Duty Coroner / E-mail: / / RECORD OF DEATH
(In community)
Phone: / 0800 266 800
Please complete this form and email it to the National Duty Coronerwho will then either (a) Call and discuss the case with you, or (b) Email it back to you with the decision as to whether or not jurisdiction is accepted in this case.
Surname of Deceased: / Date of Death: / Click here - enter date. /First Names: / Time of Death: / 24-hour clock
Gender: / / / Location of Death: / Choose one. /
Date of Birth: / Age: / Years / Last Consultation: / Click here - enter date. /
Significant medical conditions being treated: / Medication prescribed:
Brief opinion as to why death occurred: / Are you prepared to issue a Medical Certificate as to Cause of death (HP4720): / / YES
/ NO
/ Wish to discuss with Duty Coroner
Your opinion as to cause of death
(WHO format): / I. 1 a: Direct cause
(Disease, injury or complication)
1.b: Due to (or as a consequence of)
1.c: Due to (or as a consequence of)
II. Other significant conditions
Circumstances of Death: (Please answer all questions) / YES NO
Unknown cause, Suicide, Unnatural, etc / Death was: without known cause / apparent suicide / unnatural / violent / due to injury / /
Medical/Dental treatment, Care, Pregnancy, Childbirth / Death occurred during procedure or appears to be result of procedure or other treatment / /
Death occurred while under anaesthetic or appears to be result of administration of anaesthetic / /
Death occurred while giving birth, or as a result of being pregnant or giving birth / /
Drugs and Alcohol / Patient suffering from, or death was due to, drug or substance abuse / /
Official Custody / Care / Patient was in official custody or care or is under Mental Health legislation / /
Family Concerns / A person is expressing concern as to cause of death,medical treatment, or care of the deceased / /
If any of the above boxes are ticked YES then the death must be reported to the National Duty Coroner
(If you have any concerns or reservations about this death please discuss the matter with the National Duty Coroner)
Police / If you are not signing a MCCD, have Police have been notified / /
Name of Reporting Doctor: / Cellphone:
Name of Medical Practice: / Work Phone:
For Doctor’s use only / YES / NO / For Coroner’s Use only / YES NO
Family notified of death: / / / Discussed with reporting doctor
Or (name of doctor): / /
Record of death emailed to Coroner: /
Advice received back from Coroner: / / Jurisdiction Accepted: / /
Police notified of death (if applicable): / / Post-mortem required (subject to objection): / /
I am able to send medical notes electronically to pathologist if PM is required / / / Doctor’s report in-lieu of PM: / /
Name of Duty Coroner: / Click here – select name /
Date: / Click here – enter date. /
Cor28A June 2013