If a death is reported to the coroner, or indeed not reported to a coroner, and subsequent medical evidence (perhaps years later) suggests there was negligence, what are the obligations on the trust in terms of going back to/to the coroner?
Duties to notify under the Notification of Deaths Regulation 2019
The Notification of Deaths Regulations 2019 came into force on 1 October 2019, placing new duties on registered medical practitioners. The Regulations impose a duty on registered medical practitioners to notify a senior coroner of a person's death under specific circumstances.
The Regulations state that there is a duty to notify a relevant senior coroner of a death in certain circumstances if the registered medical practitioner comes to know of the death on or after the coming into force of the regulations and at least one of the circumstances described in regulation 3(1) applies. It states that the duty does not apply if the medical practitioner reasonably believes that the relevant senior coroner has already been notified of the death under these Regulations.
There are specific circumstances listed in regulation 3(1), which will give rise to the duty. The circumstances in which the duty to notify arises include:
- where the death was due to poisoning, including by an otherwise benign substance;
- where the death was due to exposure to or contact with a toxic substance;
- where the death was due to the use of a medicinal product, controlled drug or psychoactive substance;
- where the death was due to violence, trauma or injury;
- where the death was due to self-harm;
- where the death was due to neglect, including self-neglect;
- where the death was due to a person undergoing any treatment or procedure of a medical or similar nature;
- where the death was due to an injury or disease attributable to employment held by the person during that person's lifetime;
- where it is suspected that the death took place in custody or otherwise in state detention;
- where there is no attending registered medical practitioner to sign a certificate of cause of death within a reasonable time and one is required; and
- where the identity of the deceased person is unknown.
In addition, the duty also applies where the medical practitioner suspects that the death was unnatural (but does not fall within the circumstances listed).
Regulation 4 goes on to state that this must be done ‘as soon as is reasonably practicable, after the duty arises' and sets out relevant details and ways to notify the coroner. Although the Regulations are unclear as to the timeframe for this, the accompanying guidance makes clear that a death under the circumstances set out should always be notified, regardless of how much time has passed since the death.
The Regulations are accompanied by the Guidance for Registered Medical Practitioners on the Notification of Deaths Regulations 2019.
Conclusion
We therefore consider that there is a duty to notify the coroner if any of the above circumstances arise, regardless of when the death occurred.
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