Josiah Kirpalani on shaping the future relationship between medical examiners and senior coroners

New Notification of Deaths Regulations 20191, coming into effect on 1 October 2019, are set to have a significant impact on the requirements for all doctors to report deaths to coroners.

Previously, although ‘attending medical practitioners’ have been required to provide registrars with a medical certificate of cause of death2, there has been no statutory obligation upon a doctor to also inform a coroner of the death, nor have there been any regulations that stipulate the circumstances in which doctors should report deaths to coroners.

However, from 1 October 2019 it will become a legal requirement for registered medical practitioners to notify the relevant senior coroner of an individual’s death should the death have occurred in any of the 15 manners set out in the new regulations.

The Ministry of Justice has issued insightful guidance for doctors to accompany the new regulations3. The chief coroner has also issued his own guidance to explain what the new regulations mean from the coroner’s perspective4.

Many senior coroners have previously issued local guidance to medical practitioners within their area on when they should be notified by registered medical practitioners of an individual’s death.

The chief coroner, in his guidance on the law, now proposes that any such locally issued previous guidance or direction should be withdrawn and cease to be used with immediate effect. The new regulations ensure necessary greater consistency over reporting deaths.

Perfect clarity

To achieve perfect clarity, it should first be addressed that the relevant senior coroner is the senior coroner in the area in which the body lies.

Furthermore, the 15 manners, in which if a death occurs that a registered medical practitioner comes to know of the new regulations impose a duty upon the doctor (who would be responsible for completing the Medical Cause of Death) to report it to the coroner, are based around if: 1) the doctor knows or suspects the death was a violent or unnatural death, 2) the doctor knows or suspects the death was brought about through neglect (including self-neglect), 3) the cause is unknown, 4) the identity of the deceased is undeterminable, or 5) the death occurred or is suspected to have occurred whilst the individual was in custody or state detention.

The wide-ranging circumstances that fall within these categories are specified by ‘violent’ being taken to include but to not be limited to:

  • trauma;
  • injury; or
  • self-harm. 

And other ‘unnatural’ causes of death that will trigger the duty to notify under the 2019 regulations include:

  • 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;
  • the person undergoing medical-natured treatment or procedure; or
  • an injury or disease attributed to the deceased’s employment from anytime throughout the deceased’s life.

Due to the unforeseeable nature of the future, and unpredictable circumstances that may potentially cause any registered medical practitioner to come to know of an individual’s death, if despite taking reasonable steps to determine the cause of death, the death is deemed to be unnatural simply according to the registered medical practitioner’s subjective understanding, the death must be reported by the doctor to the relevant senior coroner.

Of course, ‘reasonable steps to determine the cause of death’ contains a certain degree of ambiguity, therefore, a doctor’s discretion is utilised to achieve the correct balance between ‘flooding’ the relevant senior coroner with notifications of those deceased and failing to sufficiently attempt to determine the cause of death. The same applies to ascertaining the identity of the deceased.

In addition and for complete inclusivity, 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 must still make their own notification under these regulations.

However, the duty to notify does not apply if it is reasonably believed that the coroner has already been notified of the death by another registered medical practitioner.

These new regulations were passed with the intention of encouraging good collaborative working relationships between medical examiners and coroners, partnership and mutual respect between all involved

It must also be mentioned that the new regulations detail that should the registered medical practitioner believe that no attending medical practitioner is required to sign the MCCD for the deceased, or that an attending medical practitioner is required to sign such a certificate, however, is unable to do so within a reasonable time of the deceased’s death, the relevant senior coroner must be notified.

The notification to a senior coroner must be completed in writing by the registered medical practitioner as soon as reasonably practicable. In exceptional circumstances this notification may be undertaken orally. However, following this, that same notifying registered medical practitioner must confirm the oral information in writing as soon as reasonably practicable.

These new regulations were passed with the intention of encouraging good collaborative working relationships between medical examiners and coroners, partnership and mutual respect between all involved.

To situate these new regulations in context, in part they have arisen from the backlash from serial killer Harold Shipman and the Mid-Staffs inquiry which has also resulted in the government creating the role of independent medical examiners5 as a safety mechanism to prevent such a series of unnoticed unnatural deaths from occurring again.

The failure to implement policy changes recommended in the 1971 Brodrick Report, due to conflicting views of interested parties6, has potentially provided momentum and pressure for recommendations from the review and inquiry into Dr Shipman to have actual affect and be implemented as they are being.

To ensure that the system meets the needs and legitimate expectations of society, the new regulations are intended to deter doctors of a Shipman-esq mindset from killing their patients, and to facilitate the detection of such crimes should they be committed. In other words, one main purpose of these new regulations is to protect patients from the actions of a homicidal doctor.


  1. The Notification of Deaths Regulations 2019, SI 2019/1112.
  2. Births and Deaths Registration Act 1953, s 22(1).
  3. Ministry of Justice, Guidance for registered medical practitioners on the Notification of Deaths Regulations 2019 13 September 2019.
  4. Chief Coroner Guidance No. 31 Death Referrals and Medical Examiners 19 September 2019.
  5. Hull University Teaching Hospitals NHS Trust, Medical examiners introduced to improve scrutiny of death. Last accessed 23 September 2019.
  6. The Shipman Inquiry 2003, Third Report, Cm 5854.