Hard-hitting report scathing about need to reform Coroners’ Courts system

System ‘decreasingly fit for purpose’ and creating ‘human rights violations’, says study

The Coroner’s Court in Dublin. An inquest must be held to investigate any sudden, unnatural, violent or unexplained death, to determine the identity of the deceased, when and where they died, and, without apportioning liability, how they died. Photograph: Dara Mac Dónaill

The Coroner’s Court in Dublin. An inquest must be held to investigate any sudden, unnatural, violent or unexplained death, to determine the identity of the deceased, when and where they died, and, without apportioning liability, how they died. Photograph: Dara Mac Dónaill

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The failure of successive governments to reform the “decreasingly fit for purpose” Coroners’ Courts system is creating “ongoing human rights violations” for bereaved families, according to a report published on Wednesday.

The hard-hitting study, Death Investigation, Coroners’ Inquests and the Rights of the Bereaved, published by Irish Council for Civil Liberties, says “unacceptable delays” in holding inquests, lack of legal representation for families, lack of compassion, concerns about partiality of coroners and their sometimes too close relationship with the medical-legal establishment, meant “the rights of families and their loved ones continue to be compromised.

“Inevitably, this has a lasting, damaging impact on families already suffering bereavement,” it warns.

It comes 21 years after a Department of Justice review of the coronial service and the efficacy of the 1962 Coroner’s Act recommended a full overhaul of its functioning, funding and status to meet the needs of an increasingly complex society.

Since then, says this report, despite an abandoned Coroner’s Bill in 2007 and limited amendments to the 1962 Act in 2019 legislation, fundamental problems remain.

These include that gardaí continue to work as coroners’ officers; inconsistencies in jury selection and in some areas repeated appointment of members of the local community, and unclear governance of the coronial system. It says most coroners are part-time and under-resourced, with no training for local authority-appointed coroners, and it cites a dependence on gardaí to gather documents and evidence.

The authors of the report, Prof Emeritus Phil Scraton of the school of law, Queen’s University Belfast and Dr Gillian McNaull, of the school of social sciences at the same college, found families felt cast adrift, exposed, angry and frustrated after attending inquests from which they had felt “marginalised”.

Unexplained death

An inquest must be held to investigate any sudden, unnatural, violent or unexplained death, to determine the identity of the deceased, when and where they died, and, without apportioning liability, how they died.

While families are told the sole purpose is to establish the “truth”, when “powerful institutional interests are at stake” the process will inevitably become “adversarial”, say the authors.

And though State bodies or private companies will have full legal representation, legal aid for families is generally only available in cases of deaths in State custody.

“ ‘Equality of arms’ – the principle that all sides to a legal dispute should be equally resourced – should be considered fundamental in holding inquests that examine thoroughly all avenues regarding how a person died,” the report says.

Most families arriving at inquests, “felt . . . ‘cast adrift’, with no formal liaison person allocated to them. ‘There is no-one to tell you about the process. No-one spoke to us on the day’,” said one.

‘Grieving process’

“Delays in holding inquests remain unacceptable,” the report continues, with some families waiting up to 11 years, “creating uncertainty and extending the grieving process indefinitely.”

The relationship between coroners and gardaí “is a matter of concern, particularly when an investigation involves the behaviour of gardaí and/or others in State institutions.

“The centrality of their investigative role in gathering and presenting evidence, liaising with families, and servicing inquests, created further doubts regarding coronial independence.”

Concerns raised included the perceived closeness of some coroners to the local medical-legal establishment; families being refused access to inquest documents; coroners’ failure to call witnesses or explore issues seen as crucial by families, and, inadequacy of verdicts available. One family called for “medical negligence” to be a possibly verdict.

Another was scathing: “We were expecting some level of justice, truth, and what we got instead was a whitewash, controlled by the coroner. It seemed like a circle of close friends.”

Among the report’s 52 wide-ranging recommendations are that legal aid be provided to all families at inquests requesting it; a chief coroner be appointed to oversee the national service; the 39 coroner districts be rationalised into a region-based agency reflecting population and case numbers, and, that a charter for the bereaved be drawn up setting out bereaved families’ rights.

In 2019, of the 31,134 deaths registered in Ireland 2,225 were notified to coroners, says the report.