Skip to main content
Legal changes

The Notification of Death Regulations 2019

The Notification of Deaths Regulations 2019 came into force on 1 October 2019, placing new duties on registered medical practitioners

Executive summary

The Notification of Deaths Regulations 2019 came into force on 1 October 2019. The new regulations place a duty on registered medical practitioners to notify the coroner of a death if one or more of the circumstances set out in Regulation 3(1) apply.

The Ministry of Justice has published guidance to help medical practitioners understand when they are obliged to report a death to the coroner. Medical practitioners are under a duty to report the death to the coroner’s office if they have reason to believe that the death was due to any of the circumstances set out in Regulation 3.

Regulation 3 — The circumstances in which the duty to notify the coroner arises

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

  • The death was due to poisoning, including by an otherwise benign substance (e.g. sodium/salt).
  • The death was due to exposure to, or contact with a toxic substance (e.g. toxic material/solids/liquids/gases/radioactive material).
  • The death was due to the use of a medicinal product, the use of a controlled drug or psychoactive substance (illicit/recreational drugs/prescribed or non-prescribed medication/self-administered overdose/excessive deliberate dose /given in error/psychoactive substances/legal highs/designer drugs/herbal highs).
  • The death was due to violence, trauma or injury.
  • The death was due to self-harm.
  • The death was due to neglect, including self-neglect. (This does not include where the self-neglect was caused due to dementia, or, were caused by lifestyle choices such as smoking, excessive eating or chronic alcoholism).
  • The death was due to a person undergoing any treatment or procedure of a medical or similar nature.
  • 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.
  • The cause of death is unknown.
  • The registered medical practitioner suspects that the person died while in custody or otherwise in state detention.
  • There was no attending registered medical practitioner required to sign a medical certificate cause of death (“MCCD”) in relation to the deceased person.
  • The attending medical practitioner is not available within a reasonable time of the person’s death to sign the certificate of cause of death.
  • The identity of the deceased person is unknown.

Main headlines

  • These are a short set of regulations, with an accompanying guidance note which were envisaged to be made in the Coroners and Justice Act 2009. It has taken until 2019 for them to be formalised, however (following a lengthy Government consultation) and they came into force on 1 October 2019.
  • Until now, there was no clear statutory duty on doctors to report particular deaths to the coroner. These regulations impose a new legal duty on doctors to report deaths to the coroner in certain defined circumstances and provide clarity to doctors on what their statutory duties are. Doctors will therefore be clearer on when they should be reporting deaths to the coroner.
  • The background to the existence of the Regulations is as a result of recommendations made by Dame Janet Smith who chaired the Shipman Inquiry into how Dr Harold Shipman was able to take advantage of weaknesses in the death certification system.
  • Under the Regulations, if the doctor is aware that someone other than a doctor (e.g. a family member) has reported a death to the coroner, the doctor should still make a formal notification to the senior coroner under the regulations.

Regulation 4 — Information to be provided to the senior coroner

Regulation 4(1) requires the senior coroner to be notified by the medical practitioner (doctor) as soon as is reasonably practicable, after the doctor has determined the death should be notified.

  • This notification should be to the coroner’s office.
  • No time limits for notification but it should be prioritised.
  • If the death is suspicious, the police should be informed immediately.
  • The doctor should take steps to establish the cause of death and speak to colleagues if necessary (i.e. the responsible consultant).
  • Where the death is clearly unnatural, the notification should be made to the senior coroner immediately.
  • Notifications should be made in writing.
  • Oral notifications may be made by telephone in exceptional circumstances (e.g. IT system not working/available at the time) but should be followed up in writing as soon as is reasonably practicable.

Information that must be contained in the notification to the senior coroner

Regulation 4(3) and 4(4) sets out the information that the doctor must include when reporting a death to the coroner.

  • Regulation 4(3)a
    • The doctor’s details.
  • Regulation 4(3)b
    • The deceased’s details.
  • Regulation 4(3)(c)
    • The name of the next of kin or person responsible for the body of the deceased or local authority where there is no identifiable person responsible for the body must be included.
  • Regulation 4(3)(d)
    • The reason why the death should be notified (i.e. one of the circumstances set out in Regulation 3(1).
  • Regulation4(4)
    • Any other information the doctor considers relevant (e.g. GMC number etc.). 


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, he/she may issue a 100A form or refer the case back to the doctor to issue a MCCD.

It is hoped that these long-awaited Regulations will provide further legal clarity and scope to doctors who have faced uncertainty around the certification of death. In particular, they will further assist with the completion of the MCCD and the circumstances in which the coroner should be notified of the death. The regulations should also provide a platform for further consistency in the reporting of death, though it is not expected that they will greatly impact the number of inquests that are held each year.

NHS trusts and individual medical practitioners should become familiar with the Regulations and accompanying guidance, to ensure there is a knowledge base for compliance from 1 October 2019. Any deaths arising on or after that date, which fall to be reported to the coroner, will need to be done so in compliance with the new Regulations. Education around the Regulations may be further embedded and reflected in staff training seminars/grand rounds/updates to local policies and procedures and in new staff inductions. Discussions around how the Regulations will interplay with the Medical Examiners system (which is currently being established/rolled out) will also need to be understood in due course.

The (then) Chief Coroner, HHJ Thornton, has previously published a Chief Coroner’s Guidance note (Guidance no. 23) to seek to clarify some of the pre-existing inconsistency in reporting practices; however, the note was for guidance purposes only and was not intended to replace any local procedures or practices. The new Regulations clarify the legal position and make it clearer to doctors the circumstances in which deaths should be reported to the coroner. This will hopefully have the effect of avoiding confusion that may have previously arisen and help to further streamline the system of reporting death to the coroner.

Sectors and Services featured in this article