With untrained coroners, inconsistent rulings and an inability to answer bereaved families' questions, coroner's courts urgently need reform, writes Ruadhán Mac Cormaic
'Show me the manner in which a nation cares for its dead, and I will measure with mathematical exactness the tender mercies of its people, their loyalty to high ideals and their regard for the laws of the land." Death may be a private event, but its aftermath, as the 19th-century British prime minister William Gladstone held, can reveal public truths. Last month an inquest was held into the death of a man who died after being hit by a car. In the sparsely filled public gallery sat five members of the victim's family; in the middle, the slight frame of his widow, her children at either side and a daughter's arm entwined in hers.
The inquest played out to a familiar rhythm, the coroner unfurling the evidence, questioning witnesses, poring over sketches and photographs, and taking each natural break to involve the jury and the bereaved.
On this particular day, the family members nodded politely as the coroner asked them if they had any questions, waving away each prompting with a quiet gesture to the bench. After a while, one of the reporters rested his pen on the table.
The jury members, too, had made their minds up early, and one or two started shifting in their seats. We moved briskly from witness to witness, until, suddenly, a voice was raised.
"Hold on," says the victim's son, standing in his place. "What speed was the car travelling at? Why do we not know the point of impact? . . . Look at the photograph. There's an L-plate on the car; was the driver qualified? I'd like these questions answered."
The jury turns back to the coroner.
"We can try to estimate the car's speed," she says, "but, as for your queries, I'm afraid they lie outside the remit of the inquest."
"But why did the garda not take measurements of the scene before leaving? Why are the ones he has so imprecise? Was the garda experienced?"
This time, the coroner interjects.
"I'm sorry, but I don't think I can bring it any further," she says. The victim's son sits down again, shaking his head.
The scenario is a fairly common one. In difficult circumstances, and with skill and sensitivity, the coroner had pushed the inquest to its legal boundary, beyond which she could go no further. Witnesses hadn't shown up, but they were unlikely to be pursued, and the inquest was hurried because some of the unpaid jury members assembled by the gardaí had let it be known that they had to return to work by lunchtime. And in the end, the bereaved found their expectations foiled, asking questions to which the State could give them no answers.
Over the past month, while working on a series of articles on road deaths for The Irish Times, I attended some 18 inquests at coroner's courts around the State. Violent death is one of society's enduring taboos, but in the coroner's court it is rendered banal by the unending procession of tragic cases that are handled there each month.
Among those whose inquests I covered were men, women and children, the youngest aged 17 and the oldest 88. They were pedestrians, cyclists, drivers and passengers, each taken in apparently arbitrary settings; on country lanes and urban carriageways and on the paths they walked to work.
The coroner's court - an institution about which most of us know little - is ostensibly a bureaucratic arm of State whose brief, inquisitorial rather than adversarial, is to establish the "who, when, where and how" of any death that is unexpected, unnatural, violent or unexplained. But the court is also a public service for the living, and has a social function of deeper significance to the bereaved - as the last forum in which they can publicly mourn their loss, replay a loved one's final hours, ask questions of experts and witnesses, and, if possible, find some peace of mind.
IT HAS BEEN known for decades that the State's coroner service is in urgent need of radical reform. Such are its anachronisms, in fact, that Gladstone himself would have been broadly familiar with how it works in 2006; it is organised and run much as it was in 1846.
Today, the State is divided into 48 coroner districts, ranging from those that cover small areas (Co Donegal, because it was difficult to traverse in 1846, has four) to busier ones with responsibility for handling huge population centres (there are only two for Dublin city and county).
Each coroner is a part-time State official who is either a lawyer or a doctor and is - in theory, at least - appointed by local authorities which are responsible for advertising the position. However, at present about 50 per cent of all coroners are nominally "acting coroners", an elusive category which means they were simply approached by a local authority and asked to take the job. Coroners receive no training and they are supplied with no guidelines save for the legislation under which they function.
One acting coroner, who has held that position for more than 10 years, recalls being asked to take the post as if it was a job in a local shop. "I was asked, out of the blue, to be coroner at 3.40pm one day, and I was appointed at 4pm. I was asked was I familiar with the Coroners Act 1962. I had read it, so now I'm an acting coroner. There's no training, so the only way I could train myself was to go up to Dublin, sit at the back of Dublin Coroner's Court for the entire day, take notes and work out how to hold a proper inquest. It's bizarre. There is no training at all."
Without guidelines and without rules, the interpretation of procedure rests on the personal preferences of individual coroners. Over the past month, I could often predict how long an inquest would take simply by noting the district in which it was being held. In one, the average duration of a single- fatality, two-car collision inquest, with no more than two witnesses and three gardaí, was about two hours. The depositions would be read into the record, witnesses and gardaí would be questioned in detail, the jury and the bereaved would be invited to speak, and, finally, the evidence would be summarised and the jury asked to return a verdict.
In another district, the same inquest would take no more than 15 minutes. Some (often not all) depositions would be hastily read into the record, no questions would be put, and the jury would be asked to return a verdict.
"The coroners have been paddling in a backwater for quite a long time," says Louth county coroner Ronan Maguire. "There are no rules, no directions as to how a coroner should run an inquest. The only criterion is that if he takes depositions, he keeps a copy of them, or else that he takes a note of the name and address of witnesses."
The analytical value of a 15-minute inquest is negligible, Maguire agrees. The coroners have no connection to the Courts Service, and thus have no access to official jury lists. As a result, juries are usually compiled by gardaí, and often the same juror - a retiree, perhaps - will attend every inquest in a given district every month.
Invariably, problems arise. Minutes before one hearing last month, the coroner reported that the court was one juror short of the six required by law. Before a bemused public gallery, one juror volunteered to make a call on her mobile phone to try to fill the missing chair. While she was on the phone, I was approached by another juror. "Can you report on this and sit on the jury as well," he asked.
The jury's nominal task is to evaluate the evidence and return a verdict by which each death is to be categorised (accidental, misadventure, suicide, and so on). Here as elsewhere, theory diverges from practice, and patterns are few. In some districts, a misadventure verdict (defined as the unintentional consequence of an intentional action) is relatively common in road death cases, notably when a driver was clearly over the legal alcohol limit. But in one court the coroner there instructs juries to return accidental verdicts in nearly all road crashcases.
Elsewhere, verdicts are not returned at all. In more than one district, the coroner instructs juries to return "a verdict in accordance with the medical evidence" - not a verdict as such, but a simple expression of satisfaction with the medical report provided by the pathologist.
WITH NO REASON to challenge the pathologist's report, the jury of lay people is invariably satisfied every time. But why are juries - or witnesses, for that matter - required at all if their only purpose is to defer to the pathologist's report?
RECENT CASE LAW, too, has deepened the confusion. "In 1993, the Supreme Court initially said that an inquest was to establish who, where, when and how a person died," says Maguire. "The first three are self-explanatory, but the fourth one is the nub of the inquest. The Supreme Court said that this is a medical question; it is to be construed in terms of medical evidence, usually by a consultant pathologist."
But viewing the inquest as a rubber-stamping ritual is problematic, for two reasons. First, to say that a man died of head injuries tells a pathologist everything but it tells society nothing, and the spirit of the coroner's court, with its witness statements and recommendations, clearly implies an instructive role: that inquests should educate us in order to prevent similar deaths occurring. Second, it strips the inquest of any role in helping the bereaved at the most difficult of times.
More recent judgments agreed: in Eastern Health Board v Dublin city coroner in 2001, the Supreme Court found the earlier ruling to have been too narrow an interpretation. It stated that coroners can look fully into the circumstances of each death.
But does it matter that the system is anachronistic and muddled? Is it fair that the right to learn the facts of a loved one's tragic death operates by degree, available in some districts but not in others? Lack of consistency also means that an excellent source of State-wide data on, say, road deaths or suicides, is effectively beyond reach.
The push to reform has been led by coroners themselves. In 2000, an expert working group carried out a comprehensive review of the service and published a report offering some 110 recommendations for its thorough reformation. Only a small number of these have been acted on in the intervening five years, and coroners themselves have been forced to introduce "best practice" guidelines at their own initiative.
The report proposed a new centralised Coroner Service to be set up under the single aegis of the Department of Justice (currently, responsibility is divided among three departments).
This would oversee between 25 and 30 districts (instead of 48 today) and end the involvement of local authorities. Among its findings, the report noted "a lack of consistent criteria for reaching verdicts", widely varying procedures from district to district, a failure to provide adequate information to relatives, delays in receiving postmortem results, difficulties in compelling witnesses and jurors to attend and a general lack of training and specialisation.
There are signs of movement, however. Recent changes to the law have allowed for more than two medical experts to give evidence at an inquest, while the fine for witnesses who fail to attend has increased from €7.80 to €3,000. Minister for Justice Michael McDowell has long agreed that the 1962 legislation is obsolete, and recently secured Cabinet approval for an overhaul of the system. He plans to publish a Bill this year which will incorporate many of the report's suggestions, beginning with the establishment of a new agency - the Coroner Service - based in Navan.
"It's very important to get it right," says Prof Denis Cusack, the Kildare county coroner and one of the report's authors. "Despite all its defects, the coroner system can be a very good one, which can investigate classes of deaths that otherwise wouldn't be inquired into . . . The coroner's court can make a difference."
In an article in the Medico-Legal Journal of Ireland in 2000, former attorney general Harry Whelehan said that violent death, in its infrequency, would once have held the public engrossed for weeks and months, but that now it felt like just another symptom of modern life, and one for which we have developed a more complex - if no less sensitive - appreciation. Society's engagement with public death and the bereaved has evolved, in other words, while the State's has stood still. A reformed coroner service would reorient and redress; so that the State, too, could aspire to the tender mercies that its people expect.