I thank the Chairman and sub-committee for the invitation to come here this morning. The Chairman has suggested that I might refer to the red booklet, by way of information to the sub-committee. This was prepared for the public. Persons coming to inquests or dealing with the coroner's office would be given a copy of this booklet or would request a copy. We have also provided it to professionals, hospitals and others, at their request.
I do not have an opening statement. I will refer to question No. 1, which asks who is the coroner? In our view the coroner is an independent officeholder with responsibility under the law for the medical-legal investigation of certain deaths. I have explained that the coroner's jurisdiction refers to a group of deaths — sudden, unexplained, violent and unnatural deaths. Those categories of deaths must by law be reported to the coroner. The law governing this area is the Coroners Act 1962. Additional provisions are contained in the Safety, Health and Welfare at Work Act 1989, which also refers to inquests.
On the report of a death the coroner will inquire into the circumstances. A proportion of those deaths will require an autopsy to clarify or establish the cause of death. If the death transpires to be due to unnatural causes, an inquest must be held by law. There is no discretion in the matter. If a death is unnatural, or may be unnatural, or where there are concerns about the circumstances of the death, then an inquest must be held.
We wrote the booklet in 2001. Therefore, it is due for revision. Important developments have taken place since then in terms of the jurisprudence emanating from the European Court of Human Rights. This court has held in its pronouncements that the inquest in common law countries is the means by which the State subserves its substantive and procedural duty to investigate deaths in certain circumstances. In other words, deaths at the hands of the security forces, such as the Garda, deaths in Garda custody and certain deaths that take place in the custody of institutions of the State. The European Court of Human Rights has stated that in the absence of a criminal trial that goes to a guilty verdict, or perhaps in Ireland in the absence of a specific tribunal in regard to a death, then the inquest subserves the State's function in those categories of deaths, in establishing the circumstances of the death and in vindicating the right to life of the deceased person.
An inquest is an inquisitorial process in which we are only concerned with the facts of what happened. We cannot — nor do we want under any new legislation — the power to investigate civil or criminal liability. We do not exonerate. It is a fact-finding, inquisitorial exercise, but we endeavour to make it as comprehensive as possible in order that the relevant facts pertaining to the death are established. I believe it is a matter of public record that we are not satisfied with certain provisions under the current law. The Irish tradition has been that the inquest rubber-stamped the medical cause of death. In other words, death resulted from hanging, shooting or an overdose. That is simply not sufficient, since we must establish the circumstances surrounding the death.
Some of the interpretations of the provisions of the 1962 legislation are contradictory in that regard, and even court decisions can be restrictive. They may be strictly legal interpretations and, of course, we give due cognisance to the common law and the pronouncements of the High Court and Supreme Court. Recently there have been very important judgments, a list of which I can give the committee, that have both extended and restricted the coroner's role. Perhaps the most important recent ruling was in the case of the Eastern Health Board v. the Dublin City Coroner. The court said that the inquest was confined to the proximate cause of death, and we must respect that view.
However, we contend that the proximate cause of death may not be the real one. If someone dies from aspiration pneumonia, the real cause may be a drugs overdose, while pulmonary fibrosis may result from past exposure to asbestos in the workplace. The verdict cannot, therefore, be the proximate, medical cause of death. It must be the true, underlying cause, which ought to be the means by which the death occurred — in other words, the circumstances surrounding it.
We set out in the booklet to explain the coroner's role. No. 4 sets out the broad categories, and we go on to explain what happens when a death is reported. In Dublin approximately 2,200 cases are reported annually, and of that number approximately 410 inquests are held. We would probably perform approximately 1,300 autopsies, a high rate. In other cases of death, we accept a certificate from a medical practitioner, either in general practice or in a hospital. The reason for the high autopsy rate is that there are specific problems in Dublin regarding tertiary referral hospitals. We receive tertiary referrals from all over the country, for example, to the renal unit in the Mater, the burns unit in St. James's or the neurological unit in Beaumont Hospital, leading to a concentration of cases.
We also have problems with drug use in Dublin, and it is a capital city. We have a high autopsy rate because the cases are complicated, and the cause of death may be unclear. If the autopsy shows that death resulted from natural causes and there are no other circumstances of concern, the coroner will sign off on the case. If the families express concerns about some matter, for example, the medical treatment, we must examine that, even in the context of a natural death. There may have been some want of care or other issue. We do not involve ourselves in every complaint that families may have regarding their interaction with the health service, since we cannot provide that kind of service. We are concerned only with allegations that are substantive and may go to establishing the cause of death or have a bearing on the death. Sometimes what appears to be a natural death from the autopsy report may transpire to be unnatural because of the way the patient or person was dealt with by third parties.
If the death is, or may be, unnatural, we have an inquest. An inquest is an inquiry in public by a coroner, sitting with or without a jury, into the circumstances surrounding an unnatural death. There is no discretion. In Northern Ireland there is discretion in regard to the holding of an inquest but Ireland is similar to England and Wales in this regard, in that, an inquest must be held by law when a death is unnatural. The purpose of that is to vindicate the life of a citizen or resident in Ireland, or a visitor to Ireland. Where a person dies in unnatural circumstances there ought to be some authority or means of examining the circumstances of the death. That is what we believe we are about. We do not wish to investigate civil or criminal liability and we ought not to exonerate anybody, but we need to establish the facts and place them on the public record in a neutral but comprehensive manner.
Moving to the reason I am here today, point 18 of this booklet is apropos. Under the heading who can ask questions, the heading could easily be who are the parties to an inquest or who are the interested persons, as we call them. We tend to try to avoid the term "parties" because it is more applicable to adversarial hearings; we say "properly interested persons". They will include the family and next of kin, who are probably the principal interested parties at an inquest; personal representatives of the deceased; and representatives of any board or authority in whose care the deceased was at the time of death. This might be a hospital board, a prison or another institution such as a mental hospital or a hospital for the mentally handicapped.
Those who may have caused the death are obviously interested persons. Persons who hold a life insurance policy, namely, an insurance company holding a life policy on the life of the deceased would also be included. Under the Safety, Health and Welfare at Work Act 1989, representatives of the trade unions, the employer of the deceased, an inspector of the Health and Safety Authority and any other person at the discretion of the coroner would be included. From time to time I am asked to rule on whether a person has standing at an inquest and we would examine that. Usually this is a situation where there would be legal representatives making submissions on the matter. We would rule accordingly depending on the role of that person in the inquest proceedings.
Returning to the issue of notification, the family and next of kin are probably the principal interested parties at inquest. Therefore, they must be notified about the hearing. I have given the committee a copy of the victims' charter of the Department of Justice, Equality and Law Reform. That was published around 1999. On the second page, under the heading "Inquests", it states, "The family will be informed (most commonly through the gardaí at present) of the date, time and place of the inquest as soon as possible".
I have only one copy of the report of the Coroner's Rules Committee and I will leave it for the information of the committee. It represents the most recent view of the Department of Justice, Equality and Law Reform. It is entitled the Report of the Coroner's Rules Committee, Department of Justice, Equality and Law Reform and I believe it was published in 2002.
Recommendation 6.3, Notice of an Inquest, states that the coroner should arrange to notify the next of kin regarding the holding of an inquest, and the Department suggests a minimum period of two weeks' notice should be given. That followed our deliberations with the committee which extended over a four-year period from 1998 to 2002. Two reports were produced, namely, the coroners' rules committee report and also the main report of the working group review of the Coroner Service.
I can only speak authoritatively from my own practice, but we have always taken the view that the family must have proper notification of an inquest. Our office has an intense interaction with the public. We have ten staff. Families and others such as lawyers, hospitals and the Garda, interact constantly with my staff about how the investigation is going and what we are doing. We can do better but we are endeavouring to keep them informed.
When an autopsy report is received one of my staff would telephone the family and tell them that the coroner is proposing to certify on the coroner's certificate that death is due to natural causes. It also gives the family an opportunity of interacting with us as well, if they have any other concerns.
We would have done that in recent years also as regards the time of death. As well as speaking with the doctors or with the person who found the body, we would also speak with the family and see what issues they have at that early stage.
We get a second opportunity when the autopsy report comes in. If a death is unnatural, we will go to the inquest. We will tell the family there will be an inquest. If the families are legally represented, we will be in constant touch with the solicitors. We will ensure that the families are informed in good time. What I mean by "in good time" depends on the circumstances. There are families who know months beforehand of the date of the inquest. There are others who may know through their solicitor's interaction with us or interaction with my staff or whatever. There are other families with whom we do not have any contact and therefore we must rely on the assistance of the Garda Síochána in dealing with them.
The garda in a coroner's inquiry is acting not only as a garda but also as a coroner's officer. In England and Wales there would be lay coroner's officers appointed to most coroners' offices. These are usually former members of the police who are now retired and acting as coroner's officers.
In Ireland, apart from my own staff whom, I suppose, one could call coroner's officers but who tend to do work in the office and do not go out to scenes, we use the garda as an officer. We would ask the investigating garda who is assisting us, acting as a coroner's officer, to go to the family and notify them of the date of the inquest.
We also write to families. The correspondence is carried out by my staff or we ask the garda to write. We have a standard letter which goes out to the Garda sergeant. The letter includes the list of witnesses. It also states our wish that the family be notified in writing. We may not have notified the family in writing because we did not have the address. I am looking at ways to improve this system, perhaps through direct contact from us in every case. However, it is simply not possible according to my staff. I have spoken to them many times about this issue. We may not know where the family is or there may be issues about their present residence or whereabouts. The garda will have liaised with the family at the time of the formal identification and will know the family.
If the family have not been in touch with my office, we find that asking the garda to act on our behalf is a fail-safe approach. It is fail-safe because if the family are not present at the inquest, I would ask the garda involved to explain why. I would adjourn the inquest unless we have a satisfactory explanation as to why the family did not wish to attend or the family have been in touch with the coroner's office before the hearing. In some cases the garda would say the deceased was an elderly person whose only relative was in a nursing home and unable to attend. If I was satisfied with that information, I would proceed. Those are the only circumstances in which I would do so. A garda might say that, having made inquiries, no family member could be contacted. However, there might be a witness at the inquest who knew a family member or distant relative. In that case I would adjourn and ask the garda concerned to look again. Families invariably attend. It is always a surprise to us if they are not present and we would not proceed without a satisfactory explanation for their absence.
We welcome the minimum period of two weeks but would try to improve on it if we could. If the family does not appear, the inquest ought to be adjourned but this has not been suggested in the deliberations of the Coroner's Rules Committee. However, we think it would be appropriate for the Oireachtas to consider this issue when debating the new Bill.