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.