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The Role of the Coroner in Death Investigation

This section describes the functions of the Coroner with particular reference to procedure in Cork City. It is intended as a guide for the benefit of the general public and interested parties. Further information is available from the Coroner's Office

Office Hours

Monday to Friday:   9.00am to 5.00pm

Death Certification and Death Investigation Frequently Asked Questions

  1. Disclaimer and Copyright Notice
  2. Who is the Coroner?
  3. What deaths are reported to the Coroner?
  4. Who has responsibility to report a death to the Coroner?
  5. Deaths which must be reported to the Coroner
  6. What happens when a death is reported?
  7. Why are the Garda Siochana Involved?
  8. When may funeral arrangements be made?
  9. When is a body released?
  10. How is a death registered?
  11. What is an Inquest?
  12. Can funeral arrangements be made before an inquest is held?
  13. When is a jury necessary at an inquest?
  14. Who gives evidence at an inquest?
  15. Who can ask questions at an inquest?
  16. Can a report of an inquest be obtained?
  17. Will the inquest be reported in the newspapers?
  18. What is the role of the Coroner in relation to organ transplantation?
  19. What is the role of the Coroner when a body is to be removed out of Ireland?

1. Disclaimer

Even though care has been taken in the preparation and publication of the contents of this web site, the Cork City Coroner does not assume legal or other liability for any inaccuracy, mistake, mis-statement or any other error of whatsoever nature contained herein. The Cork City Coroner hereby formally disclaims liability in respect of such aforesaid matters. The information contained within this site is of a condensed and general information nature only and can change from time to time. It should not, by itself, be relied upon in determining legal rights or other decisions. Readers/users are advised to verify, by direct and live contact with The Cork City Coroner, any information on which they may wish to rely.

Copyright Notice

Unless otherwise stated or appearing, the copyright and other intellectual rights attached to information or data contained within this web site are held by the Cork City Coroner. Reproduction of all or any of the contents of web site, in any form, is prohibited save with the prior written authorisation of The Cork City Coroner. The Cork City Coroner hereby gives a general consent to the use of such information for bona fide personal use and also for the recopying of all or any of the contents of the web site for genuine and bona fide information dissemination purposes where the source of information is properly acknowledged and where such acknowledgement contains and refers to web address of The Cork City Coroner.

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2. Who is the Coroner?

The Coroner is an independent official with responsibility under the law for the medicolegal investigation of certain deaths. A Coroner must inquire into the circumstances of sudden, unexplained, violent and unnatural deaths. This may require a post-mortem examination, sometimes followed by an inquest. The Coroner's inquiry is concerned with establishing whether or not death was due to natural or unnatural causes. If a death is due to unnatural causes then an inquest must be held by law.

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3. What deaths are reported to the Coroner?

When a death occurs suddenly or unexpectedly or is due to an unnatural cause the death must be reported to the Coroner. The Coroner will not be involved where a person died from natural illness or disease for which he/she was being treated by a doctor within one month prior to death. In such a case the doctor will issue the medical certificate of the cause of death and the death will be registered accordingly. In these cases the Coroner is not usually involved.

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4. Who has responsibility to report a death to the Coroner?

In cases of sudden, unnatural or violent death there is a legal responsibility on the doctor, registrar of deaths, funeral undertaker, householder and every person in charge of any institution or premises in which the deceased person was residing at the time of his/her death to report such a death to the Coroner. The death may be reported to a member of the Garda Siochana not below the rank of sergeant who will notify the Coroner. However at common law, any person may notify the Coroner of the circumstances of a particular death.

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5. Deaths which must be reported to the Coroner

Deaths reportable to the Coroner include the following:

Deaths occurring at home or other place of residence

Where the deceased was not attended by a doctor during the last illness

Where the deceased was not seen and treated by a doctor within one month prior to the date of death

Where the death was sudden and unexpected

Where the death may have resulted from an accident, suicide or homicide

Where the cause of death is unknown or uncertain

Deaths occurring in hospital

Where the death may have resulted from an accident, suicide or homicide

Where any question of misadventure arises in relation to the treatment of the deceased

Where a patient dies before a diagnosis is made

When death occurred while a patient was undergoing an operation or was under the effect of an anaesthetic

Where the death occurred during or as a result of any procedure

Where the death resulted from any industrial disease

Where a death was due to neglect or lack of care (including self neglect)

Where the death occurred in a Mental Hospital

Where the death occurred in a public or private resdieent unit for care of the elderly

Where the death occurred in relation to a healthcare acquired infection

A death is reported to the Coroner by a member of the Garda Siochana

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

The death of a child in care

Where a body is to be removed abroad

If in doubt as to whether or not a death is properly reportable please consult with the Coroner or his staff who will advise accordingly. The fact that a death is reported to the Coroner does not mean that an autopsy will always be required.

The Coroner is available for consultation outside office hours, however except when the matter is urgent, cases will normally be reported before 11.00 p.m. or after 8.00 a.m.

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6. What happens when a death is reported?

Where a death occurs suddenly the Coroner will inquire into the circumstances and will ascertain whether or not there is a doctor who is in a position to certify the cause of death. The doctor must have seen and treated the person within a month prior to the death, the cause of death must be known and the death must be due to natural causes. If these conditions are fulfilled and there are no other matters requiring investigation the Coroner will permit the doctor to complete a medical certificate of the cause of death and the death will be registered accordingly.

Where a medical certificate of the cause of death cannot be signed the Coroner will arrange for a post-mortem examination to be carried out. If the post-mortem examination reveals that death was due to natural causes and there is no need for an inquest the Coroner will issue a certificate so that the death may be registered.

The post-mortem examination (autopsy) is a procedure to establish the cause of death. All stages will be carried out in a professional manner. There is no disfigurement of the body, which may be viewed afterwards in the same manner as if no post-mortem had been performed.

N.B. It may take up to three months (occasionally longer) before a post-mortem report from the pathologist is received at the Coroner's Office. The death cannot be registered until the post-mortem report is received.

Queries relating to post-mortem reports should be made to the Coroner's office and not to the hospital concerned.  The Coroners Office will keep next-of-kin informed of the progress of the enquiry.

If the death is due to natural causes the Coroner's Certificate will be issued to the Registrar of Births and Deaths who will proceed to register the death. The Registrar will then issue the Death Certificate.

If the death is due to unnatural causes an inquest must be held. The death will be registered when the inquest is concluded (or adjourned in some cases).

Prior to the inquest being held (or while awaiting the post-mortem report) the Coroner's Office will provide on request an Interim Certificate of the fact of Death which may be acceptable to banks, the probate office and other institutions.

In certain Coroners Post Mortems during the course of the autopsy the Pathologist may find it necessary to retain an organ for further examination to establish the exact cause of death. In such cases the next of kin will be advised at the time of the post mortem examination by the Pathologist who will explain the procedure to them

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7. Why are the Garda Siochana Involved?

The Garda Siochana will assist the Coroner in arranging a formal identification of the body by a member of the family, or a relative of the deceased. The Gardai will send a report to the Coroner on the circumstances of the death. The fact that relatives may be met at the hospital by a uniformed Garda or that a Garda may call to the home to take a deposition, does not mean that the death is regarded as suspicious. Members of the Gardai will in most cases be acting also as Coroner's officers.

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8. When may funeral arrangements be made?

When a death is reported to the Coroner funeral arrangements should not be made until the body is released or the Coroner has indicated when release will occur. This is important at all times, but particularly so at bank holiday weekends. Cremation cannot take place until the appropriate Coroner's certificate is issued.

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9. When is a body released?

The body will normally be released to the spouse or next-of-kin immediately after the post-mortem examination has been completed, (irrespective of whether or not an inquest is to take place). (See note 7 above).

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10. How is a death registered?

Death must be registered with the Registrar of Births and Deaths for the registration district in which the death occurs. A relative or other eligible person must obtain a Medical Certificate of the Cause of Death from the medical practitioner who attended the deceased during the last illness. The certificate is brought to the District Registrar's office where the death is registered and the Death Certificate issued. Where a death occurs in hospital the death may be registered by a member of the hospital staff. Where a death is reported to the Coroner and is the subject of a post-mortem examination or inquest, the death will be registered when the Coroner issues his certificate after the post-mortem or inquest. The death certificate will then be available from the District Registrar's office. Information on registration may be obtained from: The Registrar's Office, Adelaide Court, Adelaide Street, Cork.  Telephone No:- 021 - 4275126.

Opening Times 

Monday to Friday inclusive : 9.15am to 4.00p.m.

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11. What is an Inquest?

An inquest is an inquiry in public by a Coroner, sitting with or without a jury into the circumstances surrounding a death. An inquest must be held by law when a death is due to unnatural causes. The inquest will establish the identity of the deceased, how, when, and where the death occurred and the particulars which are required to be registered by the Registrar of Deaths. Questions of civil or criminal liability cannot be considered or investigated at an inquest and no person can be exonerated. The purpose of the inquest therefore is to establish the facts surrounding the death and to place those facts on the public record and to make findings on the identification of the deceased, the date and place of death and the cause of death. A verdict will be returned in relation to the means by which the death occurred. The range of verdicts open to a Coroner or jury include accidental death, misadventure, suicide, open verdict, natural causes (if so found at inquest) and in certain circumstances, unlawful killing.

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12. Can funeral arrangements be made before an inquest is held?

If an inquest is to be held, the Coroner is usually able to allow burial or cremation once the post-mortem examination of the body has been completed (see note 7 above). Certain documents will be issued by the Coroner where a body is to be cremated or removed out of the country (see also note 18).

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13. When is a jury necessary at an inquest?

A jury is required in the following circumstances:

  • Where the death was due to murder, manslaughter or infanticide
  •  Where death occurred in prison
  • Where death was caused by accident, poisoning or disease requiring notification to be given to a government department or inspector.
  • Where death resulted from a road traffic accident.
  • Where death incurred in circumstances the continuance or possible recurrence of which would be prejudicial to the health or safety of the public or any section of the public
  • Where the Coroner considers it desirable to empanel a jury.
  • Where an inquest is held with a jury it is the members of the jury (not the Coroner) who return the findings and verdict.

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14. Who gives evidence at an inquest?

The Coroner will decide which witnesses should attend and in what order whey will be required to give evidence. The evidence will be presented in a manner so as to provide a logical sequence in relation to the circumstances surrounding the death. The autopsy report will establish the medical cause of death. Some family members may prefer not to hear details of the post-mortem examination. The Coroner will indicate when the autopsy report is to be taken so that such persons may withdraw and return later during the inquest. Any person who wishes to give evidence is entitled to come forward at the inquest but the evidence tendered must be relevant to the purpose of the inquest. A person wishing to give evidence at an inquest should make this fact known to the Coroner as soon as possible.

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15. Who can ask questions at an inquest?

Any person who has a proper interest in the inquest (a properly interested person) may personally examine a witness or may be legally represented by a solicitor or barrister. Properly interested persons include:

  • The family and next-of-kin of the deceased
  •  Personal representatives of the deceased
  • Representatives of a board or authority in whose care the deceased was a the time of death e.g. hospital, prison or other Institution
  •  Those responsible for the death in some way eg. Driver of a motor vehicle
  • Representatives of Insurance Companies (Where death resulted from an accident at work)
  • Representatives of Trade Unions
  • An employer of the deceased
  • An Inspector of the Health and Safety Authority Others at the discretion of the Coroner.
  • Properly interested persons at an inquest are entitled to be legally represented. Legal representation is not mandatory, but such persons may wish to instruct solicitors in certain circumstances.

It is helpful if solicitors notify the Coroner prior to the inquest that they have been so instructed

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16. Can a report of an inquest be obtained?

Depositions taken at inquest including a copy of the verdict are available from the Coroner's office on payment of the statutory fee, once the inquest has concluded. It should be noted that the inquest papers are not available prior to the inquest being held.

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17. Will the inquest be reported in the newspapers?

All inquests are held in public and reporters may be present. In practice a minority of inquests are reported. The Coroner is aware of the tragic circumstances and will endeavour to treat each one sympathetically. The existence of suicide notes will be acknowledged but the contents will not be read out, except at the specific request of the next-of-kin and then only at the discretion of the Coroner. Every attempt is made to ensure that the inquest proceedings are not unduly intrusive on families concerned.

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18. What is the role of the Coroner in relation to organ transplantation?

If a death is (or will be) properly reportable to the Coroner, his permission is required before organs are harvested for transplantation. In addition the written consent of the next-of-kin is required. If the Coroner grants permission for organ harvesting the subsequent post-mortem examination will be a limited one. The matter must be fully discussed with the Coroner, at the appropriate time, to allow him to reach a decision in the matter. In general, the Coroner will facilitate requests for organ harvesting and transplantation.

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19. What is the role of the Coroner when a body is to be removed out of Ireland?

The district Coroner must be notified in every case where a body is to be taken abroad, whether or not there has been a Coroners inquiry, post-mortem examination or an inquest. This applies even if the death was due to natural causes and has been certified by a doctor (i.e. not originally a Coroner's case). It is the Coroner in whose district the body is lying who must be notified. If satisfied in relation to the cause of death the Coroner will issue a certificate, usually to the funeral director, for presentation to the appropriate authorities permitting removal of the body from the jurisdiction.

When a body is returned to Ireland following death abroad, the Coroner will not normally be involved, except where a question in relation to an unnatural death abroad occurs or when next-of-kin raise concerns with the Coroner in relation to the circumstances surrounding a death.

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20. Organ Retention: City Coroner's Practice

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