Galway West Coroner Ciaran McLoughlin made his comments after hearing evidence surrounding the death of a 65-year old man in Galway.
Timothy Joyce, of 120 Corrib Park, Galway, died on May 7, 2001, after 29 days of intensive care in Galway University Hospital.
Mr Joyce’s body was released to his family for burial, despite the fact that he had suffered head injuries in a fall, which resulted in no autopsy being conducted.
“One problem I have around the result of Mr Joyce’s death is that it was not reported to me at the time and as a result no investigation took place and no post-mortem took place,” said Dr McLoughlin.
“Once reported to me that death was caused by a trauma, there is an obligation on me to investigate.”
And the coroner warned that medical staff who are found not to have followed the correct procedures in reporting deaths could be subject to criminal investigations.
“It seems that some processes of informing the coroner may not have been followed by medial staff in the hospital.
“Failure to do this can result in a criminal charge.
He said it was “important that all doctors are aware when it is mandatory to report a death to the coroner” so a situation similar to what happened in Mr Joyce’s case “could be avoided”.
“It is up to the hospital. We have a lot of doctors trained outside of Ireland and the laws relating to the reporting of deaths can be different to in Ireland.
“Consultants must take responsibility for junior staff not fully aware of the law in this country.
“The responsibility should be taken from them and given to the consultants.”
The inquest heard evidence from Dr Vinod Sudhir, an anaesthesiologist who treated Mr Joyce at the hospital, staff nurse Bernadette Phillips, who was responsible for the direct care of Mr Joyce, and Dr Shaun O’Keeffe, a consultant geriatrician who had no direct contact with Mr Joyce.
Dr O’Keeffe was called to explain the protocols surrounding do not resuscitate (DNR) orders at the hospital as Mr Joyce’s family had earlier voiced the view that they had not given the DNR order for their brother.
The coroner accepted the evidence of Dr Sudhir and Ms Phillips that a sister of the deceased had indeed agreed to the DNR order.
He returned a cause of death in agreement with the medial evidence, which he said was “not the best evidence available”.
He said the “gold standard evidence” of a consultant pathologist should have been available.
It was concluded that Mr Joyce died as a result of respiratory sepsis due to subarachnoid and subdural haemorrhage due to an accidental fall.