Coroner’s Court reform needed

An Cailín Rua

TACKLING REFORM Pictured at the launch of their book ‘Medical Inquests’ in the Mount Falcon Hotel, Ballina, were authors and legal professionals Roger Murray, Doireann O’Mahony and David O’Malley, flanked by Vivienne Traynor, RTÉ and Joe Brolly, barrister. Pic: John O’Grady

An Cailín Rua
Anne-Marie Flynn

Knowledge of or familiarity with inquests is mercifully not something this writer has acquired over the years, but attending the launch recently of a new book on the topic was quite an education on one of the one State’s oldest public services.
‘Medical Inquests’, co-authored by three experienced legal professionals – Roger Murray, Doireann O’Mahony and David O’Malley – deals extensively with the topic, outlining some of the issues that exist around practice and procedure at inquests and the Coroner’s Court. Beyond the legalities of the book, presented within its covers are some very human stories of sadness and loss, that highlight how the State urgently needs to act to prevent the experience from further traumatising bereaved families, as well as enabling the system to introduce change that may prevent future tragedies.
An inquest is an official, public enquiry, led by a coroner into the circumstances of a sudden, unexplained or violent death. Sometimes a jury, appointed by the coroner, can be involved. They can make findings on how, where and when the death occurred and what the circumstances were.
The family of the deceased person is entitled to but not legally obliged to attend, and does not need legal representation, though they may sometimes engage a solicitor to attend if legal action is being taken as a result of the death. For families, inquests are seen an opportunity to get answers, or closure. They are meant to be inquisitorial processes, without apportioning liability, aimed at centring the truth. But as the book outlines, they can often in reality be adversarial in nature.
The topic of inquests is unlikely to capture the public imagination, and so awareness among the general public of the problems and deficiencies that exist is probably low. Therefore, it was a surprise to learn that there is set of standard, consistent rules or procedures across the different courts of the coroner in Ireland.
For example, in some cases, a coroner can be a solicitor but in others, a doctor, and they can decide how to run their own proceedings. It was a surprise to learn that there is no obligation on anyone to follow up or implement recommendations made by a coroner at an inquest, which must be incredibly frustrating not only for bereaved families, but for coroners themselves.
It was less surprising to learn that the offices of the Coroner are under-resourced and under-supported – that seems to be how we do things in this country, particularly when it comes to procedures that impact upon vulnerable people.
And least surprising of all was learning that over 200 recommendations for reform were made over two decades ago by the Coroner’s Review Group, with very little done about it since.  
Over the years, there have been small changes. The 2003 European Convention on Human Rights obliged the State to carry out effective death investigations into all deaths caused by the state. In 2007, Michael McDowell, TD, then Minister for Justice, Equality and Law Reform, published the Coroners Bill 2007, announcing the establishment of a Coroner Service Implementation Office and reform of existing legislation and structure. This fell off the agenda during the recession. Some small amendments were made in 2019 to the existing Coroner’s Act 1962, but in 2021 the Irish Council for Civil Liberties released the hard-hitting ‘Left Out in the Cold’, which raised multiple concerns around resourcing, delays, impartiality, jury selection, too-close links between the legal and medical establishments, and a severe lack of compassion for families.
At the heart of it, facing into an inquest with lawyers and medical experts as a bereaved family can be unfamiliar, daunting and traumatic at a time when they are likely still reeling from a loss. There is generally no guidance, briefing or support service available. Most families simply want answers, and they want to ensure that where possible, no other family has to endure the pain of losing a loved one in the same way.
Happily, reform seems to be back on the agenda. The three authors have been invited to address the Oireachtas Justice Committee on reform of the Coroner’s Court this week, and Minister for Justice Helen McEntee, who has been refreshingly pro-active in other areas, appears committed to reform.
And rightly so. The State has a moral and urgent obligation to families to implement reform that prevent further trauma and ensures that their pain and loss of their loved ones is not in vain.