Death Investigation, Coroners’ Inquests and the Rights of the Bereaved: A RESEARCH REPORT FOR THE IRISH COUNCIL FOR CIVIL LIBERTIES

Coroners are appointed by local authorities and are qualified lawyers or medical practitioners. In Ireland, they are overwhelmingly part-time appointments. Their main role is the investigation of sudden, unnatural, violent or unexplained deaths. They determine the identity of the deceased, when and where they died, and without establishing liability for the death, ‘how’ they died. Should the cause of death be unknown, sudden, unnatural, or in violent circumstances, the coroner will hold a post-mortem and decide on the appropriateness of holding
an inquest. As discussed later, there are certain circumstances, such as deaths in prison, when inquests are mandatory. Inquests hear evidence from witnesses
called by the coroner including those giving ‘expert’ opinion. The coroner calls and examines evidence, invites further examination from lawyers representing
those given ‘interested party’ status, summarises the evidence, directs the jury on points of law, offers the jury a choice of short-form verdicts in line with the evidence heard and invites their comments and recommendations. In 2000 a full and comprehensive review of Ireland’s Coroner Service was published following informed, detailed research by a Working Group on behalf of the then Department of Justice, Equality and Law Reform. It was unequivocal in recommending ‘radical reform and a major reconfiguration of the coroner service’. It noted that full realisation of its detailed proposals would be an evolutionary process but laid the ground for a ‘clear strategy for change’, expecting its longer term objectives to be achieved in full by
2020. This research demonstrates that legal and procedural reform has fallen well short of that desired objective. There remains: no coherent national organisation of coroners working collectively under centralised direction; Gardaí continue to work as coroners’ officers; the system of selecting coroners’ juries remains inconsistent and in some Districts it is inappropriate that members of the local community are appointed repeatedly; there is a lack of centralised training for coroners appointed by local authorities; governance of the coronial system remains unclear; there has been minimal reorganisation of Districts and the bulk of coronial work is carried out by part-time coroners who are dependent on limited administration staff and Gardaí investigators. The research findings detailed in this Report demonstrate that the Public Sector Duty, introduced under the Irish Human Rights and Equality Commission Act 2014, regarding the operation of the coronial process, necessary legal reform, institutional
accountability and cultural change, has not been met. As a consequence, the rights of families and their loved ones continue to be compromised. Inevitably,
this has a lasting, damaging impact on families already suffering bereavement