Reading time 3 mins

Death of a Resident/Patient Toolkit

This toolkit provides a structured process for recording and managing deaths of residents or patients across health and social care settings. It supports respectful handling, statutory notifications, family liaison, multi‑agency escalation (coroner/procurator fiscal, police, safeguarding), and organisational learning.

Legislative Requirements

• Care Act 2014 — record deaths accurately; cooperate with coronial/regulatory processes; escalate to safeguarding where abuse or neglect is suspected; reflect learning through governance.
• Coroners and Justice Act 2009 — statutory framework for investigation of certain deaths (establish identity, how/when/where death occurred; support transparency and prevention of future deaths).
• Medical Examiners / Medical Certificate of Cause of Death (MCCD) — processes for certification and scrutiny vary by nation; recent DHSC changes (from 9 Sept 2024) affect who may complete MCCDs in England/Wales; Scotland retains its attendance requirement.
• Data Protection Act 2018 / UK GDPR — GDPR does not apply to deceased persons’ personal data; however, common‑law confidentiality continues and living persons’ data (next of kin, staff, witnesses) remains protected and must be processed lawfully and securely.

Regulatory Guidance

CQC (England)

• Providers must notify CQC without delay under Regulation 16 when a person dies while receiving a regulated activity or where death may be related to care provided.
• Notifications should normally be made within 24 hours and include date/time/place of death, whether expected, known cause (if available), involvement of restraint/medication/incidents, and whether other investigations are underway.
• Additional notifications may be required (e.g., Regulation 18) where serious injury, abuse, police involvement or events that may shorten life are involved.

Care Inspectorate Scotland

• All registered care services must notify the Care Inspectorate immediately when a person using a service dies, regardless of cause.
• Notifications include name, date/time/place of death, whether expected, brief circumstances and whether the Procurator Fiscal or emergency services are involved.

Care Inspectorate Wales (CIW)

• Regulation 38 requires providers to notify CIW without delay of any service user's death and the circumstances.
• Notifications are normally expected within 24 hours and must be followed up in writing; CIW may request further information or take regulatory action where concerns arise.

Statutory Guidance

• Accountability — clear responsibilities for recording, notification, investigation and board oversight.
• Duty of Candour — openness with families where death is associated with care failings or could cause harm.
• Safeguarding — duties continue after death; suspected abuse/neglect contributing to death must follow safeguarding pathways and multi‑agency processes.
• Reporting — ensure timely, accurate reporting to regulators, coroners/procurator fiscal and other statutory bodies as required.

Health care Guidance

• DHSC / NHS guidance (including the NHS England–endorsed Guidance for staff responsible for care after death) sets out verification, immediate actions after death, family communication and legal responsibilities.
• In England and Wales (post‑9 Sept 2024) any doctor who attended the deceased during their lifetime may complete the MCCD; Scotland retains requirement that the certifying doctor attended during last illness.
• Medical Examiners and scrutiny processes (where established) provide independent review and may trigger further investigation or referral to coroners/Procurator Fiscal.

Evidence Based Practice

• Report deaths accurately and promptly to enable oversight and learning; incomplete reporting undermines investigation and quality improvement.
• Use structured review methodologies (e.g., Structured Judgement Reviews where appropriate) to assess care quality and contributory factors.
• Involve bereaved families throughout the process, record their views, and provide clear, compassionate communication and support.

Clinical governance and Safety (NHS)

• The National Quality Board (NQB) framework requires organisations to report deaths, undertake proportionate mortality review (SJRs), involve families and ensure board‑level oversight of mortality data and learning.
• Maintain high‑quality documentation to support audits, coronial processes, investigations and regulatory compliance.
• Link death records to incident reporting, risk registers and improvement plans where care issues or system failures are identified.

PSIRF

• PSIRF reframes responses to patient safety incidents, including deaths, promoting a proportionate, risk‑based learning response rather than automatic categorisation.
• Some deaths will need a full organisational learning response; others a brief review or thematic analysis; many will not require formal investigation. The aim is system‑level learning, not blame.

Using the Toolkit — Practical Steps

1. Record the death — capture name, identifiers, date/time/place discovered and time of death (if known); record who discovered and immediate actions taken.
2. Notify family and representatives — ensure compassionate, accurate communication, log who was informed, by whom and when; offer bereavement support.
3. Preserve evidence and secure environment — where death is unexpected, preserve scene and records, restrict access and retain clinical notes, observation charts and medication records.
4. Notify statutory bodies — submit required regulator notifications (CQC/CI/CIW) without delay (normally within 24 hours); refer to coroner/Procurator Fiscal and police where required.
5. Assess need for review/investigation — apply SJR/PSIRF criteria or internal review protocols; escalate to safeguarding or multi‑agency review where indicated.
6. Document legal and certification processes — record MCCD completion, medical examiner contact, coroner referral details and any correspondence with legal or external bodies.
7. Support staff and record wellbeing actions — provide debriefing, supervision and record training or support offered to staff involved.
8. Undertake learning and governance actions — log outcomes of reviews, assigned actions, owners, deadlines and evidence of completion; share learning across services as appropriate.

Templates & Data Fields (recommended)

• Death reference, status and reporter details
• Person identifiers (name, DOB, NHS/record number), location, date/time found and date/time of death (if known)
• Discovery circumstances and immediate clinical observations
• Family/next of kin details, who was informed, times and communication notes
• Regulatory notifications (CQC/CI/CIW) — timestamps, submission IDs and outcomes
• Coroner/Procurator Fiscal referral status, police involvement, medical examiner contact and MCCD details
• Linked incidents, safeguarding flags, PSIRF/SJR decision and review type
• Evidence attachments — clinical notes, observation charts, medication records, photos (where appropriate), witness statements
• Investigation findings, action plan, owners, deadlines and closure evidence
• Access controls, sensitivity flags and retention metadata

Monitoring, Audit and Reporting

• Maintain a deaths register to track notifications, coroner referrals, review outcomes and outstanding actions.
• Dashboard metrics: number of deaths (expected/unexpected), notification timeliness, proportion referred to coroner/Procurator Fiscal, review types and overdue actions.
• Audit completeness of records, family involvement, SJR/PSIRF decisions and regulatory compliance (timeliness and quality of notifications).
• Compile extracts for board assurance, safeguarding partners, regulators and external reviews demonstrating learning and action progress.

Value Proposition

• Ensures statutory and regulatory notification duties are met promptly and consistently.
• Provides compassionate, auditable family liaison and bereavement records.
• Supports multi‑agency cooperation (coroners/Procurator Fiscal, police, safeguarding) and legal requirements for certification.
• Enables proportionate, evidence‑based review (SJR/PSIRF) and closure with captured learning to reduce future harm.

References

• Care Act 2014
• Coroners and Justice Act 2009
• Medical Examiners (Wales) Regulations 2024
• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 — CQC
• Care Inspectorate Scotland — Health and Social Care Standards
• Care Inspectorate Wales — National Minimum Standards
• Department of Health and Social Care (DHSC)
• Scottish Government — Health and Social Care Directorate
• Health and Social Services Group (Wales)
• NHS England — Guidance for staff responsible for care after death
• National Quality Board (NQB) guidance on learning from deaths
• NHS England — Learn from Patient Safety Events (LFPSE) / PSIRF
• UK GDPR / Data Protection Act 2018

Disclaimer

Radar Healthcare provides configuration templates and implementation guidance to support effective use of the platform. Any legal, regulatory or data protection examples are for general guidance only and do not constitute legal, clinical or compliance advice. Radar Healthcare acts as a data processor under customer instruction. The customer, as data controller, remains responsible for assessing and managing legal and data protection risks, determining lawful processing, ensuring clinical governance and compliance with applicable regulations.