EMed

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?

The Coroners' core function is to investigate sudden and unexplained deaths so that a death certificate can be issued. The Coroner Service not only provides closure for those bereaved suddenly but also performs a wider public service by identifying matters of public interest that can have life/death consequences.

Reporting of a Sudden Death

Those deaths which should be reported to a Coroner are listed in the Deaths Reportable section of the coroners.ie site.

In summary, these are deaths that are sudden, unexpected, violent or unnatural.

  1. Where a patient dies before a diagnosis is made sufficient to complete a death notification form
  2. Where death is due to a contributing factor of alcohol, toxin related cirrhosis/ cirrhosis of the liver, cirrhosis of the liver due to IV drug use
  3. Where the death may have resulted from an accident, suicide or homicide
  4. The question of misadventure may arise in relation to the clinical or pharmaceutical treatment of the Deceased
  5. Where any patient dies within 24 hours of admission to hospital
  6. When death occurs when the patient is undergoing an operation or under the effect of an anaesthetic or following an operation
  7. Where a death occurs during or as a result of any procedure
  8. Where death occurs from any occupational disease
  9. Where a death was due to neglect or lack of care including self-neglect
  10. Where death is directly due to a hospital acquired infection in the absence of other significant co- morbidities
  11. Where a patient is known to have a significant co-morbidity but a hospital acquired infection has brought about death at a time much earlier than would otherwise have been expected
  12. Where a death occurs to a person in the care of the state. This includes mental care patients, prisoners, prisoners on day release, prisoners released on licence
  13. All deaths occurring in the accident and emergency department
  14. All deaths occurring in the Intensive Care Unit
  15. All deaths in association of cerebral haemorrhage
  16. Any death that may be murder, manslaughter or infanticide
  17. Any death that appears to be connected with a crime or suspected crime
  18. Any death, whether or not accidental, caused wholly or partially by stabbing, drowning ,poisoning, hanging ,electrocution ,asphyxia ,or a gunshot wound
  19. Any death where the deceased person is dead on arrival at a hospital
  20. Any death where the body of the deceased person is unidentified
  21. Any death where no family member of the deceased person can be traced within a reanable time of the death
  22. Any death where the body of the deceased is found or recovered in circumstances that indicate that the death may have occurred a considerable time previously
  23. Any death ( other than in circumstances to which paragraph 22 applies ) in respect of which the date of death may noy be ascertainable
  24. Any death caused wholly or partly by any of the following;
    1. An incident, whether or not accidental, resulting in any physical injury, including a cut, fracture or contusion
    2. A fall
    3. Self – neglect
    4. An eating disorder
    5. Exposure or hypothermia
    6. Burns
  25. Any death which may be by assisted suicide
  26. Any death caused wholly or partly by any of the following:
    1. An accident arising out of the use of a vehicle in a public place
    2. An incident arising on a train ,aircraft, ship or other vessel
  27. Any death caused wholly or partly by any of the following;
    1. A notifiable disease or condition that is ,under provisions in that behalf in any other enactment, required to be notified to a Minister of the Government, a Department of State or a Statutory Body or to an Inspector or other Officer of a Minister of the Government, a Department of State or a Statutory Body including a public health official
    2. An adverse reaction to any drug
    3. A drugs overdose or the presence of toxic substances
    4. An over prescription or application or infusion of a prescribed drug whether accidental or otherwise
    5. In the case of an infant death , maternal drug addiction
    6. An infection contracted as a result of previously contaminated blood product administration
    7. A lack of care or neglect
    8. Starvation or malnutrition
  28. Any death due to a prion disease
  29. Any death caused wholly or partly by an accident at work or due to industrial or occupational disease eg "Farmers' Lung", asbestos related deaths etc
  30. Any maternal or late maternal death
  31. Any death of a stillborn child, death intrapartum or infant death
  32. Any death occurring in a hospital or other health institution that is directly or indirectly related to a surgical operation or anaesthesia (including recovery from the effects of anaesthesia ) or to any other medical, surgical or dental, procedure, regardless of the length of time between the procedure and death
  33. Any death where an allegation is made or a concern has been expressed regarding the medical treatment provided to the deceased person or the management of his or her health care
  34. Any death which may be as a result of an unconventional medical procedure or treatment
  35. Any death of a child in care
  36. Any death occurring in –
    1. An institution for the care and treatment of persons with a physical or mental disability or
    2. any public or private institution for the care of elderly or infirm persons, including a nursing home
  37. All deaths occurring in patients having been referred from a Nursing Home or long- term residential care centre

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

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.

  • 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

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. Last review Dr ÍOS 22/10/22 .