Submission to The Joint Committee on Health and Children
Dr. Myra Cullinane
Coroner Cork County Borough
Vice President of the Coroners Society of Ireland
Thank you for inviting the contribution of Coroners.
In this short submission I will confine myself to the Coronial aspects of suicide
deaths as they pertain to the subject matter of the draft report on suicide prevention of
Committee Rapporteur Senator John Gilroy.
1. The Coroner is a death investigator tasked under statute with investigating all
sudden, unexplained, violent and unnatural deaths. There are 43 Coroners
Districts in the State. Coroners at present are divided almost equally between
doctors and lawyers.
2. All unnatural deaths will be the subject of a Coroner’s investigation and
included in this group are deaths by suicide.
3. The Coronial process begins on the occurrence of a death in which suicide is
suspected. The death is reported to the Coroner either by a member of an
Garda Siochana, a hospital doctor or the director of the premises in which the
event occurred. The Coroner will then direct an autopsy.
4. A member of an Garda Siochána will carry out formal identification of the
remains in the presence of the next of kin and the garda will then attend the
mortuary to identify the remains in turn to the directed pathologist.
5. The Coroner receives the autopsy report and if an unnatural cause of death is
confirmed an inquest hearing must take place.
6. In preparation for the inquest the Coroner gathers evidence to compile a
comprehensive file including, for example, factual eyewitness accounts,
medical and psychiatric evidence, documentary evidence and the report of the
investigating garda. An Garda Siochána investigate each death initially to
exclude criminality and if so excluded they then assist the Coroner acting as
Coroners officers.
7. All gathered evidence is to assist the Coroner in making findings of fact at
inquest and returning a verdict in relation to the manner in which death
occurred.
8. As Coroners we fully recognise the issues in relation to suicide that are raised
in this report, however we are bound by a legal standard of proof before we
can record a vedict of suicide at inquest. This legal standard is ‘beyond
reasonable doubt’.
1
9. Therefore Coroners will record a suicide verdict when they can in
circumstances where the legal standard is reached, ie. ‘the deceased killed
him/herself, he/she intended to do so and the evidence before the Coroner
proves that beyond reasonable doubt’.
10. This is a high legal standard, not always reached, even in cases where the
totality of the circumstances point to suicide on the balance of probabilities. In
such cases where the legal standard has not been reached the appropriate
verdict is the Open Verdict.
11. At the conclusion of the inquest the Coroner in addition to recording of a
verdict will issue a Coroner’s Certificate to the Registrar of Deaths. This
certificate records the medical cause of death and not always the manner in
which death occurred or a verdict.
12. In view of this suicide statistics cannot be fully extracted by confining oneself
to inquests recording the Suicide Verdict. Neither can they be extracted from
the Coroner’s Certificate.
13. Historically there was some difficulty in relation to the recording of the
suicide verdict in that prior to the Criminal Law (Suicide) Act 1993 suicide
was deemed a criminal act and Coroners either did not use the verdict or were
reluctant to do so. This is no longer the case.
14. The use of the Garda Siochána Form 104 was developed and remains in use
providing the Central Statistics Office with further information.
15. Current national suicide statistics as indicated in the report of the Rapporteur
are drawn from a number of sources includng Form 104, the CSO but not the
inquest file itself.
16. Coroners concur with the concerns raised in the draft report in relation to the
reliability of national suicide statistics as currently compiled.
17. Sign Post 1 of the draft report is noted suggesting: ‘a national survey of
Coroners records to establish which deaths might be attributable to suicide
but do not meet the legal standard of proof required at inquest. We will call
this ‘the research standard’.
18. As previously indicated all deaths by suicide are the subject of a Coroner’s
inquest. At the conclusion of the inquest of a death by suicide the coroner
holds a file in relation to their investigation which could provide detailed
information for statistical analysis.
19. Currently the HRB examine Coroners inquest files in every District anually to
compile drug and alcohol associated death statistics and I understand that their
statistics are regarded as amongst the most comprehensive in Europe.
2
20. Coroners support the suggestion at Sign Post 1. Such a survey should be
carried out on an annual basis.
21. We are strongly of the opinion that Coroners hold the best primary
source of statistical and other information from which could be compiled
a comprehensive epidemiological database in relation to deaths by suicide
thus informing the national debate in a more authoratative manner in addition
to assisting in identifying and prioritising areas for intervention and prevention
and measuring the effects of such intervention.
March 2014.
3