of a death in the community. From tomorrow, wherever a notifiable death has occurred of which a doctor is aware that death must also be reported directly to the Coroner by a medical practitioner.

The duty under the Regulations will in most cases be complied with by the attending doctor who would also be responsible for completing the MCCD when appropriate, but the reporting obligation now extends further. Any doctor who now becomes aware of a death must provide the notification the Coroner if either (1) there is no attending medical practitioner required to sign a MCCD, or (2) the doctor who would otherwise sign the MCCD is not available to do so within a reasonable time[4] (unless of course another doctor has already made the notification).

Violent and unnatural deaths

Any unnatural cause of death will trigger the notification duty and the new Regulations provide a non-exhaustive list of typical ‘unnatural causes’. This includes:

  • poisoning, including by an otherwise benign substance;
  • exposure to or contact with a toxic substance;
  • the use of a medicinal product, controlled drug or psychoactive substance;
  • violence;
  • trauma or injury;
  • self-harm;
  • neglect, including self-neglect;
  • the person undergoing a treatment or procedure of a medical or similar nature; or
  • an injury or disease attributable to any employment held by the person during the person’s lifetime;

Even if the medical practitioner is aware that someone who is not a doctor (such as a police officer) has already reported the death to the Coroner, the medical practitioner still must make their own notification under these Regulations. However the notification duty does not apply if it is reasonably believed that the Coroner has already been notified of the death by another registered medical practitioner.

Form of notification

The notification must be given in writing to the Senior Coroner by the registered Medical Practitioner as soon as reasonably practicable. However, in ‘exceptional circumstances’ (not further defined) the notification may, initially, be made orally: the notifying registered Medical Practitioner must then confirm that oral information in writing as soon as reasonably practicable[5].

The Regulations strictly prescribe what the notification must include: the registered medical practitioner’s full name address and email; the deceased’s full personal details including their occupation; the next of kin’s details; the circumstances triggering notification; place and time of death; the name of any consultant medical practitioner who attended the deceased person in the last 14 days. Many of these details were previously requested by Coroners under local protocols governing hospital deaths. The Chief Coroner, who has issued recent guidance to Coroners on the new Regulations[6] now proposes that any locally devised notification practices should immediately cease to be used.

The Ministry of Justice has also issued helpful Guidance for doctors to accompany the new Regulations[7].

A long time coming

These Regulations have been over ten years in the making – provision for them having been made in s.18(1) Coroner and Justice Act 2009[8].They come in the wake of major national concerns about a system described as “over complex and vulnerable to dangerous abuse”[9]  that had previously allowed the serial killings by Harold Shipman and the failings uncovered in the Mid-Staffordshire Inquiry to go unnoticed for so long. The Luce Report in 2003 made it abundantly clear that the system for notifying and scrutinising deaths was not fit for purpose: the death certification and investigation obligations were so disjointed that a doctor might “certify his way out of trouble.”

The Regulations will be an important tool as part of an overall move to improve death reporting and scrutiny nationally, sitting alongside the National Medical Examiner system[10] that is presently being rolled-out on a non-statutory basis in NHS hospitals in England and Wales [11]. Having these new Regulations in place will ensure greater consistency nationally in the reporting of deaths and, it is hoped, provide greater safeguards for the public by ensuring far better scrutiny of all deaths through both the coronial and the National Medical Examiner systems.


Josiah Kirpalani is in his second year of the Law LLB Undergraduate degree at the University of Southampton



[1] SI 2019/1112.

[2] s.22(1)

[3] Although a common law duty of notification is said to fall on every person ‘about the deceased’ to immediately notify a coroner or coroners officer or a police officer of a death in circumstances requiring an inquest– see Jervis 5-24 quoting R v Clerk (1702) 1 Salk. 377.

[4] Reg 3(1)(e) and (f). What is a ‘reasonable time’ is undefined in the regulations

[5] Reg. 4(5)

[6] Chief Coroner Guidance No. 31 Death Referrals and Medical Examiners https://www.judiciary.uk/wp-content/uploads/2019/09/Guidance-No.-31-Death-Referrals-and-Medical-Examiners.pdf

[7] https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/831100/notification-deaths-regulations-2019-guidance.pdf

[8] Which states ‘The Lord Chancellor may make regulations requiring a registered medical practitioner, in prescribed cases or circumstances, to notify a senior coroner of a death of which the practitioner is aware.’ The regulations were eventually promised by government in its response to the 2016 consultation, Introduction of Medical Examiners and Reforms to Death Certification in England and Wales. At https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/715224/death-certification-reforms-government-response.pdf

[9]  House of Commons Constitutional Affairs Committee: Reform of the coroners’ system and death certification, Eighth Report of Session 2005-06 https://publications.parliament.uk/pa/cm200506/cmselect/cmconst/902/902i.pdf

[10]  https://improvement.nhs.uk/resources/establishing-medical-examiner-system-nhs/#h2-introduction-to-the-medical-examiner-system

[11] It is envisaged that the non- statutory scheme will cover all hospitals by the end of March 2020 and that there will be a move by the Government towards placing the scheme on a statutory footing and then a further development of the statutory scheme to cover deaths within hospitals and within the community.