Home > Data collection and recording of deaths that lead to a coroner’s inquests.

Lyons, Suzi and Walsh, Simone (2008) Data collection and recording of deaths that lead to a coroner’s inquests. Drugnet Ireland, Issue 25, Spring 2008, p. 23.

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The Central Statistics Office (CSO) is responsible for classifying the cause of all deaths in Ireland. In 1968 a statistical return (Form 104) was introduced ‘to supplement the information on the Coroner’s Certificate for the better statistical classification of cause of death’. The form was expanded in 1998 to facilitate a more detailed recording of the circumstances surrounding unexpected deaths, and now contains a number of mandatory fields: socio-demographic information, medical history, psychosocial factors, circumstances of death and contributing factors.

Deaths that lead to a coroner’s inquest generally involve a chain of notifications and information transfers. The Garda Síochána are bound to report to the coroner any death that is unexpected, the result of an accident or suicide, or occurs in suspicious circumstances. Following an inquest, the coroner’s certificate recording the verdict is forwarded to the Registrar of Births, Deaths and Marriages. The Registrar records the death on a death registration form (Form 102) and sends this form and the coroner’s certificate to the CSO. The CSO uses this information to partially complete Form 104, which is then sent to the notifying Garda. The Garda completes the form, including a statement of his/her opinion as to whether the death was accidental, suicidal, homicidal or undetermined, and returns it to the CSO. Staff at the CSO determine the classification of the cause of death using the coroner’s certificate, the death registration form (Form 102) and the statistical return (Form 104).

A report by the National Suicide Research Foundation presents the results of a study analysing data routinely collected in 2002 by means of Form 104.1 A specific objective was to evaluate the usefulness of this form for collecting routine data on deaths, particularly suicides, that led to an inquest.

In 2002, 1,815 deaths required an inquest, of which 6% were not registered on time and were not included in the official statistics for that year, resulting in an underestimation of the number and causes of death. Almost half (48%) of the inquests took place within six months of death. Fifteen per cent were performed more than a year after death, of which 9%–15% were in provinces outside Dublin, and 27% were within Dublin. Over a quarter (26.5%) of inquests in which the cause of death was undetermined took place more than 12 months after death, compared to 8% of inquests that resulted in a verdict of suicide.

A Form 104 was completed for 1,718 (95%) of all the deaths in 2002 that led to an inquest. These forms had a high level of completeness for socio-demographic information (75% and above) but low levels for medical history and contributing factors (35% and below). In 88% of cases, Garda opinion as to the cause of death (as recorded on Form 104) agreed with that of the CSO.

The majority of unreturned forms related to deaths registered in Dublin. This may have led to inaccurate recording of the external causes of deaths in the area. Furthermore, the authors suggest that cases of suicide in Dublin were commonly misclassified as being of ‘undetermined intent’, which may partially explain the lower suicide rate found in Dublin compared to other areas of the country.

The most important findings were:

  • The highest suicide rates occurred on Mondays, and in the months of April, May and June.
  • The suicide rate for men (20.5 per 100,000) was higher then that for women (5.1).2
  • The suicide rate for unemployed men (88.8 per 100,000) was higher than that for employed men (23.9). 
  •  In general, a higher proportion of male deaths than female deaths were alcohol dependent.
  • Fifteen per cent of suicide deaths were alcohol dependent, compared to one-fifth of deaths by accident, homicide or undetermined cause.
  • One-third of undetermined deaths were drug dependent, compared to 13% of accidental deaths.
  • Of the homicide deaths, one-quarter of the men were drug dependent, compared to none of the women.
  • Of the suicide deaths, 34% of women were drug dependent, compared to 16% of men, and a higher percentage of women than men were dependent on prescription medication.
Although Form 104 has increased the range of information that can be collected at the time of death, it has some limitations, notably in that it does not have a ‘natural death’ option. This has resulted in submission by Garda members of incomplete forms or separate additional handwritten explanations. During the study period, all records were paper-based and liable to contain transcribing errors, which added to the inconsistencies in the data collected. However, the information is now recorded electronically, which the authors state should lead to a decrease in data-entry errors.
The authors make a number of recommendations:
  • A new system should be developed to record medical and psycho-social information on deaths that lead to an inquest.
  • Form 104 should be improved where possible but remain in use until a suitable alternative is developed.
  • A clear written protocol should be provided to the gardaí nationally, to standardise information recorded on Form 104, especially for classification of suicides.
  • Unnecessary delays in holding inquests should be identified and improvements made where necessary to reduce distress for the bereaved family and improve the timeliness of routine mortality statistics. (Suzi Lyons and Simone Walsh)
1. National Suicide Research Foundation (2007) Inquested deaths in Ireland: a study of routine data and recording procedures. Cork: National Suicide Research Foundation.
2. Based on population data from the 2002 National Census.
Item Type
Publication Type
Irish-related, Open Access, Article
Drug Type
All substances
Issue Title
Issue 25, Spring 2008
Page Range
p. 23
Health Research Board
Issue 25, Spring 2008
Accession Number
HRB (Available)

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