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Dáil Éireann debate -
Tuesday, 13 Dec 2005

Vol. 612 No. 2

Coroners (Amendment) Bill 2005: Second Stage.

I move: "That the Bill be now read a Second Time."

I am introducing this Bill because of particular concerns about a pending inquest but there are far wider implications. I am grateful to the Government, especially the Minister for Justice, Equality and Law Reform, for agreeing to facilitate its speedy passage before Christmas, for reasons with which we are both familiar.

It says something about our sense of priorities that there has been legislation on tribunals on nine occasions since 1921, including four Acts this century, yet the Coroners Act has remained unamended since 1962, despite the fact that we have had less than 30 tribunals in the State's history, while dozens of coroners hold hundreds of inquests throughout the State every year. This fact cannot be seen as evidence that the system is working. On the contrary, the difficulties and inadequacies of the system have been known for years.

The Coroners Act 1962 is acknowledged to be in need of substantial reform. The Minister is on record as saying, "As has long since been acknowledged, the current Irish legislation, the Coroners Act of 1962, is outdated and can no longer be said to equip coroners with the appropriate measures to conduct the best possible death investigation." A working group reported to the Department of Justice, Equality and Law Reform in October 2004 and made more than 100 recommendations. The report has been accepted by the Government and work is ongoing within the Department on a comprehensive replacement statutory code. I understand a draft Bill will be brought to the Government by the Minister very soon and that it will be published early in 2006, if not this year.

The immediate need for legislation turns around the fact that a baby died of brain damage after being admitted to hospital on his second birthday for a routine operation linked to his condition as a haemophiliac. Pierce Nowlan of Saggart was admitted to Our Lady's Hospital for Sick Children in Crumlin last October to have a device fitted into a vein that would have allowed the regular injection into his blood of factor eight, a clotting agent. During the procedure, it seems an artery was inadvertently punctured as surgeons were attempting to access the vein where the device was to be fitted. Pierce bled from a hole in his artery into the left side of his chest. The oxygen flow to his brain was adversely impacted and he died as a result. His parents, Stephen and Jean Nowlan, had been told this procedure was minor and that there was "nothing to worry about".

The Dublin city coroner, Dr. Brian Farrell, held an inquest last July and adjourned it until September to study the complicated evidence that had been heard. He also wanted to consider reports on the matter that had been put before the court and to possibly consult others on the case. He needed such time, he said, in part because of restrictions in the Coroners Act that permitted him to call only two medical witnesses in any one case.

Section 26 of the Act states:

(1) A coroner may, at any time before the conclusion of an inquest held by him, cause a summons in the prescribed form to attend and give evidence at the inquest to be served on any person (including in particular any registered medical practitioner) whose evidence would, in the opinion of the coroner, be of assistance at the inquest.

(2) A coroner shall not exercise, in relation to the attendance at an inquest of a second registered medical practitioner, the power conferred on him by subsection (1) of this section unless—

(a) a majority of the jurors at the inquest, it having appeared to them that the cause of death has not been satisfactorily explained by the medical practitioner giving evidence thereof at the inquest, have by a requisition in writing called upon the coroner to cause a summons under that subsection to be served on another registered medical practitioner, or

(b) that practitioner had assisted at a post-mortem examination upon the person in relation to whose death the inquest is being held.

The effect of the section is to limit the number of medical witnesses who can give evidence at an inquest to two. The restriction is universally accepted as unwarranted and unfair, particularly in cases where the adequacy or appropriateness of medical treatment given to the deceased may be the key issue at an inquest. For example, there were 23 possible medical witnesses involved in Pierce Nowlan's case, given that 23 medical clinicians had been involved in his care. The section dates from an era when, although patients may have died, doctors never differed, at least not on the public record. The prohibition was always wrong in principle and its survival on the Statute Book is contrary to the interests of truth, accountability and justice.

When he adjourned the Nowlan inquest, Dr. Farrell called on the Government to introduce an amendment to the legislation lifting the restriction as soon as possible. He said the present circumstances ran contrary to the rights of all involved under the Constitution for access to "natural justice, fair procedures and due process". In September, the Dublin city coroner adjourned the inquest again until 9 November after considering further submissions in the case.

Mr. Raymond Bradley, a lawyer for the Nowlan family, asked for a further adjournment. He said, in the coded language used in such cases, until legislation was introduced allowing the coroner to call more than two medical witnesses, a certain verdict "cannot be delivered". He pointed out that doctors involved in the case had given conflicting versions of events. He said that unless more medical witnesses could clarify issues, "It would be wrong, it would be unjust for the family, and even for society, for a verdict to be delivered."

The lawyers representing the hospital also agreed with the coroner's views on the limitations placed on him by the Coroners Act. However, they argued there was an obligation on the coroner to bring the inquest to a speedy conclusion rather than adjourn it indefinitely while awaiting Government action on amending legislation. Dr. Farrell eventually ruled that it was beyond his powers to adjourn a case indefinitely in the hope that long-promised legislation might eventually materialise. He stated:

It would be unprecedented for an inquest to be adjourned pending a change of legislation ... In principle it would be wrong and in my view it would not be legal either.

That ruling was entirely understandable. The coroner allowed one final adjournment, until the end of next month, to give the Nowlans time to consider their position and their legal remedies, if any.

Meanwhile, the Nowlans had been in contact with the Department, me and, eventually, the Minister, Deputy McDowell. They were treated courteously by the Minister and his officials and were told that the prohibition set out in section 26 was recognised by all concerned as anomalous and that it would be repealed in the forthcoming comprehensive amending legislation. However, although that legislation was to be finalised and published as a matter of priority, there was no way it could be on the Statute Book by the end of January next year.

The purpose of this short Bill is simply to prioritise and implement immediately just one of the various recommendations of the working group on coroners, that is, the repeal of section 26(2), to fill the gap that would otherwise inevitably arise while awaiting the comprehensive legislation being worked on by the Minister. The proposal is non-contentious and has been accepted by the Government. I am grateful to the Minister and his colleagues for facilitating the speedy passage of the Bill before the end of this parliamentary term.

In Eastern Health Board v. Farrell, Mr. Justice Hardiman stated in his judgment that section 26 of the Coroners Act “is in my view ... a serious obstacle to the proper discharge of the statutory duty of a coroner in the more complex type of inquest.” He continued: “If a coroner feels that the question of how the death occurred cannot be answered without further evidence, it seems remarkable that he cannot obtain it.” It is quite shocking that the legislation under which a coroner operates is so restrictive that it prevents all the evidence relevant to the circumstances of death from being made available to the coroner.

Such a default is more apparent where there is a potential conflict of evidence as to what occurred but the coroner can only hear one version of events. Serious issues can arise as to who gets to choose which witness should be presented to an inquest and as to whether that witness is simply presenting the collective, corporate view on behalf of a hospital rather than an expert personal opinion. If a coroner can only rely upon one version of events then, in such circumstances, the capacity of the coroner to ascertain the true cause of death or make recommendations arising out of the findings or verdict delivered must be significantly compromised. It is wrong that where deaths occur in a hospital environment, which cases are inevitably more complex for the coroner in terms of the evidence required to be delivered, the coroner is fettered by virtue of the limitations associated with section 26 in ascertaining the true cause of death.

I welcome the decision of the Minister for Justice, Equality and Law Reform to accept this Private Members' Bill and the co-operation between both sides of the House to ensure all stages of the Bill are passed by the Dáil by Wednesday of this week. I am grateful that the Leader of the Seanad, Senator O'Rourke, has agreed to facilitate the early taking of the Bill in the Upper House, which should allow it to become law before the end of the year. It is relatively rare for the Government to accept an Opposition Bill. The degree of co-operation between Opposition and Government in regard to this issue is a reflection of the desire on all sides to deal with these anomalies.

I will deal briefly with the provisions of the Bill as published, and then with the Government amendments, which have been given to me in advance of Committee Stage. Section 1 sets out three amendments to the Coroners Act 1962. First, section 26(2), which limits the number of medical witnesses who can give evidence at an inquest, is repealed. Second, section 37, which provides that a person who, having been duly served with a summons to attend an inquest as a juror or witness, fails to attend at the time and place specified in the summons is guilty of an offence and is liable on summary conviction to a fine not exceeding £5, is repealed. The substance of that section is set out in a new section 38. Third, a new section is substituted for the existing section 38. The new section provides that a coroner may, for the purposes of his functions under the 1962 Act, summon witnesses to attend at an inquest, examine on oath — which the coroner is by this section authorised to administer — the witnesses attending at an inquest, and require any such witness to produce to the inquest any document in his or her power or control.

It is provided that a witness appearing at an inquest is entitled to the same immunities and privileges as if he or she were a witness before the High Court. A summons must be signed by the coroner. The section also provides that a person who on being duly summoned to attend an inquest as a juror or a witness makes default in attending, or being in attendance as a witness refuses to take an oath legally required by the coroner to be taken, or to produce any document in his or her power or control legally required by the coroner to be produced by him or her, or to answer any question to which the coroner may legally require an answer, or does any other thing which, if the inquest were court proceedings and the coroner were a judge having power to commit for contempt of court, would be in contempt of such court, is guilty of an offence. The penalties are, on summary conviction, a fine not exceeding €3,000 or imprisonment for a term not exceeding six months or both and, on conviction on indictment, imprisonment for a term not exceeding two years or a fine or both.

Section 2 provides a civil remedy as an alternative to criminal proceedings in cases where persons called to attend an inquest as witnesses refuse to do so. It provides that, where a person who having been duly served with a summons to attend an inquest as a juror or witness, fails to attend at the time and place specified in the summons, or fails to comply with a requirement to produce a document or answer a question, the High Court may, on application to it, in a summary manner in that behalf by the coroner, order the person to comply with the summons or requirement and may make such other order as it considers necessary and just to enable the order to have full effect. Section 3 makes standard provision for the short title of the Bill and its collective citation and construction.

It is clear that the Bill as initiated proposes to deal with three simple issues. The first is the repeal of section 26(2). The second is the fact that the existing mechanism for imposing penalties for non-attendance at inquests, either by witnesses or jurors, is almost certainly unconstitutional. The third is the lack of any civil enforcement mechanism where witnesses decline to attend.

The additional issues were highlighted in the case of Attorney General v. Lee, decided by the Supreme Court in 2000. In that case the Chief Justice pointed out that if a coroner were to invoke the powers purportedly conferred on him and on the High Court by section 38(2) of the 1962 Act, so as to certify the non-attendance of a witness as an offence and send that person forward on his certificate to be punished by the High Court, “he would be met with the contention that the provision in question is clearly unconstitutional, having regard to the decision in re Haughey”. The coroner in that case had decided not to adopt what the Chief Justice described as “a futile course”. Instead, the Attorney General had issued proceedings and applied to the High Court for an interlocutory injunction relying upon what was claimed to be the general jurisdiction of the High Court to enforce the law by way of an injunction or other suitable remedy on the application of the Attorney General as the guardian of the public interest, where it was just and convenient so to do. It fell to the Supreme Court to refuse the Attorney General’s application. The consequence of this decision was that the offences provisions of the Coroners Act are unenforceable and that there are no civil enforcement mechanisms to ensure the attendance of necessary witnesses.

As to the Government approach to this Bill and its amendments, my understanding is as follows. First, the Minister agrees with the repeal of section 26(2), which is my principal and most pressing objective. Second, the Minister agrees with the need to increase penalties for non-attendance of witnesses and jurors. However, he points out that identical penalties are not appropriate in the case of jurors and witnesses. I accept that argument and the amendment to cover the point. Third, my understanding is that the Government accepts there is a need for a civil enforcement mechanism. However, the Minister and his advisers would prefer to address this issue in the comprehensive Bill and not, even on an interim basis, in what is essentially short-term legislation.

I accept the bona fides of the Minister's position, although I would be surprised if his published proposals are very far removed from those set out in this Bill. In the interests of expediting this matter, in maintaining consensus and in enacting the core proposals, I am happy to accept the Minister's amendment, which has the effect of deleting a proposal for a civil enforcement mechanism.

There is much to be done in the comprehensive Bill. Apart from the recommendations of the working group, there is, for example, a recent High Court judgment declaring that the family of a deceased person has a constitutional right to legal aid when being represented at an inquest. That judgment will have to be reflected in legislation. There are also the judgments of the European Court of Human Rights where coroners' inquests and the restrictions under which they operate were considered in the context of the State's duty to ensure an independent, effective and impartial investigation into the deaths of those who die at State hands. A new Coroners Bill will not provide a complete answer to the queries posed by the European Court but it will at least provide part of the solution.

There are basic procedural issues which arise time and again in the Coroner's Court. Yet again in recent weeks the State had to agree to the quashing of a coroner's decision to refuse the family of a deceased person prior access to the witness statements taken by the Garda Síochána. A new comprehensive Bill must set out these basic entitlements plainly and with certainty. In the interim, I thank the Minister for facilitating the introduction of this Bill. He knows how important it is to the family concerned, to which everyone in this House would offer sympathy for what it has endured. I hope this legislation will provide some adequate answers.

Ba mhaith liom mo chuid ama a roinnt leis an Teachta Ó Conchúbhair, le cead an Tigh.

I welcome the introduction of this Private Members' Bill by Deputy Rabbitte and his colleagues in the Labour Party. It has a very specific focus, namely, to address certain deficiencies in the current law pertaining to the conduct of an inquest by a coroner. These deficiencies — the restriction on the number of medical witnesses and the outdated sanction for non-attendance of a witness or juror — have, albeit in a limited number of cases, combined to inhibit the conduct of inquests in a manner sufficient to inform the family and relations of a deceased person and society at large. I join Deputy Rabbitte in stating I appreciate the present law would have rendered a significant injustice if it had not been remedied for the Nowlan family. I was conscious of this when I met the family.

In recent months certain cases have helped to highlight the inadequacies of the current law as contained in the Coroners Act 1962. Since these pertinent cases are still current, the House will appreciate that it would be inappropriate to debate the details of them at this time, except to state they are very sad. They prove the need for a change in the law. I am happy to state the Government has approved my proposal that the principle of the Bill should be supported, subject to some amendments I shall be raising, largely of a technical nature.

The House will be aware that the Government's legislative programme, announced at the beginning of the session, contained a commitment to replace the Coroners Act 1962 with a modern code of law, to establish a coroner service and to transform the organisation of coroners. My proposals for a Bill have been with Departments and the Attorney General for necessary observations and I expect to be in a position to secure Government approval of the details very shortly. I intend to publish the heads, of which there are more than 190, for public consultation purposes during the drafting process.

The coroner service is one of the oldest public offices of the State and its origins date back many hundreds of years. Prior to the Act of 1962 there was a Coroners Act of 1927. My predecessor as Minister for Justice, Equality and Law Reform, Deputy O'Donoghue, began the current process of reform when he established an expert working group, the coroners review group, to examine all aspects of the coroner service with a view to bringing forward recommendations for reform. The group's report was published in December 2000 and contained 110 recommendations covering a wide range of issues. The work of the group was complemented by the subsequent report of the coroners rules committee, published in November 2003.

The Coroners Society of Ireland, as the body which represents coroners, has been active in the process of reform, for which I thank it. I have met it on a number of occasions in recent years and there continues to be ongoing contact, as well as meetings with departmental officials to advance the process.

The key objectives of the comprehensive Bill which I intend to bring to Government will be to provide for considerable updating and streamlining of the death investigation and post-mortem and inquest procedures so as to ensure a better and more proper service than is currently possible under the 1962 Coroners Act. To achieve these objectives, I am focusing on two critical elements in the reform of the coroner service — the widening of scope of the inquest and the development of optimum structures and administration for a modern coroner service. The central element of a modern death investigation service must be to allow sufficient scope to the coroner to carry out the best possible investigation. The 1962 Act and a subsequent interpretation of its intention and scope by the Supreme Court in the cases of Greene v. McLoughlin 1985 and the Eastern Health Board v. Farrell, provided for a restrictive approach to the examination at an inquest of “how” the person died. The examination is limited to establishing the proximate medical cause of death. Such a limitation is no longer appropriate, given the developments in medical care and treatment since 1962 and increasingly threatens to bring the inquest process into disrepute.

We must now move to expand the scope of the coronial investigation. We must require that the coroner seek to establish, in so far as is practicable, in what circumstances the deceased met his or her death. Widening the scope of the coroner's investigation was recommended by the coroners review group; reflects jurisprudence of the European Court of Human Rights; and is consistent with developments in other common law jurisdictions. A series of judgments of the European Court of Human Rights must, in development of my own Bill, be taken into account to ensure compliance with the European Convention on Human Rights. These judgments interpret Article 2 of the convention as providing for a more extensive investigation of the circumstances of death, beyond the strict "how in those particular circumstances" question now posed. They indicate that a certain extension of the scope of an inquest is now required to meet the obligations of the convention.

Any proposed extension of the role of the coroner's investigation would have to be balanced by maintaining the prohibition on explicit determination of questions of criminal liability at an inquest which applies under our law currently. From any widening of the scope of the coroner's inquiry, there would follow a series of developments which would include: no arbitrary restriction on the number and type of medical or other witnesses who can be summoned to appear and testify at an inquest; increased sanctions for those who refuse to co-operate with a coroner's investigation into a death; powers of compellability for the coroner akin to those available to a tribunal of inquiry; expressly stated powers for a coroner of control of the body of the deceased and other things, including power of entry and seizure; greater involvement of the coroner in the movement of bodies into and out of the State; and in a case where the coroner is concerned, that a fact of death certificate be held by an undertaker before disposal of a body. In the wake of the Shipman events in England we must be conscious that our law is deficient in some respects.

The coroners review group envisaged certain powers for the coroner akin to those available to a tribunal of inquiry. It is suggested procedures relating to evidence, access to documents, etc. will have to be developed in that regard in respect of the coroner's inquest. The right of access to documentation by all the parties concerned could become a critical point, especially regarding hospital, Garda or other State agency reports. There would clearly be a need to respect the constitutional and legal rights of witnesses similar to the conditions at a tribunal. This need to ensure better, consistent and efficient procedures in light of a new legal scenario would have resource implications; it could not be assured under the current coronial system.

The primary concern of the coroners review group was to ensure a high quality coroner service with optimal resources and supports would be developed. To achieve this outcome, it recommended a comprehensive overhaul and modernisation of the service. As regards the number of coroners, it envisaged an evolution to a regionalised structure where there would be fewer than the current 48 coronial districts provided for in the 1962 Act. I am satisfied that the current organisation of coroners must be reformed. The proposed Bill I have advanced for consideration by the Government will address all the policy issues, which include best practice in the law on coroners, their organisation and support structures.

I was, in effect, confronted by a choice. I could have chosen to table a Bill along the lines now being considered or I could have presented a full Bill of the type being finalised. As Deputy Rabbitte pointed out, the chances of the full Bill being enacted prior to the taking of the cases with which Deputies Rabbitte and O'Connor, as well as others and I, are concerned are slim. It seemed unlikely that this Dáil would deal with two coroners Bills in its lifetime. I doubt whether a Bill of this kind tabled by me would have survived the inevitable criticism of any sensible person that I was not addressing the wider issues of radical reform. I welcome this Bill as an agreed remedial measure which allows the major reform project to advance also. I hope both Bills become law before the next general election.

The short Bill, tabled by Deputy Rabbitte, can benefit from some technical amendments with which he has signalled agreement. It might facilitate the House if I were to indicate briefly the contents of those amendments. They are technical in nature, except in respect of the new sanctions for non-appearance as a witness or juror.

I will propose an additional provision in the Bill that will allow delivery of a witness or juror summons by registered post. I will propose sanctions on those persons, be they jurors or witnesses, summoned to attend at an inquest, namely, to fine jurors €500 for non-attendance on summary conviction and witnesses who fail to attend or co-operate at an inquest, €3,000, and/or impose a term of imprisonment not exceeding 12 months. I will also propose a transitional provision to ensure the new sanctions will apply only to offences committed after the enactment of this Bill because the Constitution prohibits retrospective criminalisation.

The Bill proposes the provision of increased powers for the coroner to compel attendance as a witness or a juror. Unfortunately, following consultation with the Attorney General's office, I will propose to delete the relevant sections from the Bill because without further development this aspect is somewhat problematic. If we had had another week or two to work on this, I would have been able to do as Deputy Rabbitte suggests but time was limited. I will address this issue in my proposals for new comprehensive coroners' legislation. We should, however, be prudent at this stage and not include something which is defective or suspect. I am confident that the abolition of the restriction on the number of witnesses and the increased level of sanctions will enable proper interim compliance with the coroner's requests in the investigation into deaths as a short-term measure.

The Committee Stage amendments I have outlined have been drafted and will become available to Deputies as soon as possible after Second Stage. In a spirit of co-operation, I understand the amendments, in so far as they are known to the proposer of the Bill, may be acceptable and should facilitate the early passage of the Bill as desired by the Members of this House and the Government.

I thank Deputy Rabbitte for getting me out of a difficult situation. It was, therefore, a pleasure to propose to my colleagues in the Government that we accept the Bill and expedite its passage through the Houses of the Oireachtas.

It is traditional on Private Members' Business to thank the Opposition for putting down the topic for debate. Tonight my thanks are even more sincere than usual because this is an important matter. I hope Deputy Rabbitte will not object when I call him my good friend and colleague in thanking him for his initiative in this regard. It also gives me an opportunity to thank his spokesperson, Deputy Costello, who, like Deputy Jim O'Keeffe, is my colleague on the Oireachtas Joint Committee on Justice, Equality, Defence and Women's Rights. This is a good night for democracy because we are co-operating in a definite way. I acknowledge the Minister's courtesy in allowing me to share time with him in this important debate.

There is no doubt that this motion on the Coroners Act 1962 would stand on its own merits. This is also the story of Pierce Nowlan who was born prematurely in the Coombe Hospital on 14 October 2002. He had a medical condition which required a minor procedure and was taken to Our Lady's Hospital for Sick Children in Crumlin where he died on his second birthday on 14 October 2004. His parents, Jean and Stephen Nowlan, are in the Visitors Gallery, as is his paternal grandmother, Phyllis. I have known the Nowlan family for many years and had the privilege of working with it in the past year. This gave me a welcome opportunity to work with my colleagues and represent the issues of concern to the family.

The family's bravery is evident in the way it stepped forward to ensure its baby's case was highlighted and that the anomalies it saw in the legislation were dealt with. When I raised the matter in the Adjournment debate on 17 November, I said the Nowlan family had acted sincerely in highlighting its case through the media, for example, in an excellent interview on TV3. This helped its healing process but also helped to bring an important issue into the public domain. The family is concerned about this issue not only for its own sake but also because it wishes to help other families who find themselves in this situation.

In the Adjournment debate I acknowledged, on behalf of the Nowlan family, its contact with the Minister for Justice, Equality and Law Reform who met and corresponded with it. The Minister's co-operation helped the family achieve action. I have had a great deal of contact with the Minister during the year on this subject and acknowledge his assistance and courtesy, and that of his staff. I also acknowledge the interest the Tánaiste and Minister for Health and Children displayed in the case. She, too, met the family which was happy with the meeting.

Everyone in the community was deeply upset by Pierce's death. The family wants to highlight this and to seek justice. It wants to find out what happened on that fateful day in October 2004. I hope tonight and tomorrow we can move the case forward. The legislation might enable the Nowlan family to go to the Coroner's Court early in the new year and get the answers it wants. We all understand this is a difficult situation for the family which should be commended on what it has achieved.

The current legislation is clearly outdated and can no longer be said to equip coroners with the appropriate measures to conduct the best possible investigation into the causes of a death. The inclusion of a proposed coroners Bill in the Government's legislative programme indicates a welcome commitment to reform.

Considerable work has been done in recent years in reviewing the coroner service and bringing forward proposals for reform. The coroners review group published an excellent report in 2000 which was followed in 2003 by the report of the rules committee. The coroners review group recommended a comprehensive overhaul and modernisation of the coroner service. Ireland is not alone among common law jurisdictions in engaging in reform of the coroner service. In the United Kingdom the coroner service review of 2003 recommended significant structural changes to the coroner service in England, Wales and Northern Ireland.

The judgments of the European Court of Human Rights have a bearing on the work of coroners and exert a significant influence on our legislative process. In recent years the court has made several important decisions in such cases. Our law must be updated to take account of the likely effect of its decisions.

The critical feature of Deputy Rabbitte's welcome Bill is that it seeks to abolish the outdated restriction that a coroner can call only two medical witnesses to give evidence at an inquest. It is not clear why this restriction was introduced in the 1962 Act. There is no indication in the Official Report at the time as to the thinking behind the provision. There was no restriction on the number of witnesses at an inquest contained in the 1927 Coroners Act which was replaced by the 1962 Act. I do not believe anyone can support the retention of this restriction, given its negative impact on the conduct of inquests by coroners. Many coroners have called for its swift ending.

The Bill also includes proposals for increased penalties for reluctant witnesses or jurors, which I welcome. The Minister for Justice, Equality and Law Reform has indicated he will table amendments to ensure these penalties have sufficient strength. I welcome the Minister's contention that we hold off for now in providing for new powers for a coroner to compel attendance, co-operation and the production of documents at an inquest. The Minister has stated to the House that his preference is for a comprehensive reform of the law relating to coroners. Such a proposal is contained in the Government's legislative programme. All Members will welcome these proposals which the Minister hopes to have agreed by the Government.

I am pleased the Government has supported the Labour Party's Bill in a genuine spirit of co-operation. If these proposals can be enacted swiftly by the Oireachtas, they will provide coroners with the means by which they can conduct and conclude many inquests, some of which may have been adjourned for significant periods. If these proposals become law, a coroner can use them to call new witnesses to adjourned inquests. I expect the medical profession will co-operate with coroners under the proposed new dispensation. I would not expect to see any reluctance on the part of doctors in attending inquests. Modern medical treatments, particularly in emergencies, are complex and will require adequate explanation to the family of the deceased and society at large. This is important as we need to be aware and to remedy any difficulties which may lead to further threats to public health and safety.

Initiatives to reform and modernise the coroner system are under way in other common law jurisdictions. In New Zealand and the United Kingdom, current proposals are directed at comprehensive rather than partial reform. Ireland is in a position to learn from these experiences in other countries. The aim of the reform should be to put more logical and coherent shape to the coroner service. Foremost among the issues, which I am glad the Minister will address in the forthcoming Bill, is that of the scope of a coroner's inquiry. The coroner review group considered this issue, recommending an extension of a corner's remit to establish the surrounding circumstances of death, including the medical causes of death.

We need to make a positive statement on the role of a coroner in inquiring into certain deaths. There is a requirement for greater clarity of the nature of the death by the coroner. Not all investigations into death by a coroner necessarily lead to inquests. The new legislation will also set out the procedures for the conduct of inquests by the coroner. There is a requirement for more explicit provisions to deal with those situations concerning deaths in custody or children in care where the State or its institutions had an involvement.

The coroner review group was concerned with the need to ensure a high quality coroner service with proper resources and supports available to it. The group recommended an evolution to a regionalised structure where there would be fewer than the current 48 districts. If such a change is to come about, I expect the emphasis will be on full-time rather than the current situation of part-time coroners. The Minister is working hard to bring forward his proposals for a comprehensive reform of the coroners legislation. I expect the proposals made by Deputy Rabbitte will be factored into this process.

The need for legislation in this area is obvious. While he has been working hard in the area, I am sure the Minister for Justice, Equality and Law Reform will not mind if I give credit to Jean and Stephen Nowlan and their family for their efforts in persuading the Government to change the legislation. It is always easy for a Government backbencher to patronise a Minister but in this case, the Minister has been particularly responsive. While I know the Nowlan family were anxious for action on coroners legislation, they have acknowledged the Minister's co-operation in this regard.

No one could but be affected by the death of Pierce Nowlan. I hope his family will see its campaign bear fruit when this legislation is enacted, particularly at a time of the year when his death must be more sensitive than usual. We must commend the brave way it engaged with the system, rather than sitting at home corresponding with it. It believed it was important it challenged the system, doing an enormous service to the wider community. I hope the plans for the amendment to the legislation will be a tribute to the Nowlan family. To step out into the public limelight is not an easy task, particularly for a grieving family. The family has often shared with me the genuine upset it feels. My eldest son is a long-time friend of the Nowlan family and he was deeply affected by what happened. It is important to highlight the positive aspects of what the family has achieved.

I hope the legislation will also be a lasting memorial to Pierce Nowlan. It would be important for his family and the wider community who supported it. It cannot be forgotten that a little boy died on his second birthday. I am happy the members of the Nowlan family are in the Visitors Gallery to see the co-operation between the parties on this legislation. I am not being flippant when I say I believe the Nowlans should write a little book on how to get political parties to co-operate in the Dáil, an unusual occurrence. It highlights the importance of the issue and the positive way we have all responded to the family's plight. While one expects some politics to fly around Private Members' Business, I am glad we have been able to park it, at least temporarily, and deal with important business. I support the Bill and look forward to its enactment. I congratulate the Minister on his efforts in that regard.

I wish to share time with Deputies Crawford and O'Dowd.

It says something that it has been more than 40 years since the Coroners Act was debated in the House. It says something else that it is being debated as a result of an Opposition Bill. I am pleased to support what is essentially an emergency Bill, of which there have been few examples in my time in the House. In 1990 one such Bill was introduced, essentially designed to support the business activities of Larry Goodman, while I recollect another, also in the 1990s, dealing with the issue of greyhound muzzling.

As we approach Christmas, it is lovely to have a Bill which all parties can gather around. This legislation arises from the circumstances in which a particular family, the Nowlan family, finds itself. While its effect extends beyond the Nowlans, the Bill has a particular resonance for them. Deputies are delighted to rally around the family and offer it sympathy, succour and support by amending the principal legislation to meet its needs.

I congratulate the Labour Party, in particular its leader, Deputy Rabbitte, on taking the initiative and introducing the legislation. I also congratulate the Minister who has acknowledged the urgent need for the Bill and agreed to accept its passage, particularly as the adjourned inquest is due to recommence next month.

I wish to raise two technical issues. The House must establish a process to ensure, as required, that the Bill passes this week. While I do not propose to cause a problem, Members will need time, preferably in the Chamber, to deal with amendments on Committee and Report Stages and allow the Bill to move to the Seanad. It would put the process off track if we were forced to call a special meeting of the Select Committee on Justice, Equality, Defence and Women's Rights, as to do so would consume time which is probably not available.

For the information of the Deputy, the order this morning covers all his concerns.

On a second matter, the introduction of this legislation highlights the cumbersome nature of getting Bills through the House generally. I do not point a finger at the Minister whom Deputies pointed at enough today when discussing another matter. Despite agreement on the need for reform, the House does not appear to be able to establish a procedure which would allow reform Bills to be put through the House in a reasonable timeframe. A working group issued a clear report on this issue more than five years ago. In addition, Article 2 of the European Convention on Human Rights which has been incorporated in domestic law contains clear requirements in this regard. Despite these developments, the House is still unable to get it together. In the case of coroners legislation, a new and comprehensive Bill was promised in 2002, 2003, 2004 and 2005. Perhaps we should re-examine the whole process by which we deal with reform Bills, particularly in cases where there is no political disagreement on what needs to be done. Although the reasons for delay may be complexities in the law and a desire to ensure the House produces good legislation, given the goodwill among parties on this matter, would it not be possible to find a better way of expediting reform legislation?

While the issues highlighted in the Bill introduced by Deputy Rabbitte are of extreme urgency, many other related issues are sufficiently urgent as to warrant reform. The Coroners Act is 44 years old. We need to address a series of other issues, specifically the reporting of deaths and the obligations on coroners and others. We must also deal with issues relating to the body of the deceased and the duty, as recommended by the working group, which should be placed on funeral directors to ensure a certificate of death is procurable or that clearance has been obtained from the coroner to bury the body.

Statutory requirements are needed on post-mortems. We must provide in legislation that the jurisdiction of the coroner includes the investigation not only of the medical cause of death but also the circumstances surrounding it, while at the same time treating with care the line between civil and criminal liability. Mandatory inquests should be extended to include, at a minimum, circumstances in which a death occurs in Garda custody, an issue which has arisen in the Rossiter case. An unexplained death is particularly difficult for relatives and we must make stronger legislative provisions governing their role and rights. Let us, therefore, agree to place the Bill on the Statute Book tonight.

While I congratulate the Labour Party on introducing this legislation and endorse its efforts, let us not forget the other, broader issues we should try to deal with it in the Statute Book.

I welcome the opportunity to say a few words on this important legislation. I understand from Deputy Rabbitte that it came about as a result of the tragic circumstances of the Nowlan child and that the purpose of the Bill is to try to rectify some of the anomalies which arose in that case.

Few issues have caused as much controversy in my constituency of Cavan-Monaghan as the inquest into the death of Frances Sheridan in Cootehill. The parents of this young girl had hoped for some closure as a result of the inquest but, unfortunately, the outcome raised more questions than it answered. The Sheridan case demonstrated the necessity to improve the 1962 legislation, not only through this Bill but also by carrying out a more extensive overhaul of the Coroners Act.

I seek guidance on who selects inquest juries. Is a panel in place and, if so, how many members sit on it? Does anyone have a right to object to any member appointed to an inquest jury? Although this is the case with all other juries, this rule does not appear to apply to inquest juries. Are public representatives, for example, or those with a connection to the case automatically debarred from serving on an inquest jury? Has a ruling been made in this matter? These questions have arisen because of the extraordinary circumstances which arose when advice given to a jury appeared to have been ignored. What surprised most observers of the complex case in question was that the jury reached a unanimous decision within minutes.

I welcome the efforts of the Labour Party in bringing the Bill before the House and the Minister's decision to accept it in principle. As I noted during a debate on another Bill a few nights ago, it is the right and privilege of the Minister to make amendments should they be necessary. On the other hand, it is important to achieve cross-party agreement to address expeditiously this delicate matter.

The general public expects the House to respond to circumstances as they arise. Many people in County Cavan will observe the progress of this legislation to determine how matters could be improved for other families which experience a loss similar to that experienced by the Sheridan family. It is difficult enough for families such as the Nowlans or Sheridans to lose a loved one, particularly at an early age, but the workings of the legal system cause them further problems. The Coroner's Court, as with all other courts, must not only dispense justice but be seen to do so in every respect. No individual ever wishes to do other than what is right, but whenever files are mislaid, as happened in the Sheridan case, and general practitioners' letters are not properly adhered to, there are serious doubts in the family's mind as to how the system works. The judge suggested a decision of death by misadventure should be made, but the verdict handed down by the jury was one of death by natural causes. The judge also suggested recommendations should be made on how matters should be dealt with in the future, but no such recommendations were forthcoming. One can see that, while there is not a direct link with the case with which we are dealing, my reason for raising this issue, radical reform of the whole system is required. There needs to be a clear indication in order that people can understand how the system works. I have nothing against any individual who serves on a jury — he or she does it for free and in his or her own time — but if there is any connection otherwise, it should be stated. There should be no doubt afterwards that the situation is clear and above board.

I commend the Labour Party for introducing this legislation. I sympathise with the Nowlan family on what it has gone through. I do not know its members personally, although I do know the members of the Sheridan family extremely well and I am aware of what they have been through. I know of other families in this situation also. In my own case, I had to wait three weeks for an inquest in England to allow my brother's remains to be buried. At least we have a better system here. Let us improve the legal system, as well as the coroner service.

I congratulate the Labour Party on introducing this Bill. I empathise and sympathise with the Nowlan family. In the short time available I wish to make a couple of points, one of which concerns people who have died in nursing homes during the years. As I understand it, various coroners have different rules. The Minister wrote to all coroners insisting they carry out their work in a specific way, but I am not aware that every single coroner has done this. Among the obligations on nursing homes is that they report a death to the Health Service Executive within 48 hours. In addition, if the deceased person had not been visited by a doctor in the preceding four weeks, the nursing home must inform the coroner. However, this does not happen in every case, which is one of the issues that has arisen.

We have had appalling situations where people died in nursing homes and were buried without the coroner being informed and a death certificate being issued. That is a serious and important issue. I have spoken to a number of coroners about the matter. The County Dublin coroner, in particular, has drawn the attention of the HSE to the issue. I appreciate that we are all acting together on it. I ask the Minister to use his good offices to get the best possible system in operation for those who die in nursing homes in order that there will be proper and full obedience with the rules and that the coroner is informed when he or she ought to be.

I have submitted freedom of information requests to all Health Service Executive areas because I am trying to get all coroners' reports, comments and views into the public domain. One particular Health Service Executive area has refused to give the information to me on the grounds that it must consult the people mentioned. Outside the Freedom of Information Act, perhaps the Minister would use his good offices to avail of the collective wisdom of all coroners as expressed by them in recent years in order that when he adds this to the legislation he intends to introduce, we will have full and proper vigilance on how people die in nursing homes.

An inquest takes place when a person dies in a nursing home, but a coroner can only take into account the facts as they are presented to him or her. In the case of poor nursing homes, which I stress are in the minority, evidence of appalling standards of care cannot be brought before inquest proceedings. If the HSE reports on the lack of care in a minority of nursing homes could be presented to coroners, it would change their views on how some people have died in a minority of cases, whether as a result of natural causes or absolute neglect as I believe happened in some cases.

I intend to share my time with Deputy Ó Caoláin.

Is that agreed? Agreed.

I always find it difficult to congratulate the Minister within an hour of having called for his resignation, but I will do my best.

This speech will be more sincere.

I sincerely welcome the Minister's acceptance of the proposal from the Labour Party. It is a step in the right direction, but as we all know, there is a body of legislation that needs to be dramatically reviewed in order to bring the coroner service into the 21st century. This move has arisen from a couple of cases, with which some of us are familiar. I found an apt quote from a group called Victim's Voice, describing the difficulty facing those who find themselves in the Coroner's Court. The view of Victim's Voice in England is that the bereaved are precipitated into a devastating situation and have to deal with agencies and procedures unknown to them and from which they feel totally excluded. That is certainly the message I have received from anyone who has found himself or herself facing the devastation of grief following a bereavement, as well as the angst-ridden bureaucratic difficulties of dealing with the coroner.

Two years ago a comprehensive report was produced in the United Kingdom which made widespread recommendations, with which I am sure the Minister and his staff are familiar. I wish to touch on a couple of the issues identified in that report. There was evidence that the coroner service was not identifying some suicides, drug-related deaths and deaths to which adverse reactions to prescribed drugs may have contributed. There was also a view that there was inadequate collation of data, including examining historical data and trends and number-crunching during the years. As it is crucial to examine such information in any fundamental review of the legislation, I am sure the Minister is considering these matters in his draft legislation.

The view in the United Kingdom was that the arrangements at inquests fell far below modern judicial standards of openness, fairness and predictability. That is what the European Union is saying to us, but it is also the message coming from across the water. A point that will become increasingly important in the years to come is that there is no reliable or systematic response to minority community wishes, traditions or religious beliefs. That issue has already arisen on this island.

There is a lack of resources for coroners, including administrative or secretarial support. Much more needs to be done in that regard. There are no agreed objectives or priorities and no mechanisms to encourage the system to adapt to the changing times. All these aspects need to be considered, although we must also deal with the here and now of getting people to appear at inquests. I hope we will examine far-reaching reforms of the coroner service, as well as dealing with its curiosities, for example, in having responsibility for treasure trove, with which I was not familiar before now.

I welcome the Bill. Having heard the Minister talk about the Government amendments, they are relatively sensible for the most part. I wish to lend the Bill my party's support.

Sinn Féin fully supports the Coroners (Amendment) Bill 2005 and thanks the Labour Party Deputies for introducing it. The problems it seeks to rectify have been allowed to persist for far too long, with the terrible consequence that families have been denied justice, and the court has been restricted in its ability to identity recommendations to prevent further fatalities. We join in commending the Bill to the House and urging all to support it. This State's legislation on coroners has not been updated for more than 40 years, although the case for reform of the Coroners Act 1962 is convincing. It is undeniable.

The coroners law and rules must be brought into line with internationally recognised standards for the conduct of inquests, and I wonder if any of the drafters on the Labour Party side or the Minister has read the book Melancholy Madness, which was an account of the coroner’s courts in Monaghan over a protracted period quite some time back. It was not what one would expect to be bedtime reading, but it was a very interesting book, and I commend it to anyone interested in the history of the Coroner’s Court.

Sinn Féin advocates radical reform and regrets the Government has failed to publish a comprehensive Bill for the replacement of the existing Act, despite recognition of the necessity for wide-ranging legislative reform as far back as 2000. We believe a failure to introduce a proper investigatory role for inquests violates international law and constitutional rights.

Witnesses should be compellable, and in disputed circumstances coroners should always sit with a jury, which should not be limited to findings of fact but have full powers to bring in appropriate verdicts, including apportioning responsibility for disputed deaths in general terms and making recommendations to prevent further ones where appropriate.

The parties should have a right to examine witnesses and challenge jurors. Full legal aid should be available to families for that purpose and to cover the services of expert witnesses. All evidence, including autopsy reports, witness statements and other documents should be made available to families and their legal advisers as a right, with adequate time to prepare for the inquest. Inquests should be held promptly in a manner accessible to families, and adjournments kept to a minimum.

I note that, according to the Government legislative programme, the publication of a Bill to replace the Act is scheduled for 2006. I wonder whether I would be wrong to say I should not hold my breath. In the meantime, the proposed Bill represents a worthy effort to address some of the priority concerns identified by the working group that reviewed the coroners service and by the unfortunate families that have been let down by the inquest process. It will eliminate the restriction on the number of medical witnesses and make them compellable. That must be done as a matter of urgency. However, without wishing to delay the Bill unnecessarily, Sinn Féin submitted two very reasonable amendments to address further priorities we have identified. The Bill, as proposed, does not cover two very important issues. In light of the goodwill in the House, I urge Deputies to consider improving the Bill by ensuring that it puts mandatory inquests into deaths occurring in and following custody on a legislative basis. The need is clearly illustrated by the tragic death of Brian Rossiter.

The Bill would also be greatly improved by including a provision enshrining the public interest as a positive principle underpinning the purpose of the Coroner's Court. The court should be encouraged to make general recommendations where that could prevent future fatalities, particularly in custody and hospital settings. To achieve this, the Coroners Act 1962 must be reformed to allow a broader interpretation of the purpose of the coroner's court, thereby allowing it to ask all the necessary questions.

In the tragic case of young Frances Sheridan, who died following her discharge from Cavan General Hospital, the court was not allowed to ask questions necessary to understand the causes of her death fully and hence make recommendations aimed at preventing further fatalities. The court should be able to examine the under staffing, under funding and mismanagement of health services that tragically contribute to preventible deaths.

I, too, welcome the Bill, which I obviously support. The legislation, which has particular relevance in the Cavan-Monaghan area at the moment, must be reviewed. In such a situation, one must establish the cause of death rather than lay blame at anyone's door. In many situations it can be quite straightforward to establish cause of death, but there are some situations where it is quite difficult. There are issues to address. One may call only two medical witnesses, something seen in the case of Frances Sheridan to which Deputy Ó Caoláin referred. There is no reason for that to be restricted. If a jury wishes to ask questions, it should not be limited. It is very important that every detail needed to reach a conclusion be forthcoming.

A family hopes to achieve closure following a death. It will have been through several traumatic incidents, including the death itself. The inquest is generally the last in a line of such events and constitutes the commencement of closure. However, for the Sheridan family, it has led to many more questions. To be told, despite professional advice to the jury, that a nine year old child has died from natural causes to some extent adds insult to injury. We all have family members who have had an appendix removed, and to be told that death is a natural occurrence thereafter is not acceptable. It must be re-examined.

As I said, this compounds the grief of the family, which now feels it has been let down by the health service. The child was brought in to the health service, and the GP accurately diagnosed the ailment, which was quite complicated — volvulus, I believe. The notes of the GP who examined her got lost in the system, and the notes were not available. The family felt let down by the health system, and now it feels let down by the justice system too. These matters must be examined now rather than waiting 12 months for developments.

I am very glad to support this Bill and warmly congratulate the Labour Party on its introduction, which is not before time. In my area there have been two cases where the coroner was totally and utterly helpless, being unable to do anything owing to the non-attendance of a common killer responsible for the deaths of two Mayo people who should not have died. Whatever the justice achieved by the family of the first person, the second did not deserve to die either. That person would not have died if the coroner had been able to summon this witness and act appropriately. The case to which I refer is that of Jackie Alderslade, a woman in her 50s who died tragically on the side of the road — a mere stone's throw from alternative therapist Minike Kamper's place of practice — or killing, as I would say. The lady concerned was trying to get to her because she had such faith in her. Were it not for the diary she kept the extent of the negligence, arrogance and what people will do for whatever reason would never have been known. The lady concerned who was an asthmatic was persuaded by the woman in question to stop taking her essential steroid medication. As a result, she choked to death on the side of the road trying to get to the person she thought would help her. A working group has been trying to sort out the matter since 2003 but it has still not addressed the question of licensing and regulating alternative practitioners. The second case involves Paul Howie who had a tumour in his neck which caused him to choke to death. He should not have died either. When the inquest into the death of the first poor lady mentioned opened, Mineke Kamper was summoned but did not appear. The coroner said he could do nothing about it.

I warmly welcome the Bill and the fact that the Minister will support it.

I thank the Minister for so generously and at such short notice accepting this legislation prepared by Deputy Rabbitte. We will accept the amendments he has proposed as they will improve the legislation. I thank all of the contributors, Deputies Jim O'Keeffe, Crawford, O'Dowd, Cuffe, Ó Caoláin, Cowley and Connolly. I am delighted with the level of interest in the legislation and the number of Members who contributed to the debate. I have no doubt we would have had more speakers if more time had been available.

This is simple but important legislation in that it will allow, for the first time since the Act was passed in 1962, the system to operate in such a way where more than two medical practitioners can attend the Coroner's Court. That is the first instance. In the second it will allow for powers to enforce the attendance by jurors and witnesses at the court. These may appear to be simple issues but they had the effect of preventing the coroner from doing his or her job properly. Very often families which were already traumatised by the death of a member of the family left the court frustrated with the results obtained. We must not forget that there are hundreds of such court hearings the length and breadth of the country.

I sympathise deeply with the Nowlan family which lobbied Deputy Rabbitte to consider introducing this legislation to ensure its case could be dealt with properly. Many other families will benefit from the legislation. That is the reason we are particularly appreciative that the Minister has decided to take it at short notice. Second Stage will conclude tonight. Committee, Report and Final Stages will be taken tomorrow and I have no doubt the Bill will be adopted with the support of all sides of the House by tomorrow night. It will then go to the Seanad the following day, with the result that it will be passed by both Houses by the end of the week.

There are many other issues we would like to address, which a number of speakers mentioned. They include nursing homes, prisons, Garda custody, hospitals and suicides and drugs, issues currently not properly covered in coroners' inquests. I know from experience of attending a number of inquests involving, say, the Prison Service that there are serious problems in putting together the panel of jurors. There is not a common practice and very often the local Garda sergeant is sent out to empanel a jury, the members of which are brought in, put sitting on seats and expected to do their job in that respect. That is not a satisfactory way of putting together a jury. The coroners' inquest system must be extended to cover the areas I have mentioned.

It is a shame that, with the best will in the world, we have not implemented the recommendations of the working group on the coroner service which reported in 2000 and put more comprehensive legislation in place. I trust the Minister will bring his Bill before the House in 2006 and that we will all be anxious to expedite its passage through the House.

I want to briefly mention something we are doing in examining the Séamus Ludlow case. The family of Séamus Ludlow who was assassinated by paramilitaries from Northern Ireland was not informed when the inquest into his death was taking place. It is essential that the relevant persons are informed of inquests and that such a mechanism is in place.

On the question of riders or recommendations, it is not just a matter of the simple questions of how, when and where. It should be possible to have a more robust decision-making process to answer more of the questions not being answered currently. Legal aid must also be provided.

To come back to the two main issues before us, only two medical practitioners may be present but there is often a conflict between these two practitioners and there is no mechanism to resolve it. I understand that in the Nowlan case there were over 20 medical professionals involved who would have been able to come to court to assist in getting a satisfactory outcome to the coroner's inquest. In many cases, this is a problem in that there is a simple conflict and no way of bringing others to the court to try to resolve it. This leads to enormous frustration.

On the other side of the coin there is a huge problem with witnesses refusing to come to court, the current penalty for which is a fine of approximately €6.35. This is unenforceable. There is no remedy to compel any person, a juror or a witness, to attend. Deputy Crowley outlined the details of the sad case of a natural health therapist who provided so-called medical therapy and treatment and when a person died, refused to attend court to give any evidence on the manner in which medical treatment or therapy had been provided. We cannot have a situation where such a key person can refuse to attend. We might as well not hold the court hearing if that happens. It is essential to ensure every coroner will have the relevant medical professional practitioners involved in the case present at the inquest and the power to compel the attendance of witnesses who might otherwise refuse to attend.

I am delighted the Government has accepted the Bill and that the Opposition parties have agreed to expedite its processing through the Oireachtas. I look forward to seeing the proposed legislation passed by both Houses on Thursday evening.

Question put and agreed to.
Committee Stage ordered for Wednesday, 14 December 2005.