Case ID Number:
DEPRIVATION OF LIBERTY SAFEGUARDS FORM 12
NOTIFICATION OF DEATH WHILST DEPRIVED OF LIBERTY
Full name of person who was deprived of their liberty
Date of Birth(or estimated age if unknown) / Est. Age
Date of Death
Location of person at time of death
Name and address of the care home or hospital where the person was being deprived of their liberty
Name and contact details of family member/RPR
Name of the Supervisory Body
Person to contact at Supervisory Body / Name
Telephone
Email
Contact details of the GP / Name
Address
Telephone
SUBMITTING THIS NOTIFICATION TO CORONER:
From Monday 3 April 2017 the Coroners and Justice Act 2009 will be amended so that people subject to authorisations under the Deprivation of Liberty Safeguards (DoLS) will no longer be considered to be ‘otherwise in state detention’ for the purposes of Section 1 of the Coroners and Justice Act 2009.
The effect of this is that for any death that occurs on or after the 3rd April and where the deceased was subject to a DoLS authorisation the coroner will no longer have a duty to conduct an inquest in all cases. This change will also apply in other cases where the deceased their deprivation of liberty authorised through provisions in the Mental Capacity Act 2005.
For any person with a DoLS authorisation or other deprivation of liberty authorisation under the Mental Capacity Act 2005 who dies on the 3rd April, or any time after, their death need only be reported to the coroner where the cause of death is unknown or where there are concerns that the cause of death was unnatural or violent, including where there is any concern about the care given having contributed to the persons death.
Before the doctor has signed the Death Certificate, the Managing Authority must send a copy of this form to the local Coroner’s Office.
The change in the law will not apply to any death that occurred before Monday 3 April 2017 and inquests will still be required in those cases. Such deaths should be reported to the coroner in all cases even where the report is made after the 3rd April.
As soon as practicable the Managing Authority must also give a copy of this notice to the following:
  1. The Supervisory Body for the hospital or care home
  2. Any IMCA instructed for the person
  3. Every person named by the Best Interests Assessor in their report as an interested person whom they have consulted in carrying out their assessment

Signed
(on behalf of the Managing Authority) / Name
Print Name
Date

March 2015 – V4 - FinalDeprivation of Liberty Safeguards Form 12Page 1 of 2

Notification to Coroner