The Dublin City Coroner's job is to deal with all sudden deaths, find out what happened and put it on public record, writes JOANNE HUNT
" Show me the manner in which a nation cares for its dead, and I will measure with mathematical exactness the tender mercies of its peoples . . . "
– William Gladstone
DR BRIAN Farrell is not a man you want to meet in his job. Doing so probably means you have lost a loved one in a sudden, unexpected, unnatural or violent death. After 20 years investigating such deaths for the State, the Dublin City Coroner is all too aware that the families he meets would rather be anywhere else.
As the capital’s coroner, all sudden deaths in the district must be reported to him. Last year, they numbered 2,800.
“It can be a death that occurred in hospital, at home, the workplace, a drugs-related death, a suicide, a road traffic accident, a homicide – it’s the gamut of all sudden and unnatural deaths,” he explains.
Farrell’s job is to find out what happened and put it on public record. “We establish the identity of the deceased and when, where and how death occurred,” he says.
“Of course, a family will be anxious before coming to the coroner’s court, but our approach is to try to put them at their ease as much as we can.”
Of all deaths reported to him, Farrell says that thorough inquiries made of gardaí, the person’s GP or family will result in a doctor’s medical certificate being accepted in about half of cases. The other half, about 1,400, will go for autopsy.
“It’s a high autopsy rate, but I think it reflects the city’s demographic – an urban environment with a lot of hospitals and a lot of drug-related issues,” says the former pathologist and barrister.
Where autopsy reveals a natural death, as happens in two-thirds of cases, the coroner will certify the death and a death certificate is issued.
Of the remaining third, families and loved ones will find themselves in the coroner’s court for an inquest or public hearing into the death.
Usually occurring months afterwards, raw grief may have been replaced by the desire for information. Though perhaps dreaded, hearing for the first time from the person who found the body, observations from the scene, the exact location or position of the body are details that can bring a valued understanding of a loved one’s final moments.
“This is their day in court,” says Farrell. “We encourage them to ask questions and get as much information as they can.”
So who attends the hearing? Typically it is the coroner and a member of his staff, along with the deceased’s family, the investigating garda and any witnesses to the death.
In deaths such as a homicide, a traffic accident or if the death occurred in prison, a jury may attend. “In these cases, the jury are the finders of fact . . . I give them the law, the witnesses give them the evidence, but they find the verdict,” says Farrell.
“We take families through it sequentially,” says Farrell. “The person who found the body, the last person to see them alive, witnesses who may be able to contribute further evidence, the garda who investigated the death, the pathologist who did the autopsy and any other relevant groups.
“Many families will have written to us beforehand so we’ll know what issues are troubling them – they may have concerns about what happened in the hospital or nursing home, or how the person was treated in custody – so we may have an idea of their queries before we go in.”
A hearing can, of course, reveal information the family wasn’t expecting.
“It happens frequently,” says Farrell. “They will certainly hear more about the incident that caused the death – underlying illnesses the person may have suffered from, drugs or alcohol that may have been involved, how the road traffic accident occurred, that sort of thing.”
But the satisfaction of the family with the inquest procedure is paramount for him. “If the family has questions that we can’t answer and the issues are serious and are really troubling them, we will always offer them the opportunity of an adjournment.
“What I say to the family is, ‘I don’t want you to go away feeling your questions weren’t addressed’.”
One thing the coroner’s court cannot do, however, is apportion blame. For a family looking for justice, this can be frustrating.
“Questions of civil or criminal liability cannot be considered or investigated by us,” says Farrell. “We’re investigating the facts of what happened without any blame – it may be that the facts are redolent of blame but we don’t adjudicate on that, that’s for another forum,” he says.
But while the coroner’s court isn’t about culpability, a verdict on the cause of death is given. Of the possible verdicts of accidental death, misadventure, suicide, natural causes, unlawful killing and an open verdict, it’s the difference between “accident” and “misadventure” that can cause confusion.
“If someone slips and falls into the canal on a frosty night, that might be called an accident,” says Farrell. “But if that person was intoxicated with drugs or alcohol, then there are risk factors that can take it out of the realm of a simple accident.
“A misadventure takes account of external risk factors. It is the unintended result of an intended action.”
An “open verdict”, Farrell says, is when the evidence doesn’t clearly point to the cause of death. “If you can’t establish the cause, you have to leave it open.”
An important function of the coroner’s court is to make recommendations. Farrell says examples include warnings on the configuration of a junction in a road accident, the blind spot of high-sided vehicles affecting cyclists and pedestrians or the circulation of lignocaine-cut cocaine. “Families find it important that lessons are learned so that something positive comes out to benefit the community,” he says.
One area in which coroners have worked closely with victims’ groups is where the death is a criminal matter – for example, if the deceased has been assaulted, stabbed or shot.
“One of families’ main complaints when I was appointed years ago was that where a criminal trial was pending, they couldn’t get a death certificate,” says Farrell.
“So now we open the inquest to confirm the identity of the person and the cause of death only.” The inquest is then adjourned and concluded after the criminal trial.
“This type of inquest provides a death certificate for the family, as the criminal investigation into the death might go on for months or years and then if there’s a criminal trial, it may go on for longer still.
“Victim support groups such as AdVIC have said they want to hear from the coroner . . . for example, where a guilty plea is made, maybe not a lot of evidence will have been heard in the criminal court, so increasingly families want an inquest so that the information can be heard.”
While Farrell deals with hundreds of deaths every year, anyone who has attended his court knows each case is given time.
“It’s important that the State does this well,” says Farrell, echoing the words of Gladstone that appear on the city coroner’s website. “We’re always trying to improve services for bereaved families.
“We try to offer condolence, I think that’s important,” he says. “Words of compassion and solace from the coroner seem to be important to the family, they seem to appreciate it and we wouldn’t dream of not doing it.”
THE INQUEST: Joan Deane, co-founder of AdVIC
I lost my son Russell eight years ago in a homicide. He was 28.
The inquest was about five months after the death. We were notified about a month beforehand that there would be a preliminary inquest, but that it would be opened and closed as a formality because a trial was pending.
Legally, we didn't need to be there, but of course when a loved one is murdered, you are deeply involved and, on a personal level, you absolutely need to be there.
My husband, my son and the superintendent who was liaising with us and some of the detectives came with us. They were extremely supportive.
Even just walking into the coroner's court is a totally new experience. It's very frightening because although you're not on trial in any way, it's just daunting for most families.
It was a bit of a shock to hear extremely detailed medical evidence at that inquest. We weren't prepared for it. You know what's happened, but the level of detail to do with injury – it was the first time we were hearing it. It was pretty shocking and very traumatic.
I'm not sure what difference it would have made to know in advance, except that psychologically you might have been prepared.
Having said that, the coroner was extremely sympathetic and compassionate in every way.
AdVIC's advice to families is to contact the coroner in advance of the hearing, maybe with the help of your liaison garda, to find out the exact date. Prior notice is important because you do need to prepare yourself.
You can ask to meet someone from the coroner's office to explain what's going to happen and why it has to happen.
It's also important for families to understand the limitations of the coroner's court – some people expect to get answers on the "why" and the "who" – but all the coroner has to do is establish that a death took place and the cause of death.
Ideally, AdVIC would like there to be a State-appointed family liaison office who would deal directly with families throughout the process.
