Ridout Report – November 2019 -Notification of Deaths Regulations 2019

Topics covered: legislation

On 1 October 2019, the new ‘Notification of Deaths Regulations 2019’ (the “2019 Regulations”) came into force.  The rules set out much needed clarity regarding the circumstances in which doctors are required to report a death to a coroner.

The background that led to the introduction of the Regulations

In his Report to the Lord Chancellor for 2017-2018, the Chief Coroner highlighted that more than 229,000 deaths were reported to coroners in England and Wales in 2017, with the vast majority of them being referred to coroners by GPs and hospital doctors without clear guidance on when a death should be reported. Prior to the 2019 Regulations coming into force, GPs could phone a coroner directly to discuss the cause of death and obtain permission to issue a death certificate; with no clear guidance on when to report a death.  This created the potential for confusion and uncertainty for medical practitioners and no guarantee of consistency in how deaths would be treated.  Similarly, there was a difference of approach between coroners as to when they considered a death to be reportable.

Circumstances in which a death is required to be notified to a coroner

The 2019 Regulations, which apply to England and Wales, have brought welcome clarification to a once confusing scheme, by setting out the circumstances in which a registered medical practitioner is required to make a notification of a death to a coroner.

Under Regulation 3, a death must be notified to the senior coroner of the coronial area in which the deceased lies, where there is reasonable cause to suspect that the death was due to, caused, or contributed to by at least one of the following circumstances, no matter how much time has passed since the death:

  • The death was due to poisoning, including by an otherwise benign substance
  • The death was due to exposure to, or contact with, a toxic substance
  • The death was due to the use of a medicinal product, the use of a controlled drug or psychoactive substance
  • The death was due to violence, trauma or injury
  • The death was due to self-harm (this may apply where it is reasonable to suspect that the deceased died as a result of trauma, poisoning, or injuries caused by his or her actions);
  • The death was due to neglect, including self-neglect (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 him or her with – or to procure for him or her – certain basic and obvious requirements)
  • The death was due to a person undergoing any treatment or procedure of a medical or similar nature (the guidance for medical practitioners to the 2019 Regulations emphasises that a death that has occurred following a medical or similar procedure may not necessarily have been caused by the treatment; and therefore the medical practitioner should consider whether there is a relationship between the treatment and the subsequent death)
  • 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 (a death is typically considered to be unnatural if it has not resulted entirely from a naturally occurring disease running its natural course, where no other cause is suspected)
  • The cause of death was unknown (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 his or her knowledge and belief, based upon a conscientious appraisal of the known facts, including after suitable consultation with colleagues or a medical examiner).

There are further duties to notify a coroner where a death occurs in custody or state detention (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), or where the deceased cannot be identified.  Where a deceased cannot be identified, it is recommended that the death is also reported to the police.

Whilst this clear guidance should give doctors greater confidence to know when to report a death, there still remains some scope for interpretation of the 2019 Regulations.  Grey areas are of course inevitable with Regulations which are designed to capture a wide spectrum of circumstances, including the medical assessment of whether or not a death was ‘unnatural’.


The form that reports should take

Where there is a duty to report a death, the report should be made “as soon as reasonably practicable after the duty arises”.  Notifications must be made in writing unless there are exceptional circumstances justifying the report being made orally (which should then be confirmed in writing as soon as reasonably practicable in any event).

A notification must include key information on the deceased, in addition to the name of “any consultant medical practitioner who attended the deceased person during the period beginning with the fourteenth day before death and ending with the person’s death” and any other information that the reporting doctor considers to be relevant.

 Implications and good practice

 Whilst the 2019 Regulations bring greater clarity to when medical practitioners should notify a coroner of a death, they also place a greater emphasis than was the case previously on the need to scrutinise both medical and wider care practice in the lead up to a person’s death.  This increased scrutiny will no doubt heighten doctors’ awareness of any evidence that may lead to a charge of neglect or harm caused in care and have ramifications for care providers if there is any suspicion that they may have contributed to a person’s death.

We would suggest that the sensible course of action for medical practitioners and care providers is to ensure that the care provided to patients and residents is carefully recorded at all times, with particular emphasis on the final days of a person’s life.  This will assist medical practitioners and care providers in being able to swiftly provide coroners with any information requested of them.  This will also assist medical practitioners and care providers in being able to evidence what care was provided, in the worse-case event that they are alleged to have been negligent or to have caused harm in the care that they provided.

Share on socials:


Get content like this straight to your inbox! 

* indicates required
Choose to receive...
Ridouts’ E-Newsletter tailored to:
Events and more

I agree to my data being processed in accordance with Ridouts' privacy policy: