1. The Role of the Coroner in Fatal Fires

2. Medicolegal Death Investigation

3. Sudden, unexplained, violent and unnatural death

4. Article 2 European Convention of Human Rights

5. Death Investigation Coronial system Medical examiner Procurator fiscal Magistrate Forensic service Police

6. An inquest must be held in all unnatural deaths.

7. All fire deaths must be reported to the district coroner. An inquest must be held.

8. Domestic/industrial fires Arson/homicide Major disasters

9. Major Disaster Incident involving multiple fatalities Requires special arrangements to be made

10. Report to coroner Preliminary inquiry Autopsy

11. Identification Visual/body characteristics Photographic Fingerprinting Dental charting DNA profiling

12. Preservation and forensic examination of scene Statements of witnesses

13. Are there any suspicious circumstances?

14. Autopsy Hospital pathologist Forensic pathologist Toxicology Special examination Medical reports Hospital chart

15. Toxicology Carbon monoxide Cyanides Alcohol levels Drug screen

16. Cause of Death Burns Carbon monoxide poisoning (smoke) Inhalation injury Infection Multiorgan failure Other causes

17. Inquest Public hearing Inquisitorial (not adversarial) Interested persons Circumstances of death Findings/verdict Recommendations

18. Witnesses Identification witness (or forensic evidence in relation to identification) Witnesses who can give evidence in relation to the circumstances of the fire Person who last saw the deceased alive Members of the fire service and rescue teams Scenes examiner Investigating Garda Pathologist

19. Verdict Accident Misadventure Suicide Homicide (unlawful killing) Open verdict Natural causes

20. Certificate for death registration Follow-up on any recommendations made by the coroner or jury