The Coroner is an official charged with the legal responsibility for investigating sudden, unexplained and unnatural deaths in his or her district. The Coroner is appointed by the local authority in whose area the Coroner’s district is situate.

A Coroner must be a barrister or a solicitor or a registered medical practitioner of at least five years standing. Although the Coroner system is subject to the general supervision of the Minister for Justice, Equality and Law Reform, a Coroner is independent in his or her function. The Coroner acts on behalf of the State in the public interest. Although the office has important medical functions, it is a legal office.

The public policy underlining a Coroner’s inquest into deaths was identified in November, 1999 by the Irish Supreme Court in the case of Dublin City Coroner v The Attorney General. In its judgement the Supreme Court said that “few” would dispute the need to have a public inquiry by a person with appropriate legal or medical qualifications into the death of a person as a result of violence or in circumstances that render such an investigation appropriate.

In the case, the Supreme Court also enunciated a number of public interest duties of the coroner:

  • to determine the medical cause of death;
  • to allay rumour or suspicion;
  • to draw attention to the existence of circumstances which, if un-remedied, might lead to further deaths;
  • to advance medical knowledge;
  • to preserve the legal interests of the deceased person’s family, heirs or other interested parties.

The Coroner’s Inquiry

All sudden, unexplained, violent and unnatural deaths must by law be reported to a Coroner. No doctor may certify a death which is due directly or indirectly to any unnatural cause. The Coroner’s inquiry is concerned with establishing Whether or not the death was due to natural or unnatural causes.

If death is due to unnatural causes then an inquest must be held by law. There is a legal duty placed on a registered medical practitioner, amongst others, to report such deaths to the Coroner. The death may, however, be reported to a member of the Gárda Síochána not below the rank of sergeant, who will then notify the Coroner.

At common law, any person may notify the Coroner of the circumstances of a particular death.

Reportable Deaths

The general rule is that any death which is due directly or indirectly to any unnatural cause must be reported to the Coroner. It is recommended that if a doctor has any doubt in the matter, he or she should telephone the District Coroner.

The fact that a death is reported to the Coroner, or that the doctor wishes to seek the advice of a 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 should normally be reported at a reasonable time, usually before 11p.m. or after 8a.m.


A doctor must attend the inquest if requested to do so by the Coroner. In normal circumstances, a formal Witness Summons will not be issued. A doctor will usually inform his or her consultant about the request to attend.

Before the inquest, witnesses are asked to submit a written statement. This statement should contain a full factual account, in chronological order, of the doctor’s personal attendance on the deceased. The purpose of this statement is to assist the Coroner in preparing for the inquest.

A doctor will bring a copy of the medical report to the inquest, together with any relevant notes of other material that he may wish to refer to. The original medical chart will be in evidence at the inquest and will be available for consultation by doctors attending the inquiry or by lawyers acting on the doctor’s behalf.

Inquest With or Without a Jury

The inquest will be held before the Coroner with or without a jury. A jury is required to be empanelled at the inquest in certain circumstances which are laid down by law. These include where death was due to homicide, or occurred in prison, or resulted from an accident at work, or as a result of a road traffic accident. A jury is also necessary if a death occurred in circumstances, the continuance or possible recurrence of which might be prejudicial to the health or safety of the public or any section of the public.

Giving Evidence

During the course of the inquest, the doctor will give evidence on oath or affirmation. The Coroner will hear the medical report, and then take the doctor through the factual statement and ask questions designed to clarify any matter. The doctor should endeavour to explain terminology, particularly if a jury is present, and try to avoid matters of hearsay.

When the Coroner has concluded his examination, any properly interested person, or a lawyer acting on their behalf, may examine the witness. It is important for doctors to understand that an inquest is not a trial. It is a fact-finding inquiry. Questions of civil or criminal liability cannot be considered or investigated at the inquest and no person can be exonerated.

Attendance by Doctors at Inquest

A doctor attends an inquest as a medical witness to give evidence of facts within his knowledge in relation to his attendance on the deceased patient. While the doctor may be examined in some detail in relation to his medical report, no allegation of negligence can be considered at a coroner’s inquest. However, the Coroner must allow legal representatives on behalf of the family and hospital to examine the doctor with a view to clearly establishing the facts. Any question which directly or indirectly impugns the competence of the doctor will be disallowed by the Coroner.

The fact that the circumstances concerning the death are clearly established at an inquest will be beneficial to all concerned and in many cases the relatives of the deceased are satisfied. In other cases a civil action may follow, but the relevant issues will have been properly clarified.


The current staff level for the Coroner’s Court and City Mortuary is fourteen (2014).