You can tell a lot about a society by how it treats its dead. You can tell even more by how it treats the bereaved. The coroner service, which investigates sudden or unexplained deaths, is therefore one of the most important the State provides.
Yet it is also one of the most neglected, ill-equipped and poorly-resourced. Operating in a 19th century structure largely overseen by local authorities, coroners are doctors or lawyers who are in the main appointed to these positions through an opaque system. They are paid per death and most serve part-time.
A well-run inquest, balancing legal formality with compassion, can restore the dignity to the dead, comfort the bereaved and even save lives through the production of useful recommendations. A badly-run inquest can compound a family’s grief and leave vital questions unanswered. Practices vary dramatically across the country, with delays common and some inquests taking place in civic offices, hotels or even theatres. Jury members in some districts are recruited on the street by gardaí; in some places the same jurors show up every month. It is not clear what happens to recommendations once they are made.
In the absence of consistency or communication, there is confusion over the purpose of the inquest. At times lawyers seem not to grasp that the process is inquisitorial, not adversarial and that, unlike in the courts, the aim is to understand what happened rather than to apportion blame.
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Coroners and others have been calling for an overhaul of this system for decades. A Department of Justice-commissioned review in 2000 recommended how that could be done. But while useful legislative changes have been made in the intervening 22 years, successive governments have skirted the fundamental issues around the structure and funding of the service. That failure was the focus of an illuminating hearing of the Oireachtas justice committee last week.
The State urgently needs a national Coroner Service agency that would standardise procedures, centralise information and ensure consistency. A Chief Coroner should lead this professionalised service, and all coroners should be appointed transparently. They need proper training, their service needs to be independent of An Garda Síochána and juries, if they are needed, should be representative of the community. Recommendations ought to have some force.
Depriving the coronial system of proper funding is a false economy; one of the reasons so many people go to court after a death in contested circumstances is simply to get answers that they cannot obtain elsewhere. But the moral case is more important than the monetary one. To maintain a system that is clearly not fit for purpose amounts to a failure by the State to provide one of the most basic services citizens have a right to expect.