Reporting deaths - a guide for medical practitioners

The Scottish Fatalities Investigation Unit (SFIU) is a specialist unit of Crown Office and Procurator Fiscal Service (COPFS). SFIU has responsibility for receiving reports of deaths occurring in Scotland which are sudden, suspicious, accidental or unexplained and fall within the categories set out below and deaths which give rise to public anxiety.

This document is intended to provide a clear and concise guide to assist practitioners in deciding whether a death requires to be reported to the Procurator Fiscal and how to go about this.

The doctor with the most detailed knowledge of the circumstances of the death should report it. The reporting doctor must understand clearly why the death is being reported and must be able to answer any questions about the circumstances of death which the Procurator Fiscal may ask.

The Procurator Fiscal may require to discuss the circumstances of the death in the days following initial report. If the reporting doctor is to be off duty, they must provide details of a colleague who is also aware of the circumstances of death and whom the Procurator Fiscal may contact if necessary.

All reportable deaths must be notified to the Procurator Fiscal as soon as possible after they have occurred and before any steps are taken to issue a death certificate. If a death certificate has been issued to the family and the Procurator Fiscal declines to accept the cause of death, this will have to be retrieved from the family, a distressing process which must be avoided as far as possible. 

In normal circumstances, deaths should be reported to the Procurator Fiscal during office hours. In situations of urgency, particularly where the death is suspicious or there are religious rites which require to be observed, the Procurator Fiscal may be made aware of the death outside office hours using the on-call service, contactable through the police. This facility should be used in exceptional circumstances only where the matter cannot wait until the next working day.

Deaths which do not fall into any of the reportable categories should not be reported to the Procurator Fiscal. In cases of doubt or difficulty, the relevant SFIU team may be contacted during office hours to discuss the circumstances and provide advice – contact details for SFIU can be found here Contact us about a death investigation | COPFS. Please note however that, where it is determined that the death is reportable, a report will still require to be submitted in the usual way.

The Death Certification Review Service (DCRS) sits within Healthcare Improvement Scotland and is also able to provide advice and assistance in relation to the categories of death to be reported to the Procurator Fiscal, as well as the certification of the death itself. Doctors can seek advice from DCRS if they are unsure of how to complete the Medical Certificate of Cause of Death (MCCD). Their contact details are as follows:

Phone: 0300 123 1898
Email: his.dcrs@nhs.scot

Website: Death Certification Review Service (DCRS) – Healthcare Improvement Scotland

In addition, information is available at the NHS Support Around Death website

The following deaths must be reported to the Procurator Fiscal (‘reportable deaths’):

Unnatural cause of death:

Any death which cannot be entirely attributed to natural causes (whether the primary cause or a contributing factor) including:

• Suspicious deaths – i.e. where homicide cannot be ruled out
• Drug related deaths – deaths which may be linked to specific drug or drugs intake including deaths due to adverse drug reactions reportable under the Medicines and Healthcare Products Regulatory Agency (MHRA) (Yellow Card Scheme)
• Accidental deaths (including those involving falls, fractures or choking, no matter the timescale where it is considered that the event may have contributed in any way to the death)
• Deaths resulting from an accident in the course of employment
• Deaths of children from overlaying or suffocation
• Deaths where the circumstances indicate the possibility of suicide

Natural cause of death:

Deaths which may be due in whole or part to natural causes but occur in the following circumstances:

(a) Any death due to natural causes where the cause of death cannot be identified by a medical practitioner to the best of his or her knowledge and belief

(b) Deaths as a result of neglect/fault

Any death:

• which may be related to a suggestion of neglect (including self neglect) or exposure
• where there is an allegation or possibility of fault on the part of another person, body or organisation

(c) Deaths of children

Any death of a child

• which is a sudden, unexpected and unexplained perinatal death
• where the body of a newborn is found
• where the death may be categorised as a Sudden Unexpected Death in Infancy (SUDI)
• which arises following a concealed pregnancy

Any death of a child or young person under the age of eighteen years who is ‘looked after’ by a local authority, including:

• a child whose name is on the Child Protection Register
• a child who is subject to a supervision requirement made by a Children’s Hearing
• a child who is subject to an order, authorisation or warrant made by a Court or Children’s Hearing (e.g. a child being accommodated by a local authority in foster care, kinship care, residential accommodation or secure accommodation)
• a child who is otherwise being accommodated by a local authority 

(d) Deaths from notifiable industrial/infectious diseases

Any death:

• due to a notifiable industrial disease or disease acquired as a consequence of the deceased’s occupation in terms of column 1 of Part 1 of Schedule 3 to the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (see http://www.legislation.gov.uk/uksi/1995/3163/schedule/3/made and 'Asbestosis, mesothelioma and asbestos-related lung cancer' of this guidance)
• due to either a Notifiable Infectious Disease or Organism in terms of Schedule 1 of the Public Heath (Scotland) Act 2008 (see http://www.legislation.gov.uk/asp/2008/5/schedule/1) or any other infectious disease or syndrome where there is an acute and serious risk to public health, 
• Deaths associated with seasonal influenza do not however require to be reported to the Procurator Fiscal unless the circumstances of the death fall within any of the other reporting categories detailed in this guidance. 

(e) Deaths under medical or dental care 

Any death:

•  the circumstances of which are the subject of concern to, or complaint by, the nearest relatives of the deceased about the medical treatment given to the deceased with a suggestion that the medical treatment may have contributed to the death of the patient.
•  the circumstances of which might indicate fault or neglect on the part of medical staff or where medical staff have concerns regarding the circumstances of death
• the circumstances of which indicate that the failure of a piece of equipment may have caused or contributed to the death
• the circumstances of which are likely to be subject to an Adverse Event Review (as defined by Healthcare Improvement Scotland)
• where, at any time, a death certificate has been issued and a complaint is later received by a doctor or by the Health Board, which suggests that an act or omission by medical staff caused or contributed to the death
•  caused by the withdrawal of life sustaining treatment or other medical treatment to a patient in a permanent vegetative state (whether with or without the authority of the Court of Session)
• which occurs in circumstances raising issues of public safety. 

(f) Deaths while subject to compulsory treatment under mental health legislation

Any death of a person who was, at the time of death:

• detained or liable to be detained under the Mental Health (Care and Treatment) (Scotland) Act 2003 or Part VI of the Criminal Procedure (Scotland) Act 1995; or
• subject to a community based compulsory treatment order or compulsion order under the above provisions.

Health Boards are also required to notify the Mental Welfare Commission for Scotland (MWCS) of certain deaths that fall within their remit to investigate as specified in the MWCS notification of death form. Certifying doctors should complete the form if asked to do so by their Health Board. This may include deaths which also require to be reported to the Procurator Fiscal.

(g) Any death not falling into any of the foregoing categories where the circumstances surrounding the death may cause public anxiety.

Deaths in legal custody:

Any death of a person subject to legal custody. This includes (but is not restricted to) all persons: 

• detained in prison
• arrested or detained in police offices
• in the course of transportation to and from prisons, police offices or otherwise beyond custodial premises e.g. a prisoner who has been admitted to hospital or a prisoner on home leave

Only deaths which fall into the categories set out above require to be reported. In circumstances where the death does not fall into one of the above categories, the following are not reasons for rendering the death reportable:

• That the death occurred within 24 hours (or any other timescale) of admission to hospital
• That the death occurred within 24 hours (or any other timescale) of an operation;
• That the deceased, who had a terminal illness died earlier than expected;
• That the deceased had not been seen by a GP for some time; and
• That a consultant has instructed that the death be reported without specifying the reasons why.

A death certificate may be issued if a medical practitioner is able to identify a cause of death to the best of their knowledge and belief. Certainty is not required.

There are three SFIU teams in Scotland (North, East and West) which are made up of a number of legal and administrative staff.

The SFIU North team is based in the Procurator Fiscal’s offices in Dundee, Aberdeen and Inverness. The SFIU East team is based in the Procurator Fiscal’s office in Edinburgh and the SFIU West team is based in the Procurator Fiscal’s office in Glasgow.

The death should be reported to the SFIU team in whose area the significant event leading to the death occurred. Annex 1 contains a map showing each SFIU area and a list of contacts for each team.

Our website has information for nearest bereaved relatives on our role in investigating deaths. In order to help families to understand the process, the reporting doctor may wish to refer them to the website or this booklet using the details at Annex 2.

Deaths occurring in hospital

Where a person has died in hospital, the hospital doctor must report the death by completing an EF5 form and sending it by email as soon as possible after the death to the relevant COPFS Scottish Fatalities Investigation Unit (SFIU) team. Full contact details of the reporting doctor and consultant including direct dial telephone numbers and email address should be included. Please bear in mind that forms submitted after working hours or over the weekend will ordinarily not be considered by SFIU until the next working day and therefore contact details should be provided for whoever will be available as the main point of contact on that day.

An email rather than telephone call to the appropriate SFIU mailbox is the quickest and preferred means of contact. Where the doctor wishes to discuss the possibility of organ or tissue donation, the email should be marked as urgent and this should be highlighted in the email heading so that it is prioritised on receipt. 

Once the form has been received, a Procurator Fiscal will consider it and contact the doctor by email or telephone to discuss the circumstances with them or to provide an update on the decision taken. A death certificate should not be issued until confirmation has been received from the Procurator Fiscal.

Deaths occurring in the community

General Practitioners must make the Procurator Fiscal aware of any reportable medical death occurring in the community and must do so by submitting a report using the SCI Gateway. This includes deaths where the General Practitioner is unable to issue a Medical Certificate of Cause of Death (MCCD) due to medical uncertainty but has no concerns in relation to the circumstances of the death. It is the responsibility of the General Practitioner and not the Police to report these deaths to the Procurator Fiscal. 

Every section in the report must be completed to the best of the GP’s knowledge and belief. Certainty is not required. Doctors can seek advice from DCRS using the contact details listed above if they are unsure of how to complete the MCCD. Please bear in mind that reports sent after working hours or over the weekend will ordinarily not be considered by SFIU until the next working day and therefore contact details should be provided for whoever will be available as the main point of contact on that day. Where possible, a direct contact number for the reporting doctor or the practice manager should be provided. Once the form has been received, a Procurator Fiscal will consider it. The GP Practice will then either receive an electronic notification from SFIU of the Fiscal’s decision or the Fiscal will contact the GP directly to discuss the death. A death certificate should not be issued until confirmation has been received from the Procurator Fiscal.

Attachments should not be sent with the report as this will prevent the report being received by SFIU. Any relevant attachments should be sent separately by email to the relevant SFIU team.

The reporting doctor should provide the Procurator Fiscal with all of the information required by the ‘Notification of Death’ form in relation to a death in hospital or by way of the SCI Gateway in relation to a death in the community.

The Procurator Fiscal requires sufficient information regarding the deceased’s medical history and circumstances of death to enable a decision to be made as to whether it is appropriate to accept a death certificate which may be offered, or to initiate further action (see section below).

The Procurator Fiscal is not medically qualified and in cases of particular difficulty may contact their local forensic pathology team for advice regarding certification issues. In such circumstances, a Pathologist will review the Notification of Death form and the proffered cause of death and provide advice with regard to the best way to proceed.

Accept the death certificate offered and take no further action

This is likely to be the decision if the doctor reporting the death is prepared to issue a death certificate certifying the cause of death to the best of their knowledge and belief (certainty is not required) and the Procurator Fiscal is satisfied from the history and circumstances of death reported that the death occurred due to natural causes and does not require to be investigated.

Consent to a hospital (non-PF) post mortem examination

Occasionally, where a reportable death in hospital is due to natural causes and has not been certified, a medical practitioner may seek a hospital post mortem examination for the sole purpose of achieving more accurate certification. In these circumstances, the Procurator Fiscal and the reporting doctor may decide, after discussion, that it is appropriate for a hospital post mortem examination to proceed. Consent from the nearest relatives will be required. The cause of death must be intimated to the Procurator Fiscal following the hospital post mortem examination. 

Request a police report

Where the cause of death has not been ascertained or the Procurator Fiscal requires further information, a police report is likely to be requested. This does not indicate that the Procurator Fiscal regards the matter as criminal; rather it reflects the fact that the police act as agents on behalf of the Procurator Fiscal and gather information on their behalf. The Procurator Fiscal will invariably instruct a police report where they anticipate instructing a post mortem examination.

Instruct a post mortem examination

If no medical practitioner is able to certify the cause of death or, rarely, if the Procurator Fiscal is not prepared to accept a certificate which is offered, a post mortem examination will usually be required to ascertain the cause of death. This may be a full post mortem or an external examination known as ‘view and grant’. A 'view and grant' examination may be carried out where a pathologist examines the deceased's body, considers the medical history and the circumstances of death and is able to grant a death certificate certifying the cause of death without the need to undertake a full post mortem examination. Where a full post mortem examination is necessary for an effective investigation into the deceased’s death, the Procurator Fiscal’s right to instruct it may have to override any objection thereto.

Release of the body

Once a death has been reported to the Procurator Fiscal, the Procurator Fiscal has legal responsibility for the body, usually until a death certificate is written. The Procurator Fiscal will usually surrender legal responsibility for the body once the death certificate has been issued. In most cases where a post mortem examination is carried out, the body will be released when the examination is complete and a death certificate has been issued.

On a death being brought to their attention, it is the duty of the Procurator Fiscal to make initial enquiry and decide whether and to what extent further investigation is required and to initiate that investigation.

In circumstances where the Procurator Fiscal accepts the death certificate being offered by the medical practitioner; or where a post mortem examination is carried out, death is certified as having occurred due to natural causes and there are no matters of concern, the Procurator Fiscal’s investigation is complete.

In other cases, the Procurator Fiscal, acting in the public interest, may carry out further enquiries in relation to the circumstances of the death in order to achieve an effective investigation; whether to eliminate suspicion or establish criminality or to identify reasonable precautions whereby a death might have been avoided and identify any defects in a system of work which caused or contributed to the death.

At the conclusion of such investigations, consideration will be given as to whether it is in the public interest to hold a Fatal Accident Inquiry (FAI) into the death.

Most deaths under medical care represent an unfortunate outcome where every reasonable care has been taken. However, some deaths associated with the provision of medical care may involve fault or negligence on the part of medical or paramedical staff and may give rise to questions of public safety and, in rare cases, may be associated with criminality.

Medical care includes surgical, anaesthetic, nursing or other care/treatment whether provided in a healthcare or non-healthcare setting. 

The Procurator Fiscal may decide to instruct an independent expert in the relevant field to provide an opinion on the circumstances of the death. The expert may wish to discuss the circumstances of the death with the doctor/(s) involved in the treatment of the deceased. 

Similar principles should apply to any death in the course of dental treatment. 

The acquisition of an industrial disease following asbestos exposure, such as asbestosis, mesothelioma and asbestos-related cancer may give rise to a civil claim for compensation.

A number of industrial diseases, including asbestosis, mesothelioma and asbestos-related cancer can be accurately diagnosed in life and it may be possible to accept the cause of death offered by the reporting doctor without the necessity of a post mortem examination.

If a conclusive diagnosis is not made during the patient’s life, the Procurator Fiscal will require to instruct a post mortem examination to establish the cause of death and to preserve the necessary evidence in the event that the nearest relatives wish to pursue a claim in relation to the industrial disease caused by previous asbestos exposure. A death does not however require to be reported to the Procurator Fiscal if there is evidence of the presence of pleural plaques but the doctor is satisfied that it played no part in the person’s death. The Procurator Fiscal can be contacted to discuss any deaths where there is uncertainty about whether it falls to be reported.

The doctor who reports the death must complete Part 3 of the Mesothelioma Pro Forma. See Chief Medical Officer’s letter dated 17 March 2014

Court proceedings may follow a death in a variety of circumstances. Medical personnel, particularly hospital medical staff, who were involved in the treatment of a patient whose death becomes the subject of criminal or FAI proceedings may require to be called as witnesses in a criminal trial or an FAI at Court.

Given the time-critical nature of the organ transplantation process, it is important that the Procurator Fiscal is contacted as soon as possible to discuss potential organ or tissue donation.

A Protocol has been agreed between COPFS and the Scottish Transplant Group with regard to organ and tissue donation. A summary of the important points are:

• where there is reason to believe that the death may be reported to the Procurator Fiscal, no body parts will be removed without their prior consent;
• the Procurator Fiscal may object to removal of organs in a case which is likely to result in a charge of homicide or where, in the time available, insufficient enquiry is able to be carried out to allow an informed decision. There are procedures available which will allow the Procurator Fiscal not to object to transplantation in cases of homicide but early discussion with the Procurator Fiscal is essential;
• the Procurator Fiscal will normally permit removal of organs subject to the need to ensure that any future post mortem examination to establish the medical cause of death is not prejudiced; and to ensure that sufficient evidence is available for any subsequent criminal proceedings or Fatal Accident Inquiry; and
• where possible, the Procurator Fiscal will provide consent.

The case of Law Hospital NHS Trust v Lord Advocate 1996 SLT 848 establishes that when a hospital which has care of a patient who is in a persistent vegetative state, or any relative of that patient, seeks withdrawal of treatment, there should be an application to the Court of Session for authority to discontinue treatment. After the decision, the Lord Advocate indicated that any qualified medical practitioner (or any person acting upon the instructions of such a practitioner) who, acting in good faith and with the authority of the Court of Session, withdraws or otherwise causes to be discontinued life sustaining treatment or other medical treatment from a patient in a persistent, or permanent, vegetative state, with the result that the patient dies, will not be prosecuted.

Immunity from prosecution does not automatically extend to medical practitioners who, without seeking the authority of the Court, withdraw life sustaining treatment in a persistent or permanent vegetative state with the result that the patient dies. The Lord Advocate has expressed the view, however, that if doctors and those acting on their instructions were acting in accordance with accepted medical practice and had exercised the proper degree of care expected of them, it would be very unlikely that any prosecution in the public interest would be brought against them.

Any death of a patient in a permanent vegetative state as a result of the withdrawal of life sustaining treatment or other medical treatment (whether with or without the authority of the Court of Session) must be reported to the Procurator Fiscal as soon as it occurs.

Full information and contact details for the SFIU teams can be found on the dedicated SFIU webpage.

In normal circumstances, death reports should be made to the Procurator Fiscal during office hours. SFIU hubs are open Monday to Thursday 9am – 5pm and Friday 9am – 4.30pm. Outwith these hours, there is an answering machine service where a message can be left.

In situations of urgency, particularly where the death is suspicious or there are religious rites which require to be observed, a death report may be made outside office hours to the on-call service. This facility should be used in exceptional circumstances only where the matter cannot wait until the next working day. The number of the On Call Procurator Fiscal can be obtained from the police on 101 (some Hospital Reception Desks may also have this number).