There is no statutory requirement for the Registrar of Births and Deaths to refer the deaths of those who are subject to a DOLs authorisation to the coroner. However, there is a common law duty which applies to everyone, to refer deaths to the coroner where there is reasonable cause to suspect that the person died a violent, unnatural or sudden death, the cause of which is unknown, or where the person died in prison or police custody.
There has been an indication from some coroners that they expect managing authorities to refer to them all deaths of those who are deprived of their liberty under the DOLs regime set out in the Mental Capacity Act 2005. All local authorities and primary care trusts should ascertain the expectations of their local coroner in this regard.
In the event that a person in their care should die whilst subject to a DOLs authorisation, care homes and hospitals who are managing authorities need to know how to contact the relevant coroner’s office. If in doubt, it is always preferable to report the death.
The action taken by the coroner will vary and could include the commissioning of a post-mortem examination or the opening of an inquest (with or without a jury). Equally he could decide that no further action is necessary. Until the coroner has made a decision on whether to undertake a further investigation, a doctor should not issue a medical certificate of cause of death.