Guidance

Practice advice: Dealing with sudden unexpected death (accessible)

Updated 7 March 2024

Applies to England and Wales

February 2024

Introduction

This guidance provides advice on dealing with the initial stages of a sudden and unexpected death. Separate guidance provides advice on the medical and pathology aspects of any subsequent homicide investigation.

Together, they replace Chapter 11 (Pathology) of the ACPO (2006) Murder Investigation Manual and have been approved by the National Police Chiefs’ Council, the Chief Coroner and the Coroner’s Society of England and Wales.

This advice relates to the investigation of the death of adults. Separate practice advice can be found for the investigation into the death of children in the College of Policing library.

In this document, the word ‘suspicious’ refers to a death where a crime may have been involved due to the actions or inactions of a third person or organisation.

Dealing with death

Dealing with the death of a person is a fundamental role within policing which has, over the years, brought much criticism to the police service in England and Wales.

The system of death investigation in England and Wales essentially fits into one of four pathways:

1. Death which is anticipated due to naturally caused ill health and where a medical doctor is able to issue a Medical Certificate of the Cause of Death (MCCD).

2. Death where a doctor is unable to issue a MCCD because there is reason to suspect the death is violent or unnatural or they have not recently attended upon the deceased or because the cause of death is unascertained. The case is then referred to a coroner for investigation. This will usually involve the police and a coroner’s officer, who attends the scene of the death to complete an initial investigation on behalf of the coroner. If the outcome of that investigation is that the death is not suspicious and there is no third-party involvement, the coroner will continue with the investigation. This is often assisted by the police and may involve the coroner appointing a non-forensic hospital pathologist (known as a ‘histopathologist’) to conduct a post mortem examination to help determine the medical cause of death (Section 14, Coroners and Justice Act 2009).

3. Non-suspicious, unnatural deaths that will need automatic referral to a coroner, for example, deaths from industrial disease, suicides or drug-related deaths.

4. Death where the outcome of the police investigation is that the case is suspicious (caused by a criminal act). The police then take on primacy in the investigation. In consultation with the police, the coroner will appoint a Home Office registered forensic pathologist to conduct the post mortem examination. Normal non-forensic post mortem examinations and forensic post mortem examinations are very different. Therefore, if the outcome of an initial police investigation is flawed, and the decision by the police is that the case is not suspicious, there will be no forensic examination of the body and a potential homicide could be missed.

A report published by the Forensic Science Regulator on GOV.UK in December 2015 ‘A Study into Decision Making at the Initial Scene of Unexpected Death’ highlights the potential to ‘miss’ a homicide. In this study, many cases were examined where the initial police investigation was that the death was non-suspicious, but later at post mortem examination, it was identified as suspicious. To reduce the likelihood of such a miss, it is essential that the police service deals with death in a systematic and professional manner.

The following diagram outlines the process of death investigation in England and Wales. It includes the boundaries between this guidance and ‘The medical investigation of suspected homicide’ guidance. Figure 1 below, shows the process of a death investigation which now includes the Medical Examiners scrutiny of the MCCD.

Initial response and actions

Police involvement in a sudden and unexpected death will usually begin with a call to the command and control centre. This may lead to the deployment of an officer to the scene where the body lies. This is an important phase of the investigation, and it is essential that the call handler ensures that the following actions are completed (please note, that if the case involves the death of a child, each force will have its own policy based upon the national guidance – see above):

• caller details are obtained
• location of the body is established
• confirm an ambulance has been deployed
• turn on body worn video
• establish who is present with the body
• ensure intelligence checks are made in respect of the deceased and the address where the body is located
• risk assessment is undertaken prior to deployment of resources
• deployment of resources is made in accordance with force procedures
• when deploying officers, ensure use of language is non-judgemental and unbiased so that the attending officer does not pre-judge whether the death is suspicious or not

The main priorities for the attending officer are firstly their own health and safety, and secondly to preserve life. The person may not be dead, so whether or not life is extinct will need to be established. The officer should consider first aid and other life saving measures as a priority and confirm ambulance dispatch with the control room. If there is any doubt as to whether the person is dead, an ambulance should be deployed. Ensure that any doctor or other healthcare provider deployed is suitably trained in dealing with potential crime scenes.

Confirmation of death

Note: It is a fundamental responsibility of the police service to preserve life. First attending officers should not assume a person is dead unless the circumstances are plainly obvious to the non-medically qualified. If there is any doubt whatsoever, call for an ambulance immediately. Obvious examples that may not require the attendance of a medical professional to pronounce death would be a decapitated or badly decomposed body, multiple body disruptive trauma, where a body is severely burnt or has been subjected to prolonged submersion or has been predated by animals (where the body is missing essential parts).

If the case appears to be non-suspicious, the doctor who has attended upon the deceased within  28 days of death may issue an MCCD after scrutiny by a medical examiner unless the case is otherwise reportable to the coroner. Once this has been issued, there may be no further need for police involvement other than for the security of any property.

Actions to be taken before the post mortem examination

If an MCCD cannot be issued, the case will have to be referred to the coroner for investigation. It may also be considered a suspicious death and therefore the attending police officer will need to conduct and confirm the following:

• identification of the deceased, if possible
• note what is seen and what the officer does (consider body worn video/notes, sketches, etc.)
• assess the body – injuries/trauma/evidence of burning/state of clothing etc.
• sign of break in/disturbance/alcohol/drugs (including paraphernalia)?
• search the scene for other bodies/offender present or hiding?
• establish if the deceased was vulnerable due to age, disability, substance abuse or alcohol
• intelligence checks on the deceased and on the property
• identify witnesses
• consider the death suspicious until otherwise identified
• if third-party involvement is suspected, protect the scene and set up a cordon. Call for assistance and maintain a scene log
• capture and preserve body worn video footage of the scene
• take and record ambient temperatures if a room or other environment appears unusually warm or cold
• ABC – Assume nothing; Believe nobody; Challenge everything! There is a need to be professionally curious
• ensure a supervisor and the crime scene investigators are informed

The following diagram outlines guidance on first actions:

In terms of seizing relevant items, including but not limited to all medicines found.

End of document.

Version control

This police practice advice is managed by the Home Office Forensic Pathology Unit within the Home Office Science Directorate.

Any suggestions for improvements or comments should be directed to the team at: pathology@homeoffice.gov.uk.

Version	3
Effective Date	23/02/2024
Last Review	23/02/2024
Next Review	two-year intervals
Audience	Police

Version history

Version number	Date published	Published by	Brief description
Version 3	February 2024	Home Office	Amendments following feedback from Homicide Working Group and Coroner’s Society.
Version 2	October 2023	Home Office
Version 1	03 May 2019	College of Policing	Amendments made from Chapter 11 Pathology in ACPO (2006) Murder Investigation Manual.