The Notification of Death Regulations 2019 (SI 2019/1112) came into force on 1 October 2019. They cover the reporting of deaths by registered medical practitioners (RMPs) to a coroner in England and Wales in certain ‘prescribed circumstances.’ They result from the recommendations of Dame Janet Smith, Chair of the Shipman Inquiry.

The threshold for referral

A death must be reported to the senior coroner for the area where the deceased’s body lies if the RMP has reasonable cause to suspect that it was due to (more than minimally, negligibly or trivially), caused or contributed to by the relevant circumstance.

Relevant circumstances

Guidance published by the Ministry of Justice (MoJ) gives examples of what is covered by the various categories which include.

  • Poisoning including by an otherwise benign substance
    For example, sodium poisoning. Alcohol and smoking-related deaths should only be reported if there is acute rather than chronic poisoning
  • Exposure to or contact with a toxic substance
  • Use of a medicinal product, controlled drug or psychoactive substance
  • Violence, trauma or injury
  • Self-harm
  • Neglect, including self-neglect
    This covers inadequate nourishment, liquid, shelter, warmth, medical assessment, care or treatment
  • A person undergoing any treatment or procedure of a medicinal or similar nature
    A relationship must exist between the treatment and death.
  • Injury or disease attributable to any employment held during the person’s lifetime
  • This would cover such things as a scaffolder falling from height or a paint worker dying from bladder cancer.
  • The person’s death was unnatural but does not fall within any of the above categories
  • For example the wife of a construction worker who died of mesothelioma after washing his asbestos covered overalls.
  • The cause of death is unknown.
  • The RMP suspects that the person died while in custody or otherwise in state detention.
  • ‘State detention’ would include detention under the Mental Health Act 1983 or a person otherwise deprived of their liberty..

The notification

The duty on RMPs extends to those deaths already reported to the coroner by others, irrespective of the passage of time.  Suspicious deaths should be reported immediately.

For other deaths notifications should be made ‘as soon as is reasonably practicable’, in writing, with supporting documents. Usually the RMP should take ‘reasonable steps’ to establish the cause of death before notification. The notification should include: next-of-kin (or person responsible for the body if none or Local Authority if no identifiable responsible person); the reason why death should be notified; any further relevant information (including RMP’s GMC number).

In cases where there is no coroner’s investigation the guidance recommends that a clear record is made in the patient’s notes by the notifying RMP, detailing the notification and subsequent re-referral back to the RMP by the coroner.


There is no material change to the current requirements for reporting certain deaths to coroner, but the Regulations put reporting on a statutory footing for the first time and place a specific obligation on RMPs. In prescribed circumstances. The clarity they provide should mean more consistency in reporting of deaths, although it is unlikely that overall numbers will increase.

How Capsticks can help

Capsticks is a market leader in the healthcare and inquest field and is ranked in the top tier for inquests and clinical negligence work by the Chambers Guide to the legal profession and the Legal 500. If you require inquest representation or would like to discuss any inquest related issues please contact Adam Hartrick, Philip Hatherall or Tracy Lucas.