Duty Coroner / E-mail: / / RECORD OF DEATH
(In the community)
Fax: / 09 969 6569
Phone: / 0800 266 800
Please complete this form and email or fax it to the National Duty Coroner who 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:First Names: / Time of Death: / (24-hour clock)
Gender: / / / Location of Death: / Own home/Rest home/Community
Date of Birth: / Age: / Last Consultation:
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 (MCCD-HP4720): / / YES
/ NO
/ Wish to discuss with Duty Coroner
Your opinion as to the cause of death:
1 a: Direct cause
(Disease, injury or complication)
1.b: Due to (or as a consequence of)
Circumstances of Death: (Please answer all questions) / YES NO UNSURE
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 suffered 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 deceased / / /
If any of the above boxes are ticked YES or UNSURE then the death must be reported to, or discussed 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 Duty Coroner’s Use only / YES NO
Family notified of death: / / / Discussed with reporting doctor
Or (name of doctor): / /
Record of death emailed or faxed to Coroner: / /
Discussed with Duty Coroner (name): / Jurisdiction Accepted: / /
Advice received back from Coroner: / / / Post-mortem required (subject to objection): / /
Police notified of death (if applicable): / / / Doctor’s report in-lieu of PM: / /
I am able to send medical notes electronically to pathologist if PM is required: / / / Coroner: / Date:
Cor28A Nov 2014