Reporting deaths to the coroner
Correct as of September 2009
If a death occurs in a violent or unnatural manner, in custody, or suddenly but without certain cause, a coroner has a duty to enquire into the death. This factsheet sets out the role of a coroner, the reporting process and what will happen once you have reported a death to the coroner.
The Coroners Service
In Northern Ireland, coroners are independent judicial officers appointed by the Lord Chancellor, but hold office under the Crown. They must be a qualified and experienced barrister or solicitor, preferably with a medical background, although this is not essential. The Coroners Service is headed by a High Court Judge; there is one senior coroner and three coroners.
Coroners are supported by police officers, even in cases where no criminal offence is suspected. Police officers can obtain medical notes and reports and make enquiries on behalf of the coroner.
Reporting deaths to the coroner
Deaths should be referred to the Coroners Service if there is reason to suspect that the death has been:
- As a result of violence or misadventure or by unfair means
- As a result of negligence, misconduct or malpractice of others
- From any cause other than natural illness or disease
- From natural illness or disease for which the patient had not been seen and treated by a registered medical practitioner within 28 days prior to their death
- In such circumstances as may require investigation
- In prison or in police custody (this list is not exhaustive).
A death in hospital should be reported if:
- You suspect that the deceased may have died as a result of medical negligence or misadventure
- The death occurred before a provisional diagnosis was made, and the GP is not willing to certify the cause
- The cause of death is unknown
- The patient died as the result of the administration of anaesthetic.
Coroners have a duty to enquire into a death if the body of the dead person lies within their jurisdiction and the death meets the conditions above. A coroner’s enquiries may involve holding an inquest. Once a death has been referred to the coroner, it cannot be registered until the coroner’s enquiries have been completed and a death certificate issued and provided to the General Register Office.
If you are unsure about whether or not to report a death, contact the Coroners Service, who will be able to advise you whether a formal report is appropriate.
In order to complete the Medical Certificate of Cause of Death (MCCD), the doctor must have attended the patient within the 28 days leading up to the death, or seen the body after death and be sufficiently familiar with the patient to be sure of the cause of death. If the medical cause of death is reasonably clear but there is still some uncertainty, or the doctor who attended the patient in his last illness is not immediately available to sign the MCCD, the matter can often be resolved by a discussion with the coroner directly, or via the coroner’s officer.
If satisfied that neither an inquest nor a postmortem examination is necessary, the coroner will issue Pink Form A, which allows the General Register Office to register the death so that the deceased can be cremated or buried.
A coroner will usually request a postmortem examination if there is uncertainty over the cause of death, or the death was sudden and the cause unknown. If the postmortem reveals that the death was due to natural causes, the coroner will issue Pink Form B to the Registrar, which means that the death can be registered and the body released for cremation or burial.
However, if a coroner finds that the death was unnatural, an inquest will be held. Individuals whom the coroner believes may be able to provide relevant information will be asked to submit a statement. Witnesses may be called to give evidence in person or required to submit written evidence to be presented at the inquest.
Duty to report deaths
Section 7 of the Coroners Act (Northern Ireland) 1959 states:
"Every medical practitioner…who has reason to believe that the deceased died…as a result of negligence, misconduct malpractice on the part of others, or from any cause other than natural illness or disease for which he has been seen and treated by a registered medical practitioner within 28 days prior to his death, or in such circumstances as may require investigation, shall immediately notify the coroner.”
The guidance issued by the General Medical Council states: “You must co-operate fully with any formal inquiry into the treatment of a patient ... You must disclose to anyone entitled to it any information relevant to an investigation into your own or a colleague’s conduct, performance or health. You must assist the coroner ... in an inquest or inquiry into a patient’s death by offering all relevant information. You are entitled to remain silent only when your evidence may lead to criminal proceedings being taken against you.”
You should not delay in notifying the coroner of a death as this will lead to delays in the involvement of, for example, the police. It will also delay the registration of the death and the release of the body for either cremation or burial, adding to the distress of the bereaved.
The General Register Office currently has a statutory duty to report certain types of deaths to the coroner – for example, where it appears that the death occurred during an operation, and deaths due to industrial disease.
Registration of a death
Before a death can be registered, there must be either an MCCD issued by a registered medical practitioner (the death certificate is issued by the Registrar of Births and Deaths) or a certificate from a coroner issued after appropriate investigations.
If you are the attending medical practitioner in a patient’s last illness, you are required by law to sign a certificate stating the cause of death to the best of your knowledge and belief. This must be submitted to the Registrar of Births and Deaths. The certificate is a legal statement and therefore false or inaccurate statements could result in criminal charges.
Other functions of the coroners
A coroner must also be notified in every case when a body is to be taken out of Northern Ireland. Coroners also currently have responsibility for all the treasure troves in their district, so if you find any treasure you are legally obliged to notify a coroner within 14 days.
Further information
- Coroners Service for Northern Ireland – www.coronersni.gov.uk
- General Register Office – www.groni.gov.uk
- Death Certification and Investigation in England, Wales and Northern Ireland – Report of a fundamental review – www.archive2.official-documents.co.uk
- Modernising the Coroners Service in Northern Ireland – The Way Forward – www.coronersni.gov.uk/publications
- Coroners Act (Northern Ireland) 1959 – www.opsi.gov.uk.