The Coroner: Death Registration and Inquest Verdicts

Medicolegal Death Investigation

Investigation of sudden, unexplained, unnatural and violent death Where a death is due to natural causes (and there are no concerns) the coroner will normally be able to accept a Medical Certificate of the Cause of Death from a registered medical practitioner

Reportable Deaths Dublin District Coroner Deaths reported Autopsies ordered Inquests held

Registration of death: (Civil Registration Acts ) –Death Notification Form (Part I) Medical Certificate of Death –Coroners Certificate

Death Notification Form MEDICAL CERTIFICATE OF DEATH I.I Disease or condition (a)…………………………... directly leading to death ……………………………… due to (or as a consequence of) Antecedent causes(b)……………………………. due to (or as a consequence of) (c)……………………………. II.II Other significant conditions………………………………

Medical Certificate of Cause of Death No unnatural cause of death

Issues Unclear terminology Complications of operation or medical procedure Fractures in elderly Alcohol related death Malnutrition/dehydration

Incomplete Certification Nosocomial infection Pulmonary fibrosis Mesothelioma Intra-cranial haemorrhage Multiorgan failure HIV and hepatitis Spongiform encephalopathy “Acute kidney injury”

Death Certification Formulation of Cause of Death Cause of death must be clearly formulated Questions of causation are very important

What is causation in death certification? The proximate cause of death does not always satisfy the question of causation What is the proximate cause of death?

Proximate Cause Eastern Health Board v Farrell (Dublin City Coroner) [2000] 1 ILRM 466 (HC); [2001] 4 IR 627(SC)

Proximate Causes Cardiorespiratory failure Hepatorenal failure Pulmonary oedema Cardiomegaly Post operative complications Septicaemia Aspiration pneumonia

Underlying cause must be given Otherwise the medical certificate is incomplete and may be referred to Coroner by Registrar of Deaths

Deaths Reportable to Coroner Rules of Law Rules of Practice Reportable Deaths for Maternity Hospitals (Dublin District Coroner) [see handout]

Inquest Public Policy Considerations (i) to determine the medical cause of death; (ii) to allay rumours or suspicions; (iii) to draw attention to the existence of circumstances which, if unremedied, might lead to further deaths; (iv) to advance medical knowledge; (v) to preserve the legal interests of the deceased person’s family, heirs or other interested parties.

Farrell (Dublin City Coroner) v AG [1998] 1IR 203 Morris v Dublin City Coroner [2000] 3IR 592 HC; [2000] IESC 24 Eastern Health Board v Farrell (Dublin City Coroner) [2000]11LRM 446 (HC), [2001] 4 IR 627 (SC) Ramseyer v Mahon (Coroner for Offaly) [2004] IEHC 70; [2005] IESC 82

S18 (4) CA 1962 “…deceased died directly or indirectly as a result of violence or misadventure or by unfair means or as a result of negligence or misconduct or malpractice….”

Section 30 CA 1962 “Questions of civil or criminal liability shall not be considered or investigated at an inquest….”

EHB v Dublin City Coroner “…the prohibition on any adjudication as to civil or criminal liability should not be construed in a manner which would unduly inhibit the inquiry. That would not be in accord with the public policy considerations relevant to the holding of an inquest to which I have referred.”

EHB v Dublin City Coroner “It is clear that the inquest may properly investigate and consider the surrounding circumstances of the death, whether or not the facts explored may, in another forum, ultimately be relevant to issues of civil or criminal liability.”

Verdicts Accident/misadventure Suicide Unlawful killing Open Narrative Occupational related disease Stillbirth ADR Natural causes

Accident Unforeseen contingency Chance/fortune Event without apparent cause

Misadventure (Medical Misadventure) Unintentional result of intended action Accident with risk factors Bad fortune/mishap Unfortunate circumstances Complications of procedures

Suicide – Legal Test (at Inquest) Deceased killed him/herself Intended to do so Proof beyond a reasonable doubt

Open Means by which death occurred not ascertained Self-inflicted death (evidence does not satisfy legal test)

Inquest Issues A: Legal Expectation of next of kin Adversarial approach by lawyers Prior release of documents (pre-inquest disclosure) Verdict/riders/recommendations

McLoughlin v Aviva Insurance (Europe) 2011 IESC Disclosure of evidence in Non-Life Insurance case

Inquest Issues B: Medical Autopsy reports Medical reports Pre-inquest disclosure Role of legal advisors Expert evidence

Hierarchy of (Legal) Norms Irish Constitution (Bunreacht na hÉireann) ECHR Act 2004 Statute Law Common Law (Practice and Procedure)

Legislation Coroners Act 1962 Coroners (amendment) Act 2005 Miscellaneous Provisions Act 2009/2011 Courts & Civil Law (Misc. Prov.) Act 2013

(Near) Future Constitutional Issues Jurisprudence of ECHR in Irish Courts Coroners Bill 2007 Structural changes in delivery of Coroner Service

Dublin District Coroner Website: Coroner’s Service Website: