• Doctors previously under no formal obligation to report deaths
  • Changes part of rollout of new medical examiner system
  • Names of consultants who saw patient 14 days prior to death to be included in notification

New laws will come into effect tomorrow requiring doctors to report deaths to coroners for the first time in a bid to modernise the death reporting process in England and Wales.

Until now, doctors were under no formal obligation to report a death to a coroner, while many local coroners operated their own guidance for doctors.

As part of the national rollout of the new medical examiner system and changes to the death certification process, regulations will come into force tomorrow, making clear when and how doctors should report deaths and what information should be included.

Doctors will be required to notify a coroner in writing unless there are “exceptional circumstances” and, in such situations, will be required to follow-up with written information later. Many local areas have relied on oral notification to coroners’ officers but this will now be replaced by a formal written system.

As well as including information about the patient, doctors will also be required to include the names of any consultant who saw the patient within 14 days prior to their death.

Michael Osborn, from the Royal College of Pathologists, told HSJ the change was about modernising the coronial system and would not be a huge additional burden on doctors.

He said: “The main difference is that doctors will now have an obligation to refer cases. This is something people have been doing for a long time but it is now being codified in law.

“It will reduce any regional variation that there was and it brings everyone onto the same playing field.

“It could bring a number of benefits including highlighting problems like Harold Shipman and institutional issues like Mid Staffs and ensure action is taken. It also means data will be collected and enable us to learn from deaths.”

Guidance published by the chief coroner Mark Lucraft QC stated: “Hitherto there have been no such regulations and the circumstances of reporting of deaths by medical practitioners to coroners has varied across coroner areas. To address this, some senior coroners have issued local guidance to medical practitioners within their area.

“With immediate effect, any locally issued guidance or direction should be withdrawn and the principles set out in this document used by all coroners to ensure greater consistency over death reporting.”

Under the regulations, doctors responsible for signing a death certificate should report a death to the coroner if the death involved:

  • Poisoning or exposure to a toxic substance;
  • Use of a medicinal product, controlled drug or psychoactive substance;
  • Violence, trauma or injury;
  • Self-harm;
  • Neglect, including self-neglect;
  • Treatment or procedure of a medical or similar nature;
  • An injury or disease attributable to employment; or
  • A suspicion the death was unnatural.

Deaths should also be reported where the cause is unknown, the person died in state custody or detention, or their identity is unknown.

The chief coroner added: “Medical examiners are now part of the wider death oversight and investigation system in England and Wales. Their duties are different to coroners but they are the counterpart for coroners and coroners and their staff should work in a spirit of partnership and mutual respect with the medical examiner.”