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Published 19 September 2019
It has been a long time coming, but doctors are finally about to have a clearer legal steer on when they should be reporting deaths to the Coroner.
‘The Notification of Deaths Regulations 2019’ have existed in draft form for several years, but will at last see the light of day when they come into force from 1st October 2019.
These new Regulations set out the range of circumstances in which deaths must be notified to the Coroner, with further practical detail provided in the recently published accompanying guidance document.
We look at what the new Regulations say and their possible impact.
Until now, there have been no statutory criteria for reporting deaths to the Coroner. In the words of the Chief Coroner in his 2017/18 annual report, this has created ‘uncertainty and inconsistency’.
Whilst there are some pointers for doctors on this within existing guidance on completing Medical Certificates of Cause of Death (MCCDs), this is broadly drawn and has no legal force.
There have accordingly been calls for a clearer, more binding set of criteria for some time.
The new Regulations place a duty on registered medical practitioners to notify the relevant Senior Coroner of a death if one or more of the circumstances set out in Regulation 3(1) applies. These need to be read alongside the accompanying guidance document which gives a practical steer on the situations which might fall within each category.
The list of circumstances requiring notification include where the medical practitioner ‘suspects’ (likely to be interpreted as a low hurdle) that the person’s death was due to (i.e. more than minimally/trivially caused or contributed to by) any of the following:
In addition, the Regulations stipulate that a death must be notified to the Coroner where:
The guidance anticipates that, in practice, the person who notifies the death to the Coroner will generally be one of the attending medical practitioners who is qualified to complete the MCCD.
In terms of timing, the Coroner should be notified of the death via his/her office ‘as soon as reasonably practicable’ after the medical practitioner decides that the death falls within any of the circumstances requiring notification. The guidance further highlights that the notification should be made regardless of how much time has passed since the death.
A notification should still be made even if someone other than a medical practitioner (e.g. family member or the police) have already reported the death to the Coroner, because they may not have provided the full medical picture.
The Regulations list the information which needs to be provided by the medical practitioner when making the notification, which should include the reason why he/she believes the death should be notified - e.g. by reference to the relevant circumstances as set out in the Regulations. As part of this, the guidance suggests, Coroners will expect to be provided with a detailed explanation of the likely cause of death in narrative form, including the proposed medical cause of death where possible.
Importantly, the Regulations also specify that the notification to the Coroner must be in writing (which includes by e-mail or other electronic means such as web-portal) unless there are exceptional circumstances which justify notifying orally - e.g. by phone - in the first instance (to be followed up in writing as soon as reasonably practicable). The guidance suggests that ‘exceptional circumstances’ might include, for example, if IT systems are not available at the time. This provision essentially formalises what should already be happening in practice given most coroner jurisdictions now have written notification systems in place.
The hope is that these new Regulations will in practice mean more clarity and more consistency in terms of when deaths are notified to Coroners.
Given that the extent of the Coroner’s duty to investigate deaths will remain unchanged (i.e. if he/she has reason to suspect that a death was violent, unnatural, in state detention or cause of death unknown), these new Regulations should not in principle have a significant impact on inquest numbers. It is, however, quite possible that - particularly whilst the new Regulations ‘bed down’ - we may see a spike in numbers of deaths being reported to Coroners, especially as this is the first time there has been a legal duty to notify. It will be interesting to see if this is borne out in the next set of annual coroners statistics.
It will be particularly important for medical practitioners to familiarise themselves with the new Regulations ahead of these provisions coming into effect on 1st October, as failure to notify a death as required could potentially lead to a referral to their professional body and/or possible disciplinary action by their employer. Any intentional failure to report a death in line with these requirements could also amount to an offence under coronial law.
Healthcare providers also need to be alert to the new provisions and ensure these are reflected in local protocols on reporting and learning from deaths, as well as ensuring they are covered in staff education and training programmes - e.g. as part of junior doctor induction and as part of training for nursing and other clinical staff who need to understand the circumstances in which deaths should be reported to the Coroner even though they are not actually doing the notifying themselves. Consideration will also need to be given to how the Regulations will tie in with the new local Medical Examiner systems which are in the process of being set up via NHS Trusts across the country.
Our national team of healthcare regulatory lawyers has extensive experience of advising on a wide range of matters relating to patient deaths and inquests, and the support we can provide includes advice and training on the application of these new notification of deaths requirements.
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