Guidance for registered medical practitioners on the Notification of Deaths Regulations 2019

The notification requirement

1. A registered medical practitioner means a person on the General Medical Council's list of Registered Medical Practitioners, who has a licence to practice.

2. It is anticipated that in practice, where available, it will be one of the attending medical practitioners who is qualified to complete the medical certificate cause of death (MCCD) who will be making the notification to the senior coroner.

3. If you have questions about the cause of death, or about completing the MCCD, you should discuss these with a medical examiner where one is available.

4. A death may have already been reported to the coroner by a person other than a medical practitioner, such as a friend or family member of the deceased, or the police. Such reports will not usually include the information required at regulation 4(3) and (4), and may not provide the coroner with the full medical picture.

5. Therefore, even if a medical practitioner is aware that someone other than a medical practitioner has reported a death to the coroner, the registered medical practitioner should still make a notification under the Regulations.

Circumstances in which a notification should be made under regulation 3

6. A death under the circumstances set out as follows should always be notified, regardless of how much time has passed since the death.

7. A death must be notified to the relevant 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 following circumstances:

The death was due to poisoning including by an otherwise benign substance

8. This applies to deaths due to the deliberate or accidental intake of poison, including any substance that would otherwise be benign, beneficial or tolerable but at certain levels is injurious to health, such as sodium (salt).

9. In regard to alcohol or smoking related deaths, only those due to acute poisoning should be notified to the coroner. Deaths due to natural chronic/long lasting conditions (caused by alcohol or cigarette consumption) should not be notified to the coroner.

The death was due to exposure to, or contact with a toxic substance

10. This applies to any cases where death was due to the exposure to a toxic substance. Examples of this include, but are not limited to deaths due to:

• Toxic material, including toxic solids, liquids and gases.
• Radioactive material.

The death was due to the use of a medicinal product, the use of a controlled drug or psychoactive substance

11. This applies to deaths due to either the deliberate or accidental intake or administration of medicinal products or any other drugs, or any complications arising from this. Examples of this include, but are not limited to:

• Illicit, or recreational drugs.
• Medical drugs, including but not limited to, prescribed or non-prescribed medication (e.g. a self-administered overdose or an excessive dose given either in error or deliberately).

12. Any circumstance where the death may be due to a psychoactive substance should be notified to the coroner. A psychoactive substance includes any substance which is capable of producing a psychoactive effect in a person if, by stimulating or depressing the person's central nervous system, it affects the person's mental functioning or emotional state. Examples of this include, but are not limited to:

• New psychoactive substances, also known as "legal highs" or "designer drugs"
• Herbal highs, such as salvia.

The death was due to violence, trauma or injury

13. A death may be considered due to violence, trauma or physical injury where, for example, the deceased:

• Died as the result of violence, trauma or injuries inflicted by someone else or by themselves.
• Died as the result of violence, trauma or injuries sustained in an accident, such as a fall or a road traffic collision.

The death was due to self-harm

14. This may apply if it is reasonable to suspect that the deceased died as the result of poisoning, trauma or injuries inflicted by his/herself or his/her actions.

The death was due to neglect, including self-neglect

15. Neglect applies if the deceased was in a dependent position (e.g. a minor, an elderly person, a person with a disability or serious illness) and it is reasonable to suspect that there was a failure to provide them with - or to procure for them - certain basic and obvious requirements. This would include, for example, a failure, omission or delay by any person to provide or procure:

• Adequate nourishment or liquid.
• Adequate shelter or warmth.
• Adequate medical assessment, care, or treatment.

16. This also includes a death, albeit from natural causes, where it is reasonable to suspect that the death results from some human failure, including any acts/omissions.

17. Self-neglect applies if the death is a result of the deceased intentionally or unintentionally not preserving their own life. However, this does not include circumstances where there has been a documented, reasonable and informed decision by the deceased not to act in a way that would have preserved their own life. This may include a decision not to take a certain course of treatment.

18. There may be cases where people fail to take adequate nourishment or proper personal care due to the natural progression of an underlying illness, such as dementia. Although this may hasten their death, this death should not be notified to the coroner unless there was neglect by others.

19. It does not extend to deaths where the lifestyle choices of the deceased - for example, to smoke, eat excessively, or to have a chronic alcohol condition- may have resulted in their death.

The death was due to a person undergoing any treatment or procedure of a medical or similar nature

20. This applies if the death may be related to surgical, diagnostic or therapeutic procedures and investigations, anaesthetics, nursing or any other kind of medical care. It includes scenarios such as:

• Death that occurs unexpectedly given the clinical condition of the deceased prior to receiving medical care.
• Errors made in the medical procedure or treatment e.g. the deceased was given an incorrect dosage of a drug.
• The medical procedure or treatment may have either caused or contributed to death (as opposed to the injury/disease for which the deceased was being treated).
• Death follows from a recognised complication of a procedure that has been given for an existing disease or condition.
• The original diagnosis of a disease or condition was delayed or erroneous, leading to either the death or the acceleration of the death.

21. It should be noted that a death that has occurred following a medical or similar procedure may not necessarily be due to that treatment; the medical practitioner should consider whether there is a relationship. It is only in circumstances where the medical practitioner believes that the death was due to this procedure that the death should be notified.

The death was due to an injury or disease attributable to any employment held by the person during the person's lifetime

22. This includes injuries sustained in the course of employment (including selfemployment, unpaid work, work experience or contracted services), for example if the death was due to a fall from scaffolding, or being crushed in machinery. It also includes deaths that may be due to diseases received in the course of employment even if the employment has long ceased.

23. Diseases in the course of employment made include, for example:

• A current or former coal miner who died of pneumoconiosis.
• A current or former furniture worker who died of cancer of the nasal sinuses.
• A current or former construction worker who died of asbestos-related lungdisease e.g. asbestosis or mesothelioma.
• A current or former rubber or paint worker who died of bladder cancer

The person's death was unnatural but does not fall within any of the above circumstances

24. A death is typically considered to be unnatural if it has not resulted entirely from a naturally occurring disease process running its natural course, where nothing else is implicated. For example, this category includes scenarios in which the deceased may have contracted a disease (e.g., mesothelioma) as a result of washing his/her partner's overalls which were covered in asbestos however long before the death occurred.

The cause of death is unknown

25. The duty to notify the coroner of unknown causes of death applies to an attending medical practitioner who is unable to determine the cause of death to the best of their knowledge and belief, based upon a conscientious appraisal of the known facts, including after suitable consultation with colleagues or a medical examiner.

The registered medical practitioner suspects that the person died while in custody or otherwise in state detention

26. This is relevant where the person was compulsorily detained by a public authority regardless of the cause of the death. This applies whether the custody or state detention was in England and Wales or elsewhere and includes:

• Hospitals, where the deceased was detained under mental health legislation (including instances when the deceased is on a period of formal leave).
• Prisons (including privately run prisons).
• Young Offender Institutions.
• Secure accommodation for young offenders.
• Secure accommodation under section 25 of the Children Act 1989
• Any form of police custody e.g. the deceased was under arrest (anywhere) or detained in police cells.
• Immigration detention centres.
• Court cells
• Cells at a tribunal hearing centre.
• Military detention.
• Bail hostel.
• When the deceased was a detainee who was being transported between two institutions.
• Any death in which the person would ordinarily have been in state detention but had been temporarily released (for example for medical treatment) or had absconded from detention.

27. This does not include circumstances where the death occurred while the deceased was subject to a Deprivation of Liberty Order unless the person was additionally subject to custody or detention as described at paragraph 25 above. There was no attending registered medical practitioner required to sign a medical certificate cause of death in relation to the deceased person

28. Only an attending medical practitioner - a registered medical practitioner who attended the deceased during his/her last illness before his or her death - can complete an MCCD, without reference to a senior coroner. Under the Registration of Births and Deaths Regulations 1987, any MCCD that has not been completed by an attending medical practitioner who has seen the deceased either in the 14 days prior to the date of death, or after death, must be reported to the coroner by the Registrar.

29. In hospitals there may be several medical practitioners in a team caring for the patient. It is ultimately the responsibility of the consultant in charge of the patient's care to ensure that the death is properly certified. In general practice, more than one general practitioner may have been involved in the patient's care and so be able to certify the death.

30. If there is no attending medical practitioner then the death must be notified to a senior coroner. The notifying medical practitioner will need to provide the senior coroner with the relevant medical and supporting information as is known by them.

The attending medical practitioner is not available within a reasonable time of the person's death to sign the certificate of cause of death;

31. If there is an attending medical practitioner who is responsible for signing the MCCD, but this medical practitioner is unable to sign this certificate within a reasonable period, then the death must be notified to the coroner.

32. It is ultimately for the discretion of a medical practitioner to determine what would be a 'reasonable time' based on the individual circumstances of the case. However, it is recommended that where there is an attending medical practitioner, they should be completing an MCCD as soon as possible.

33. It should be noted that a death must legally be registered within 5 days from the date of death, and that the MCCD is needed for such a registration to be made within this time limit. Therefore, the completion of the MCCD must not exceed this time limit.

The identity of the deceased person is unknown

34. If the identity of the deceased is not known, then it follows that there will be no attending medical practitioner and/or the deceased's medical history is unknown, precluding the completion of an MCCD. In this scenario the death must be notified to the senior coroner.

35. Where the identity of the deceased is unknown it is recommended that the death is also reported to the police

Information to be provided to the senior coroner Information to be provided to the senior coroner

36. Regulation 4(1) requires the notification to the senior coroner to be made as soon as is reasonably practicable after the medical practitioner has determined that the death should be notified. This will usually be via the office of the local coroner. While the regulations do not prescribe a specific time limit for notifications this notification should be prioritised. If the death arises from an event or occurrence that may be suspicious then the police should be informed immediately.

37. The medical practitioner should usually take reasonable steps to establish the cause of death before notifying the coroner. This may include seeking advice from another medical practitioner, such as a medical examiner or any other responsible consultant. However, where the death is clearly unnatural it may be more appropriate for a notification to be made to the senior coroner straight away.

Written Notifications

38. Notifications in writing include submission of documents by courier or electronically (including email, web portal or other scanning methods).

Oral Notifications

39. Regulation 4(2) allows a notification to be provided orally in exceptional circumstances. It is expected that medical practitioners will operate with IT systems which will facilitate the electronic transfer of information and records to the coroner, which includes the scanning of paper records and documents or the creation and transfer of electronically stored records and documents.

40. However, there may be circumstances or occasions where the IT infrastructure or systems required to facilitate the transfer of information, records and documents is not available in order for a timely written notification to be made to the coroner. Where the notifying medical practitioner does not have access to the facilities required to make a notification in written form you should inform the coroner of the reasons for this when making an oral notification.

41. Oral notifications may include notification by telephone.

42. Following an oral notification, the notifying medical practitioner must, as soon as is reasonably practicable provide a written notification, confirming the information given in the oral notification.

The Notification

43. Regulation 4(3) and 4(4) prescribes the information that a medical practitioner must, in so far as it is known to them, provide to a senior coroner when making a notification. If this information is not known to the medical practitioner, they do not have a duty to provide it as part of their notification.

44. Regulation 4(3)(c) requires the medical practitioner to provide to the coroner the name of the next of kin or, where there is none, the person responsible for the body of deceased. Where there is no identifiable person who may be responsible for the body, the medical practitioner should provide the name of the Local Authority who will be responsible for the disposal of the body

45. Regulation 4(3)(d) requires that the medical practitioner indicate the reason why it is deemed that the death should be notified. The Regulations do not specify how this notification should be made and in certain circumstances it may be sufficient to refer simply to the sub-paragraph number within Regulation 3(1). However, it is expected that in most cases, the notifying medical practitioner will provide a detailed explanation of the likely cause of death in narrative form. Where possible, this should include the proposed medical cause of death and an explanation of any technical terms used.

46. Regulation 4(4) requires the medical practitioner to provide any further information that they consider to be relevant to the coroner. It is recommended that the medical practitioner making the notification provides their GMC number in this section. This provision allows for circumstances where a coroner requests medical practitioners to include information relevant to their investigation that is additional to that specifically listed within the Regulations.

47. A coroner's investigation may not be necessary in all notifiable cases. If the senior coroner is satisfied that he/she does not need to open an investigation then he/she may issue a 100A form, or refer the case back to the medical practitioner, who can issue a medical certificate of cause of death. For example, this might happen if the deceased was receiving palliative care at home, and this was documented in the general practitioner notes, but the general practitioner was unavailable at the time of notification. If this occurs, a clear record should be made in the patient notes by the medical practitioner who notified the death to the coroner, detailing the notification and subsequent re-referral back to the medical practitioner by the coroner.

Reference:

• Ministry of Justice. Guidance for registered medical practitioners on the Notification of Deaths Regulations 2019.