Coroner



Background

  • The role of the coroner in Ireland is regulated by the 1962 Coroners Act, by common law and by a number of provisions contained in separate legislation.
  • A coroner’s post mortem examination is a procedure carried out to establish cause of death only.
  • It is normally carried out within 24-48 hours of death.
  • The body may be viewed afterwards in the same manner as if no post mortem had been performed.
  • The coroner is an independent official with responsibility under law for the medical legal investigation of certain deaths.
  • If the coroner directs that a post-mortem take place, consent from next of kin is not required.

Procedure

  • A senior doctor on duty will contact the Coroner 021-4806645, or via switch.
  • Following discussion the coroner will decide if a post mortem is necessary.
  • If a post mortem is not required, this information will be immediately given to the next of kin and the remains will be released by the hospital.

If a Coroner’s Post Mortem is required

  • The hospital will notify the Gardaí at Anglesea St Station 021-4522000.
  • The Gardaí in these cases act as Officers of the Coroner and are always required for formal identification of the deceased patient.
  • This formal identification needs to be carried out in the hospital in the presence of a relative.
  • If The Gardaí need to gather information for the coroner from relatives, this will be carried out in a private area.
  • When the Gardaí have formally identified the deceased patient, Mercy University Hospital (MUH) will arrange removal to the mortuary in Cork University Hospital (CUH) for post mortem. Contact Crowley Funeral Directors (021–4874777) to arrange removal.
  • Until removal to the CUH, the deceased will remain in the MUH mortuary.
  • The medical notes are to be placed in a sealed transport bag clearly marked ‘For delivery to the Mortuary Cork University Hospital’. The transport bag is brought to the CUH by the undertakers.

Funeral arrangements

  • When a death is reported to the coroner, funeral arrangements should not be made until the body is released. This is important.
  • The body will normally be released to the next of kin immediately after the post mortem has been completed.
  • Cremation cannot take place until the appropriate coroner’s certificate is issued.

Registering a death following a Coroner’s Post Mortem

  • Following a Coroner’s Post Mortem the completed autopsy report is forwarded to the coroner for review.
  • If an inquest is not required the coroner will issue a certificate directly to the registration office.
  • The next of kin will be notified by the coroner’s office.
  • The next of kin can then contact their local Registrars’ Office to get a copy of the final death certificate.
  • Please be aware that it may take a number of months before this will be available.
  • An Interim Certificate of the fact of death will be provided by the coroner's office on request which is acceptable to banks, insurance companies and the Department of Social and Family Affairs for bereavement entitlements and other benefit claims. If the coroner directs that an inquest must be held, the process may take a little longer. The coroner will issue a certificate in the same manner at the conclusion of the inquest.
  • The death certificate will then be available from the District Registrars Office Adelaide Street (021-4275126).
  • The coroner's office can be contacted for further information 021-4806645, Coroner@corkcity.ie www.coroners.ie (General information on Coroners service in Ireland)

What deaths are reported to the Cork City Coroner?

  • Where a death may have resulted from an accident, suicide or homicide.
  • All deaths occurring in the Emergency Department (or ITU)
  • Where any question of misadventure arises in relation to the clinical or pharmaceutical treatment of the deceased.
  • Where a patient dies before a diagnosis is made.
  • Where any patient dies within 24 hours of admission to hospital.
  • When death occurred while a patient was undergoing an operation or was under the effect of an anaesthetic or following an operation.
  • Where the death occurred during or as a result of any procedure.
  • Where the death resulted from any occupational disease.
  • Where a death was due to neglect or lack of care (including self neglect).
  • Where death is directly due to a hospital acquired infection in the absence of other significant co-morbidities.
  • Where although a patient is known to have a significant co-morbidity hospital acquired infection has brought about death at a time much earlier than would otherwise have been expected.
  • Where a death occurs to a person in the care of the State.
  • All deaths in association with intracerebral haemorrhage.
  • All deaths occurring in patients who have been referred from a Nursing Home or long term residential care facility.

If in doubt as to whether or not a death is properly reportable, please consult with the Coroner who will advise accordingly. Basic clinical history is helpful when informing the Coroner.

The fact that a death is reported to the Coroner does not mean that an autopsy will always be required.

Phone: 021-4806645 (office) or Coroners mobile number at switch (The Coroner is available for consultation outside office hours, however except when the matter is urgent cases will normally be reported before 10pm or after 8am).


Death reported by others

  • A death is reported to the Coroner by a member of the Garda Síochána:
    • Where a death may have resulted from an accident, suicide or homicide
    • Where a death occurred in suspicious circumstances
    • Where there is an unexpected or unexplained death
    • Where a dead body is found
    • Where there is no doctor who can certify the cause of death
  • A death is reported to the Coroner by the Governor of a Prison: Following the death of a prisoner.

Other categories of death reportable include

  • Sudden infant deaths
  • Certain still-births
  • Death of a child in care
  • Where body is to be removed abroad.

Current Oncological practice and the coroner

Actively managed patients

Inform the coroner when

  • Unanticipated idiosyncratic response to chemotherapeutic agents i.e. overwhelming marrow suppression, leading to death.
  • Allergic response to chemotherapeutic agent leading to death.
  • Prescription error in chemotherapeutic agent leading to death.
  • Where any question of misadventure in relation to the treatment of the deceased arises.
  • Where although patient has significant underlying cancer diagnosis, death is brought about at a time much earlier than would otherwise have been expected due to hospital acquired infection Print version

Palliative patients

Inform coroner when

  • Cancer diagnosis relates to an occupational disease.
  • Where death occurs without a diagnosis.

Palliative protocol in Coroners Cases

Cork County Borough

The patient whose care is confined to palliation is upon death very seldom reportable to the Coroner. When considering whether to report, do so in the following circumstances. Print version

  • Questions of a criminal offence in the history of presentation irrespective of the passage of time.
  • Trauma in the history of the presentation irrespective of the passage of time.
  • Where any question of misadventure in relation to the treatment of the deceased arises.
  • Where a causative factor in death relates to a per operative or anaesthetic event or relates to a medical procedure.
  • Where death relates to an occupational disease.
  • Where death occurs without a diagnosis.
  • Death within 24 hours of admission.
  • Where death is directly due to a hospital acquired infection in the absence of other significant co-morbidities and such infection was diagnosed before a palliative status was assigned.
  • Where although a patient is known to have a significant co-morbidity hospital acquired infection has brought about death at a time much earlier than would otherwise have been expected. Print version

Completing the medical certificate in non reportable hospital acquired infection

  • If Hospital Acquired Infection is appearing on a medical certificate as to the cause of death it is by definition only where rules 7 and 8 (left) do not apply. Print version
  • In such cases if the organism is known it should appear by name on the certificate.
  • If death is due to septicaemia please record the originating focus if known.
  • The positioning of the fact of hospital acquired infection on the medical certificate is dependent on whether it was the actual cause of death in which case it appears at 1A with the most significant pre existing co-morbidity appearing at 1B and or 1C.
  • If the infection was considered significant but not the primary cause of death it may appear at II.
  • Terms such as palliative or end stage may appear on a medical certificate as to the cause of death if the use of such term clarifies the clinical situation further for the Registrar of Deaths.
  • Colonization such as with MRSA is not recordable.
  • The Coroner will assist with any queries in relation to the above. Print version

TB cases

  • Notify the Director of Public Health of any probable or definite TB case following post mortem by the pathologist (using the prescribed form)
  • The Public Health Department will then liaise with the G.P. (or hospital consultant) as appropriate prior to contacting the deceased's next of kin for the purposes of TB contact tracing.
  • The Coroner will subsequently forward a copy of the final post mortem report, when available, to the Director of Public Health

CJD cases

  • In all cases of suspected CJD a post-mortem is required to establish the cause of death.
  • As the post-mortem is being carried out, because the cause of death is unknown, it is by definition a Coroners post-mortem.
  • At the time of death the Coroner must be contacted for a direction.
  • If a post-mo1tem is directed firstly the local Gardai must be notified in order that a formal identification process can take place.
  • .
  • Secondly the City Mortuary must be contacted on 021-4922525 to co-ordinate the transfer of remains and notes etc. to the designated centre for such post-mortems at Beaumont Hospital in Dublin and the City Mortuary will co-ordinate the ultimate return of remains and/or retained organs.
  • In this manner proper procedures will be followed and there is less opportunity for oversight in these atypical circumstances.

Coroners post mortem reports

The post mortem document does not form part of the Medical Records and should not be copied or release or otherwise uttered.

This is a legal document and is the property of the Cork City Coroner. Any inquiries in relation to this document should be directed through the Office of the Cork City Coroner, Courthouse Chambers, Washington Street, Cork City.

A copy of the post mortem report can be sent to a Consultant at the conclusion of the Coroners Inquest or in the event of a Natural Death as soon as the post-mortem report is available. A request must be sent to the Office of the Cork City Coroner as we are not always aware of all of the relevant clinicians.



Content by Dr Íomhar O' Sullivan on 17/09/2004. Reviewed by Dr ÍOS 23/05/2006, 28/05/2007. Last review Dr. ÍOS 27/02/17 .