The Coroners Investigation in Fatal Road Traffic Collisions - - PowerPoint PPT Presentation

The Coroners Investigation in Fatal Road Traffic Collisions

Medicolegal investigation of sudden, unexplained, violent or unnatural deaths.

Some Indicia of Coroners System.

• Comprehensive death investigation system
• Check on death certification
• Public information on safety matters
• Information in relation to mortality
• Independent investigation
• Public hearing

“ The coroner service is a public service for the living, which, in recognising the core value of each human life, provides a forensic and medico-legal investigation of sudden death having due regard to public safety and health epidemiology issues”

[Review of the Coroner Service 2000]

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.

DR Coroner's Certificate Natural Death DR Coroner's Certificate Inquest Unnatural Death Autopsy Investigation Preliminary investigation DR Medical Certificate Death Reported

Unnatural death

• road traffic collision;
• any accident in the home, workplace, or

elsewhere;

• any physical injury;
• falls and fractures;
• fractures in the elderly;

Unnatural death

• drug overdose or drug abuse;
• neglect, including self-neglect;
• burns or carbon monoxide poisoning;
• starvation (including anorexia nervosa);
• exposure and hypothermia;
• occupational illness/injury;

Unnatural death

• drowning;
• hanging;
• firearm injuries;
• occupational disease;
• all suspicious deaths;
• homicide.

Medical Procedures

• Death directly or indirectly resulting from

any surgical or medical treatment or any procedure

Section 30 CA 1962

• “Questions of civil or criminal liability shall

not be considered or investigated at an inquest….”

Section 30(1) CA 1962

• “Neither the verdict nor any rider to the

verdict at an inquest shall not contain a censure or exoneration of any person.”

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.”

• All Road Traffic Deaths will come to

inquest

• Vehicle Drivers

– Private – Commercial – Rescue Services and Garda

• Cyclists

– Bicycle – Motorcycle (including vehicle competitive races)

• Pedestrians

Preliminary Issues

• Pronouncement of death
• Identification
• Autopsy
• Toxicology
• Medical history

(a) Pronouncement of Death

• Registered medical practitioners
• Presumption of death

– Paramedics – Ambulance crew – Rescue services

(b) Identification

• Body identification to Garda (on behalf of

the Coroner)

(c) Forensic (Medical) Investigation

• Autopsy

– Histopathologist – Forensic pathologist

• Toxicology will include alcohol /

medications / drugs of abuse

• Medical history

Inquest

• Where a death is (or may be) unnatural an

inquest must be held

• An inquest is held with/without a jury

Inquest

• Family should be given a time for the hearing
• Procedure should be explained (including right

to be legally represented)

• Investigation must be thorough and effective
• Inquest should not be unduly intrusive on the

family

• Right to privacy should be respected

Inquest Adjournment

• Inquest opened and adjourned where the Garda

investigation indicates the possibility of a criminal offence

• Where the Garda Ombudsman is investigating

the incident

• On adjournment, evidence of identification and

the cause of death will be given to enable the death to be registered

• Death certificate available to the family

• When Garda (or Ombudsman) investigation

is complete:

– File may go to the DPP – If a criminal charge is to be preferred in relation to the death the inquest will be adjourned sine die [S25CA1962]

• In all other cases the inquest will go into the

list for hearing, awaiting autopsy report, toxicology and Garda file

Garda File

• All witness statements
• PSVI report
• Forensic collision investigator report
• Maps/photographs of scene, CCTV footage

etc.

Inquest preliminary

• Liaise with family/legal representatives
• Interested persons
• Review statements
• Autopsy / toxicology reports
• Select witnesses
• Pre-release of documents

Liaison with Family

• Coroner’s office staff
• Garda family liaison officers
• Garda (acting as coroner’s officers)
• Information booklets
• Website

Jury

S40 CA 1962 : “An inquest shall be held with a jury … if …the coroner becomes of

• pinion...

(d)… “that the death of the deceased was caused by an accident arising out of the use

• f a vehicle in a public place…”

Witnesses

• Identification witnesses
• Persons who saw the incident
• Persons who saw the vehicle/deceased prior to incident
• Persons present at scene
• Rescue services DFB / ambulance / paramedics
• Medical personnel at scene /A&E Dept.
• Medical /nursing staff at hospital
• Garda personnel
• Pathologist
• Driver of vehicle/s

Garda Witnesses

• Identification
• Gardai at scene
• Garda member investigating incident /

Ombudsman

• Senior Garda Officer (if criminal matter)
• PSV Inspectors
• Garda Forensic Collision Investigators

Public Service Vehicle Investigators (PSVI)

• Report on damage to vehicles
• Pre-collision state of vehicle (road

worthiness)

• Photographic evidence

Forensic Collision Investigators

• Scene examination
• Reconstruction of incident
• Specific factors (speed, direction, braking,

configuration of roads junctions etc.)

• Photographs/maps
• Conclusions / causation

Medical evidence

(Advice to family/next of kin)

• Medical reports
• Autopsy/toxicology reports
• Transplant coordinators

Driver

• Driver is always called
• Legal advice

Examination of Witnesses

• Coroner examination of witness
• Family/Legal representatives
• Other interested persons

• Findings and Verdict returned by Jury

(under direction of coroner)

Inquest Findings

• Record of evidence
• Statutory findings
• Verdict
• Rider or recommendation(s)

Verdicts

• Accident
• Misadventure (risk factors)
• In accordance with verdict of a criminal

court

• Unlawful killing
• Suicide/open
• Narrative

Riders/Recommendations

• Must emerge from the evidence
• Relate to safety/health issues
• Address risk factors identified in evidence
• Designed to prevent death occurring in

similar circumstances

• Directed to Government Dept./ City /

County Councils, RSA / vehicle manufacturer etc.

Post-Inquest

• Death registration
• Inquest documents (“Coroner’s Report”) on

public record

• Communication with relevant authority

All relevant facts must be established and exposed to public scrutiny.

Dublin City Coroner Email: coroners@dublincity.ie Website: www.coronerdublincity.ie Coroner’s Service Website: www.coroners.ie