Coroner’s court a cold place for families of bereaved

New Bill only goes part of way to reform Ireland’s inadequate investigation of deaths

This week the Coroners (Amendment) Bill 2018 completed its passage through the Dáíl and now goes to the Seanad. It introduces significant changes to the Irish coronal system yet it will receive minimal public attention.

Given that their focus is on deaths in sudden or controversial circumstances, few people understand the coroner’s role or function. In 2000, the Department of Justice, Equality and Law Reform Working Group report called for fundamental reform, making it clear that inquests prioritise the needs of bereaved families.

Each year, approximately 30,000 people die in Ireland and approximately 2,000 inquests are held. They determine who, when, where and how an individual died, In theory they respond to essential questions raised by grieving families. Did a person take their own life? Or die by natural causes? Did they die quickly, or could their life have been saved with quicker intervention or appropriate medical care? What factors contributed to the death?

Families need the opportunity to ask such questions of those who can provide informed, detailed responses. These are the questions that emphasise the significance of inquests for close relatives and for communities.


Undoubtedly, many working within the system are committed and highly professional, but the neglect of the system can undermine those efforts

Inquests also have a role in preventing future deaths. By understanding how a person died, inquests can make preventative recommendations. For instance, the World Health Organisation reports that 80 per cent of maternal deaths – mothers who die within six weeks of childbirth – are preventable.

Each year a small number of maternal deaths occur in Ireland and, following the passing of this legislation, all will have inquests. As well as providing bereaved families with answers, such public examination of circumstances should enable the prevention of some deaths.

Dignified treatment

The current Bill also introduces mandatory inquests when people die in the detention or custody of the State – in prisons, Garda custody or mental health institutions. These cases raise important issues concerning the State’s duty of care. When a person in care dies, it is imperative to ask questions about State responsibility in its administration of its powers. The proper and dignified treatment of those in the care of the State is a human rights obligation in democratic states.

Clearly, Ireland does not have a strong record regarding these issues. It is a central issue in the institutional policies and practices that prevailed in the Magdalene Laundries and the mother and baby homes. It is now well-established that there was no transparency on nor investigation into the deaths of women and children who died in the care of the State.

This issue extends to the operation of prisons. In April an inquest in Cork found that prison officers failed in their duties to check regularly on a prisoner with psychiatric illness. He took his own life. Officers had recorded they had carried out checks.

A value-for-money audit report published last year revealed that no new coroners had been appointed since 2000

Examination of the files of two-thirds of vulnerable prisoners who have died in Ireland during the last seven years revealed inaccurate or misleading records.

It is therefore a significant advance that Ireland is to make inquests in such cases mandatory. A concern remains, however, that many other operational practices within the system are inadequate and outdated. Coroners are not required to publish reports. This makes it impossible to discern patterns of the problems highlighted by inquests.

The legislation on which they are based was established in 1962, reflecting a different Ireland – one which had very different attitudes towards death. Various reports and studies have detailed extensive problems with the system. Undoubtedly, many working within the system are committed and highly professional, but the neglect of the system can undermine those efforts.

Outdated legislation

The working group report of 2000 demanded “radical reform and a major reconfiguration of the coroner service”. It found the legislation to be outdated, necessary support services unavailable, and the system structured in a way that prevented the delivery of appropriate services. Most coroners are part-time, have no support staff and don’t have a designated place in which inquests can be accommodated appropriately.

An Oireachtas hearing in 2015 was told that the system suffers from informalism and inconsistencies, that the experience of an inquest can vary dramatically dependent on where a person died.

A value-for-money audit report published last year revealed that no new coroners had been appointed since 2000 and that “more coherent organisation of coronial work” is required.

Most worryingly, a study published earlier this year found that “family members [bereaved by suicide] experienced distress and fear as a result of several elements of the inquest process”.

The proposed legislation may bring more grieving families into an inadequate and neglected system that compounds their grieving. While it is an important development, it is only the beginning of a more fully developed conversation on the investigation of deaths in Ireland.

Vicky Conway is a law lecturer at DCU and is conducting research on the coroner’s system for the Irish Council for Civil Liberties with Prof Phil Scraton of Queen’s University Belfast