When and how should a GP involve the coroner in cases of unexpected or unexplained deaths?

General practitioners (GPs) should involve the coroner promptly in cases of unexpected or unexplained deaths when the cause of death is unknown, suspicious, or unnatural, or when the death occurs suddenly without a clear medical explanation. This includes deaths that are sudden and unexpected in people with known conditions such as epilepsy or in infants where sudden unexpected death in infancy (SUDI) is suspected. The GP must notify the coroner if they cannot certify the cause of death or if there are concerns about the circumstances surrounding the death, such as potential neglect, violence, or other non-natural causes ¹.

The process involves the GP informing the coroner’s office as soon as possible, typically by telephone or through the local coroner’s notification system, providing all relevant clinical information and circumstances of the death. The coroner will then decide whether to order a post-mortem examination or further investigation. The GP should avoid issuing a death certificate if the cause of death is unclear or if the death is reportable to the coroner ¹.

In cases such as sudden unexpected death in epilepsy (SUDEP), the GP’s role includes recognizing the need for coroner involvement due to the sudden and unexplained nature of the death, which may require medico-legal investigation to clarify the cause and prevent future occurrences (Verma and Kumar, 2015). Similarly, in SUDI cases, clinicians are advised to notify the coroner promptly to facilitate thorough investigation, including autopsy and scene examination, which are critical for understanding the cause and contributing factors (Fitzgerald et al., 2022).

Overall, the GP’s involvement with the coroner is a legal and clinical responsibility to ensure that deaths that are unexpected, unexplained, or suspicious are properly investigated, supporting public health and legal processes ¹ (Verma and Kumar, 2015; Fitzgerald et al., 2022).