Northland District Health Board says it would certainly have referred the death of a Kaitaia man from a heart attack to the coroner if it had known the man had earlier taken part in the "ice challenge" game.
Chief Coroner Judge Neil MacLean criticised the DHB on Friday after it had failed to refer the death of Willis Tepania, a 40-year-old father, to his office after he died last Monday.
Mr Tepania took the "ice challenge" last Saturday night and is believed to have then consumed a large quantity of bourbon within minutes - possibly as much as a full litre bottle - and five hours later suffered a cardiac arrest. It is understood he died in Whangarei Hospital last Monday night.
Judge MacLean said he was "concerned" at Northland DHB staff's response to the death and when the duty coroner was finally informed and took jurisdiction of the death, Mr Tepania's body was already buried.
"It seems a doctor was prepared to sign a death certificate in circumstances that, in my opinion, were not appropriate.
"I am satisfied there are issues surrounding the death that meant the duty coroner should have been notified promptly," he said.
Northland DHB CEO Nick Chamberlain said he has had the opportunity to review its position on the matter.
"We had no knowledge that the patient's cause of death could have been contributed to by the 'Ice Challenge' game he had apparently participated in," Dr Chamberlain said.
"We were unaware that the patient had participated in the 'Ice Challenge' which, had we known, would have triggered notification immediately to the coroners' office. There are absolutely no issues with our clinical care.
"This matter is now in the hands of the coroner and Northland DHB will co-operate fully with the coroners' office."
The ice challenge has become a viral phenomenon in New Zealand and around the world. It involves a participant submerging themselves in ice cold water or having a bucket of ice water poured over them. They then nominate others to take the challenge and make a donation to charity.
But in countless online videos, the exercise is conducted hand-in-hand with the consumption of a lot of alcohol.