Deaths that must be reported to the coroner

You are required to report the death to the coroner if:

Refer to how to report a death to the coroner if you need further information or want to get advice on reporting a particular death.

Do not complete an MCCD if you intend to report a death to the coroner.

The probable or likely cause of death is unknown

You must report the death to the coroner if:

you think it is unlikely that the cause of death was due to natural causes like illness, age-related decline or infirmity or

there is no relevant medical history and no circumstances that point to a likely natural cause of death and

you have taken all reasonable steps to determine the cause of death and
you are unable to establish a probable or likely natural cause of death, or there are suspicious circumstances surrounding the death.

Reasonable steps can include:

thoroughly reviewing the available facts and medical records
making a reasonable effort to consult with any health practitioner known to have attended to the person before they died
considering the most probable or likely cause of death given the circumstances
talking to a clinical advisor at the National Initial Investigation Office (0800 266 800)
discussing the death with the police officer in charge of any relevant investigation into the death.

The death is suspected to be the result of self-harm

You must report the death to the coroner if you suspect that the death was self-inflicted, or the direct or indirect result of self-harm.

This includes deaths where it is reasonable to suspect that the person died because of:

poisoning (including intentional or accidental overdose of prescription or illegal drugs)
trauma or injuries inflicted by themselves or their actions.

The term self-harm does not include lifestyle choices such as smoking, unhealthy diet or alcohol dependency.

Assisted dying does not qualify as self-harm.

Unnatural, violent or accidental deaths

You must report any unnatural deaths to the coroner. This includes deaths where the person appears to have died as the result of violence, trauma or injuries:

inflicted by someone else or by themselves
sustained in an accident; common examples include a fall, road traffic collision, motor vehicle incident or other physically traumatic incidents
sustained in a natural disaster or event (for example, cyclone, earthquake, avalanche)
caused by choking, electrocution, burns, or hypothermia.

Note: An exception to this rule applies if the person was aged 70 years or more and their death was due to an age-related accident.

Unexpected deaths during or as a result of medical procedures or anaesthetic

You must report a death to the coroner if the death appears to be due to a medical procedure or anaesthetic and the death was medically unexpected.

Medical procedures include treatments or operations that are medical, surgical, or dental (or similar), and the administration of medicine or an anaesthetic.

A death is medically unexpected if a health practitioner who is competent to perform the procedure or anaesthetic:

considered that death was not a likely outcome of the procedure, given the type of procedure and the patient’s underlying medical conditions and general health, and
had knowledge of the deceased’s medical condition before the procedure began.

Examples of deaths that should be reported to the coroner include situations where:

a person who was relatively well, (that is, had no underlying health conditions that increased their risk of dying), and was expected to survive a procedure, died during, or because of, a medical procedure or anaesthetic
a person’s death was due to human error(s) or equipment malfunction during the medical procedure or treatment (for example, the deceased was given an incorrect dosage of a drug)
the person’s death appears to be the result of a medical procedure that was performed by an unregistered medical practitioner or a medical practitioner who was working outside their scope of practice.

Where a medical procedure, or a complication arising from the medical procedure, may have caused or contributed to a person’s death (rather than the death being a result of the disease that was being treated), ask yourself the following questions:

Was the procedure indicated for the patient’s condition?
Was it competently performed?
Was the complication a known risk of the procedure?
If the complication would not typically be lethal, did the patient’s underlying health problems make them more likely to die because of the complication or the procedure itself?

If the answer to all of the above questions is yes, the death does not need to be reported to the coroner. If you are unsure, you can ring NIIO and ask to talk to a clinical advisor or the coroner.

Note: The reporting doctor should be someone qualified to express that the death was unexpected, or they should confirm that they have discussed this with someone qualified to express this opinion.

Note: You do not have to report a death to the coroner if a person received a medical procedure and died some time afterwards, but the procedure did not cause or contribute to their death. The is no rule that the death of a patient following a procedure must be reported to the coroner, or that the death of a patient within a particular timeframe of a procedure must be reported to the coroner.

Pregnancy or birth-related deaths

You must report a death to the coroner if a person has died while giving birth, or the death appears to be related to giving birth or pregnancy.

This includes deaths of a pregnant person that occurred following:

termination of pregnancy
a pregnancy or birth-related complication.

Deaths in official custody or care

You must report a death to the coroner if the person died while they were in official custody or care, even if there is a known natural cause of death. A person in custody or care could be located in a facility or in the community when they died. The death should be reported regardless of the person’s location when they died.

Official custody or care includes situations where a person is:

in police custody
subject to a public protection order
in prison or in the custody of a corrections officer
in Oranga Tamariki care– this includes in the care of an iwi social service, a cultural social service, a residential care operator, or the director of a child and family support service or any custody arrangement arranged by Oranga Tamariki
subject to an order under the Mental Health (Compulsory Assessment and Treatment) Act in 1992 that requires the person to be detained as an inpatient or treated in the community
detained as an inpatient for alcoholism or drug addition treatment
in compulsory care or rehabilitation because of an intellectual disability under the Intellectual Disability (Compulsory Care and Rehabilitation) Act 2003.

The identity of the deceased person is unknown

You must report a death to the coroner if you cannot establish the identity of the deceased. This includes where you cannot be sure of the person’s identity because they are decomposed.

Exposure to poison, toxins, drugs or medication

Deaths that are likely to have been caused by exposure to poison, toxins, drugs, or medication could be considered unnatural and you should report these to the coroner.

This applies to deaths caused by the deliberate or accidental:

intake of poison, including any substance that would otherwise be benign, beneficial or tolerable but at certain levels can cause harm, such as sodium (salt)
exposure to toxic or radioactive materials or substances
intake or administration of medical drugs including (but not limited to) prescribed or non-prescribed medication (for example a self-administered overdose or an excessive dose given either in error or deliberately), except where the death is a result of assisted dying
intake or administration of medicinal products or other drugs, and any complications arising from this (includes illicit, or recreational drugs, psychoactive substances and other drugs known as ‘legal highs’, ‘designer drugs’ and ‘herbal highs’).

You do not need to report deaths that are related to known complications of a drug that was appropriately prescribed and administered (for example is the death of a person after contracting an infection because they became neutropenic after chemotherapy).

If the death is alcohol or smoking related, only report acute poisoning to the coroner.

Deaths due to chronic/long lasting conditions (including those caused by alcohol or cigarette consumption) should not be reported to the coroner.

Deaths related to historical exposure to toxins (for example, asbestos) do not need to be reported to the coroner but are notifiable to the Medical Officer of Health(external link)

Deaths due to neglect, including self-neglect

You must report a death to the coroner if the deceased was in a dependent position (that is, a child, an elderly person, a person with a disability or serious illness), and it is reasonable to suspect that there was a failure to provide them with certain basic requirements and this contributed to their death.

This includes, a failure, omission, or delay to provide a dependent person with adequate:

nourishment or liquid
shelter or warmth
medical assessment, care, or treatment.

Self-neglect

Self-neglect is where a person does not provide themselves with, or refuses, adequate nourishment or liquid, shelter or warmth or medical assessment, care, or treatment and this contributed to their death.

It can be difficult to determine whether self-neglect contributed to the person’s death. If you are unsure, you can contact NIIO to connect you with a clinical advisor.

If it appears that a person used self-neglect, for example refusing to eat, to intentionally cause their own death, this could be considered self-harm and must be reported to the coroner.

You should report the death to the coroner if a person died because of any kind of self-neglect and you, or any other person connected to the person who died, have concerns that the support, care or advice the person who died received may have caused or contributed to their death.

You may not need to report a death caused by self-neglect to the coroner where there has been a documented, reasonable, and informed decision by a competent adult to act in a way that would not have preserved their own life. This may include an informed decision to refuse or stop treatment for the disease that ultimately led to their death. For example, you do not need to report a death to the coroner if the person decided not to receive life-prolonging treatment for a terminal illness because of loss of quality of life.

Other examples of deaths that you do not need to report to the coroner include circumstances where:

the deceased has failed to take adequate nourishment or proper personal care due to the natural progression of an underlying illness, such as dementia. Although this may hasten their death, this death should not be notified to the coroner unless there was neglect by others
the deceased’s lifestyle choices such as smoking, unhealthy eating or alcohol dependency may have resulted in their death.

Assisted dying is not self-neglect.

Whānau, caregiver or medical team concerns

There may be situations where the whānau or friends, caregivers or members of the medical team caring for the deceased have concerns about the health care or treatment the deceased person received before their death. They may also raise concerns that the death resulted from a deliberate act by another person.

You should report a death to the coroner where there are concerns that:

an aspect of the health care or treatment the deceased person received (or did not receive) contributed to their death
another person’s actions (or lack of action) contributed to the death.

Administrative concerns raised by the whānau or friends of the deceased person only require a report to the coroner if these concerns may have contributed to a person’s death. Administrative concerns could include concerns about quality, quantity or frequency of communication, or concerns about staffing levels.

If the concerns raised are not likely to have contributed to the death, the deceased person’s whānau or friends may consider making a complaint with the relevant health facility or other relevant regulatory authority about the health care the deceased person received.

The Ministry of Health website includes information about making a complaint about a health and disability service(external link)