When a patient dies it is important that the coroner be notified so that a forensic investigation can be conducted if necessary. A clinician who fails to notify the coroner may be in legal jeopardy.
The criteria for coroner notification varies between jurisdictions but often includes:
(1) death directly or indirectly related to an accident or injury
(2) suspicion of foul play or suicide
(3) death during or following a medical procedure
(4) unexpected death
(5) death of an infant or small child
(6) inability to certify the cause of death (unknown cause of death)
(8) death of a person placed in custody or care
Reasons for a failure to notify the coroner:
(1) The clinician was unaware of the legal requirement to do so.
(2) The clinician decided that notifying the coroner was unnecessary.
(3) The clinician forgot or was too busy to do so.
(4) The clinician thought that someone else would do so, including delegation.
(5) The process was started but not completed for some reason.
(6) The history of an accident or injury was not known.
Prevention:
(1) education about the legal requirements, especially in the Emergency Department
(2) review of all deaths with performance assessment
(3) follow-up with clinicians who failed to notify the coroner, with disciplinary action if needed
