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HM Senior Coroner for Leicester City and South Leicestershire

UPDATED 25.09.18 - Reporting Deaths to the Coroner

There are a number of conditions that must be satisfied before a doctor can issue a MCCD. Drs generally know what these are but it has become apparent that they are often unaware of the following:

Once the doctor has ascertained a cause of death that does not need to be reported to the Coroner, before the doctor can issue a MCCD the doctor will need to have attended the deceased in their last illness that caused the death and either:

A. Seen the deceased whilst alive within 14 days of the date of death;

or

B. Seen the body of the deceased after death.

Where a doctor has not seen the deceased whilst alive within 14 days but has attended the deceased in their last illness that caused the death, the doctor should view the body of the deceased after death as this will be sufficient for the Registrar to complete the formalities and issue the burial documentation.

It is accepted that sometimes a doctor has not seen the deceased whilst alive within 14 days of the date of death and cannot see the body after death as they are dealing with medical emergencies or the body has been transported miles from where they are located. In these circumstances the death should then be reported to the Coroner

Guidance can be read here


On Wednesday 14th February 2018, Dr Nainesh Chotai (LMC Chair) and Charlotte Woods (LMC, Office Manager) met with the Coroner’s office, Anne Orange and Dr Christina Swann (Assistant Coroner). At the meeting we presented the questions raised by our members in advanced of the meeting.

There were a few themes that came from our members which we can report back on:

a. GPs would like to be informed of the post mortem results of their patient to aid learning and provide knowledge to the GP.

The Coroner’s office confirmed they would be happy to send either the cause of death or full post-mortem report to GP’s. This needs to be requested from a secure NHS.net email address to Leicester.coroner@nhs.net

Practices should allow the following time after post-mortem to allow the report to be available.

  • Cause of death – One week
  • Full post-mortem report – 6 weeks

There will be no fee for this service.

b. GP’s seeking clarity around the position of verification of death of expected demise.

The Coroner’s office will present this to Mrs Mason for her view on the matter and will report back to the LMC. Mrs Mason has nothing further to add. Verification of death is not a Coronial matter.

c. The manner in which the coroner’s office can deal with cases can sometimes be unpleasant.

The Coroner’s office was surprised by the comments raised. A complaint brought to their attention related to the Coroner’s Office for North Leicestershire. The Coroners office for Leicester City and South Leicestershire can only deal with matters relating to that office and that jurisdiction should such matters arise the practice should contact Anne Orange at the City and South Coroner’s office, in the first instance and she will be happy to investigate. Please contact Ann on her email address: Anne.Orange@leicester.gov.uk

Any Concerns relating to the Coroners Office for North Leicestershire and Rutland must be directed to that office. Mrs Mason has no jurisdiction.

d. GPs wanted us to clarify what should be regarded as an operation.

Any procedure carried out requiring anaesthetic should be regarded as an operation, however the coroner’s office felt that any procedure that could have made a material impact to the patient’s death should be reported e.g. urethral catheterisation in a patient who died from urinary sepsis. However, a minor procedure which is clearly unrelated does not need to be reported.

Please see the reporting guidance (UPDATED OCTOBER 2018)

e. Can GP’s be sent of the coroner’s report to assist in a Significant Event meetings (SEM)?

A GP can request a copy of the post-mortem report from coroner’s office.

If an inquest is held the Coroners office will be happy to provide GPs with the Coroners Conclusion. Please request this via the Leicester.coroner@nhs.net address following the date of the inquest hearing. The date of the inquest hearing can be found on the request for reports sent to the GP Or on the Coroners website http://coroners.leicester.gov.uk

This needs to be requested from a secure NHS.net email address to Leicester.coroner@nhs.net

The LMC also approached the office to consider more realistic fees for attendance at an inquest and raised the prospect of fees for professional reports.

Dr Swann and Mrs Orange explained the fees are those set in statute (The Coroners Allowances, Fees and Expenses Regulations 2013)

The LMC provided the coroner’s office an opportunity to raise any issues with members.

  • There is no requirement to report on DOL's to the Coroner’s office, this was stopped in April 2017. In the last couple of months, the coroner’s office had an influx of DOL’s reports.
  • The coroner’s office would welcome direct contact telephone numbers for GPs to make easier communication rather than ringing practice switchboards.
  • The coroner’s office praised the reports written by GPs and described them as exceptional and really helpful, so often there is no need to call the GP to an inquest.
  • The coroner’s office requested GPs report using prism and that it is emailed to Leicester.coroner@nhs.net rather than scanned. It will be emailed back to the email address it was sent from.

Any questions, please don't hesitate to contact the LMC office.


The LMC recently had a constructive meeting with Mrs. Mason, HM Senior Coroner for Leicester City and South Leicestershire, and her team.

The purpose of the meeting was to clarify concerns surrounding the communication she sent, via the CCG, in August 2017 (attached).

Constituents should be reassured that little has changed from current practice.

Since the passing of a new act in 2013, the Coroner is required to set a date for an inquest as soon as it is opened. In that respect GPs will be advised of an inquest date when a report is requested, this date could potentially be many months in the future. Once the Coroner has received all reports, she will either release the GP from appearing or produce a witness list where the GPs name will appear and it is this list that should be regarded as a summons.

The witness list will usually be produced 6 weeks before the inquest and it is only on receipt of this list that should GPs make arrangement for backfill. There is no anticipation that GPs will be required to attend any more inquests than at present. The Coroner will positively consider requests to change the order of witnesses if that would minimize impact upon the Doctor’s practice.

With regards to communication the Coroners officer confirmed that their office normally speaks to the practice manager on the telephone before a report is requested or a witness list produced to identify the best way to communicate documents e.g. by email to an NHS.net account, by post or by fax. Attached is an example of the request for report.

The LMC also raised some scenarios that have been raised by constituents.

Mrs. Mason was clear that the 14 day rule is laid down in statute and not a local direction.

The death should be reported to the Coroner (electronically) by the Doctor who attended the deceased during the last illness. If that Doctor has not seen the deceased within 14 days or after death, the death must be referred to the Coroner.

The Coroner may well then allow the Doctor to issue the MCCD and the Coroner will complete the necessary paperwork for the Registrar.

If no attending Doctor is available the death should be reported to the Coroner, and if the attending Doctor is away the Coroner’s office will liaise with the family and provided the family are willing to wait, the certification can wait until that Doctor returns. If this is likely to be protracted or simply not possible then an open and shut inquest may be held but the reporting Doctor would have to provide a report using the PRISM process and the certificate issued by the coroner.

The Coroner has provided this link to guide Doctors with certification - https://www.gro.gov.uk/Images/medcert_July_2010.pdf

In order to make a claim to the Coroners office following an inquest, please find attached two versions of the expenses form.

  1. Professional Witness Expense Claim (Locum employed) - The first enables locum cover to be collected (invoice to be included).
  2. Witness Expenses Sheet

The amounts that can be claimed are noted on each form.

The Coroner has approved the above communication and has kindly agreed to meet the LMC every 4 months. Beforehand, the LMC will seek constituent views to determine what themes need to be discussed or clarified.

If there are any queries with regards to this communication please contact the Coroners office on: 0116 4541031

Updated on 15 October 2018, 1005 views

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