This is a very meagre Bill, and it really does nothing except confirm what is at present the duty of the Coroner.
CORONERS BILL, 1925
And that not very fully.
The only recommendation for the first section here is that it is taken from an English Bill now before the House of Lords. It would be better if Senator Brown gave the Committee an idea of how legislation stands at present, and if he referred to matters that it is desirable to deal with, When we have done that, we can settle our procedure.
There are three Coroners Acts practically in force in Ireland now. Of course there was a certain amount of common law before any of these Acts. The principal Act is the Coroners (Ireland) Act of 1846 which practically repealed all the then existing Acts, as far back as 1829. The next one was the Coroners (Ireland) Act of 1881, which amended the Act of 1846 in respect of the qualification of coroners, the remuneration of coroners (salary instead of fees), payment of poor witnesses, discharge of jury failing to agree and the holding of a new inquest. It also provides for bail in manslaughter cases. The Local Government (Ireland) Act of 1898, section 14, transferred the appointment of coroners to County Councils, gave power to alter districts and abolished the old regulations under which the election was held. It also provided that the salary was to be fixed by the County Councils, with the approval of the Local Government Board. There is also the Coroners (Ireland) Act of 1908, which deals entirely with the appointment of deputy coroners. Prior to that, two magistrates acted. Under the Act of 1846, section 22, it was the duty of a coroner, if he deemed it necessary, to hold an inquest where a dead body was found, or where there was a case of sudden death under suspicious circumstances. In such cases notice had to be given to the coroner and, on receipt of that notice, if he deemed an inquest necessary, he issued his precept.
Who was to give him notice?
The District Inspector of police was the only one on whom that duty was cast. That is the law at present. One of the old Acts obliged the coroner to hold an inquest on any person who died in prison.
That is repealed now.
No. You have to have an inquest on any person who dies in prison.
Does not the statute do away with that?
I think not. It is recognised in England that if a man dies in prison there must be an inquest. That position was never defined, however.
We ought to deal with it.
The Irish Act of 1846 always left it in the discretion of the coroner to hold an inquest if he deemed it necessary. The English Act under which coroners act at present is the Act of 1887. It defines it as the coroner's duty to hold an inquest where the coroner " is informed that the dead body of a person is lying within his jurisdiction, and there is reasonable cause to suspect that such person has died either a violent or an unnatural death, or has died a sudden death, of which the cause is unknown, or that such person has died in prison, or in such place or under such circumstances as to require an inquest in pursuance of any Act." I have never been able to find " any Act." Obviously, these words were put in as a catch or safeguard. In England it is compulsory on the coroner, under the Act of 1887, to hold an inquest. On the question of the duty of the coroner, which is really the only thing this Bill deals with, I suggest that it would be a wise thing to put in a section which will fully define such duty. I have drafted a section which is practically on the same lines as a section in the English Act. It is as follows:—
" Subject to the provisions of section . . . of this Act, it shall be the duty of the coroner, in every case in which he is informed that the dead body of a person is lying within his district, and there is reasonable cause to suspect that such person has died either a violent or unnatural death, or has died a sudden death of which the cause is unknown, or that such person has died in prison, or in such place or under such circumstances as to require an inquest under any Act other than the Coroners (Ireland) Act, 1846, to hold an inquest upon the body of such person, in accordance with the provisions of the Coroners (Ireland) Act, 1846 or of this Act."
The only trouble is the time it might take to make a post-mortem. For instance, in a case of suspected poisoning, where the contents of the stomach had to be examined, it might take some days, and in the meantime the person ought to be buried.
The coroner has the right to have the analysis made under a section of the Act of 1846.
Has not the coroner, where he is holding an inquest, power to order a post-mortem?
Yes.
The coroner has that power, but he must have started the inquest. What the Senator suggests is to give power to have a post-mortem before he starts to hold the inquest. The delay, while awaiting for the result of the post-mortem, and the holding of an inquest, might give a criminal an opportunity of escaping.
I think the idea is that the coroner should have power to order a post-mortem and on the result of that, see whether it is necessary to have an inquest. In many cases it might not be necessary to have any inquest. You would also have to dispense with the jury seeing the body.
We are doing that. That is the reason for the section I drafted. That is practically taken from the English Bill, and I do not think you could make it any wider without making it vague.
It has the merit of imposing the duty upon him.
It would replace this first section here in this Bill.
Yes.
Senator Brown leaves a blank, because he proposes to introduce a subsequent section dealing with special cases.
The next question which would come up naturally, following the English Act, would be the power to hold inquests without a jury in certain cases. I have not provided any section dealing with that matter, because I think it is such a serious question. I would like to discuss it before doing anything.
The provisions in the English Bill dealing with this are:—
(1) " Subject to the provisions of this Section "—that is, Section 12 of the new English Bill—" a coroner within whose jurisdiction the dead body of a person is lying, may, in lieu of summoning a jury, in the manner required by Section 3 of the Coroners Act, 1887, for the purpose of inquiring into the death of that person, hold an inquest on the body without a jury.
(2) If it appears to the coroner either before he proceeds to hold an inquest or in the course of an inquest begun without a jury, that there is reason to suspect—
(a) That the deceased came by his death by murder, man-slaughter or infanticide; or
(b) that the death occurred in prison or in such place or in such circumstances as to require an inquest under any Act other than the Coroners Act, 1887; or
(c) that the death was caused by an accident, poisoning or disease notice of which is required to be given to a Government Department, or to any inspector or other officer of a Government Department, under or in pursuance of any Act; or
(d) that the death was caused by an accident arising out of the use of a vehicle in a street or public highway; or
(e) that the death occurred in circumstances the continuance or possible recurrence of which is prejudicial to the health or safety of the public or any section of the public;
he shall proceed to summon a jury in the manner required by the Coroners Act, 1887, and in any other case if it appears to him, either before he proceeds to hold an inquest or in the course of an inquest begun without a jury, that there is any reason for summoning a jury, he may proceed to summon a jury in the manner aforesaid."—Coroners (Amendment) Bill, 1926. (H.L.) (16 Geo. 5.)
That is a pretty good safeguard.
There is no doubt that in many cases it would be better to let the coroner act without a jury. He is bound to be a qualified man. In this country he must be a qualified medical person of seven or ten years' standing, or he must be a barrister or a solicitor, or under the old régime a Justice of the Peace; at any rate he must be a man competent to hold such an inquiry.
The object of having an inquest by the coroner alone is to avoid the necessity of calling in a jury.
And also if there was some reason to suspect foul play he might not be able to get a jury, or he might get a jury that would bring in a verdict excusing some person or persons suspected.
But is there not a danger, if the coroner turned out to be a type of man different from what he was supposed to be on his appointment, he might deal with a case if left to himself in a way which might not be to the public interest?
There is, of course, that danger.
The more responsibility you put upon the coroner, the greater is the duty of appointing a proper man for the office.
Yes, but you have to get back to the origin of the appointment. We know there may be cases where a coroner may be appointed by one section simply because they have a majority. He may be a qualified man all right, but he may have other drawbacks which make him not very suitable.
You could provide that the election should be subject to the approval of some Minister, either the Minister for Justice or the Minister for Local Government.
If that section were put in we could get something added that would safeguard future appointments
I would agree that the election should be subject to the approval of the Minister for Justice.
The election could be left to the County Council, with the approval of the Minister for Justice or Local Government.
You are concerned with an officer here who is dealing with the lives of the very poorest of the people.
There is a point, I think, not covered either in the Coroners Act of 1846 or the second Act. In 1881 the Registration Act was passed requiring every death to be registered. There is no reference, so far as I can see, in either Act to that very important matter.
There is, in the section which I suggest ought to be put into this Bill: That is where the coroner directs a post-mortem examination and when, on the report of the case, he comes to the conclusion that the death is properly explained and that no inquest need be held, he certifies the death to the registrar, who is obliged to put the death on the register.
That is a step in advance. At present what happens? Fully 70 per cent. of the deaths that occur in many districts are uncertified by any medical attendant. There is nothing to indicate the cause of death, and the whole of our statistics about deaths are worth nothing and are absolutely useless. I have seen many certificates of death of people of fifty years of age who were not attended by medical men. They did not die at fifty years of age of senile decay. They died of some cause which should be, but was not, made known.
An American was staying over here for some time and he saw where the death of a person had been certified as heart failure, and he said, " in America we would not take that, because you might as well say a man died of shortness of breath."
I am satisfied that 70 per cent. of the deaths in the country in certain districts take place without medical attendance, and they are registered without proper certificates, whereas if the coroner had a right to say, " if there is no medical attendance I must hold an inquest," it would have the effect of bringing pressure to bear upon the relatives of persons who died to have the death properly certified.
Would you add, " in all cases where no medical certificate is forthcoming "?
No body should be buried unless the coroner or a medical officer certifies the cause of death. I would think a clause should be put into the Bill to that effect.
But that is not a matter for the coroner and that would be going outside the scope of the Bill.
Under the law as it stands at present, have not the relatives to obtain a certificate of the death and are they not liable to prosecution otherwise? I thought you should produce the certificate before the interment takes place? At least, that is so in the cemeteries around Dublin.
Yes, but apparently it is different elsewhere.
I have heard of numbers of cases where persons came to register a death, but no medical attendant was present at the time of the death. It was a case of getting the insurance money, and when the people were asked where they buried the deceased they answered. " in a country graveyard, 10 or 12 miles away."
For statistical purposes you want to know the exact cause of death?
Yes, as nearly as possible.
Take the case of a man who is knocked down by a tram. The impact may have been such as not to cause death, but the coroner puts this down as a tram accident. There might have been no impact at all, and the death may have been due not to the accident, but to heart failure.
But, providing that there is an accident, the coroner must hold an inquiry.
The people that you have in mind here are very poor people and these people do not really require a certificate, because the number of uninsured amongst those people would be relatively very small. They are nearly all insured in the Prudential or the Royal Liver.
Speaking of the urban districts that is true.
Yes, and in the rural areas also it is largely true.
Of course people will always have to have certificates in order to get the insurance, and they have to look after that, but in many of the country districts it is different.
Is not industrial insurance getting into the rural districts now ?
Assuming that, as a whole, people are insured in the urban districts, and to some extent in the rural districts, then would not the whole thing be secure if you put in the addition I suggest, which would compel the coroner to hold an inquest in any case in which he failed to get the medical certificate.
Where it is a question of insurance, they must go to the registrar and register the death before they can get paid.
I follow, and the result would be, that the addition I suggest would not impose a very heavy obligation, but it would be a precaution in cases where no certificate was forthcoming.
I am quite in favour of safeguarding the people, but in remote districts where they are not very conversant with regulations and things like that, the holding-up of the burial of the dead person might inflict severe hardship.
You could add words that would give the coroner discretion.
I am quite in favour of having all the statistics got as far as possible.
It should be provided that the coroner must hold an inquest if there was no medical attendant present at the death and no certificate.
I think it is an excellent idea if you had the proper machinery for carrying it out. But how is he to find out about a death for which there was no certificate? You would practically have to put upon the coroner the responsibility of seeing that every death in his district was certified by a medical certificate. That would be putting a tremendous burden upon him.
In the case of burial grounds in and around Dublin no person is allowed to be buried without getting either a note from the doctor or from the registrar with whom the death has been registered. If we could insist on the same procedure in the case of every graveyard in the country, matters would be all right.
As a matter of fact, undertakers in Dublin will not undertake the burial of a person unless such a document is supplied.
It may be all right in cities, but a great many country burials take place in old churchyards that are rarely used. How are you going to deal with such cases?
Later on the Medical Officer of Health may take a little more notice of these country graveyards and probably he will know all about these cases.
I think I can devise a sub-section with the other one giving the coroner power to hold an inquest where he becomes aware of this or to make inquiries where it is necessary.
One general section might cover the whole thing.
Such a section would have the effect of ensuring that persons would have proper medical attendance before death.
It might give many people a chance of having their lives saved who, without medical attendance, would die.
We are leaving over the section dealing with the power to hold an inquest without a jury. The next matter we have to deal with is the viewing of the body. Up to the English Bill we have got here, both the coroner and the jury were bound to see the body. Before the Act of 1881, the jury had to be sworn in the presence of the body. There is no necessity for that in ninety-nine out of a hundred cases, and I have suggested that we ought to adopt the section in the English Bill in regard to this, that is sub-section (1) of Section 13:
" (1) At or before the first sitting of an inquest on a body the coroner shall view the body, and if before the body has been buried the coroner so directs or a majority of the jury so desires, the body shall be viewed by the jury also: Provided that where a previous inquest on the body has been begun but not completed, it shall not be obligatory upon the coroner holding a subsequent inquest to view the body."
As a corollary to that, I think we ought to add the provision in the English Bill which enables the coroner, after he has viewed the body on which he is to hold the inquest, to issue an order authorising the burying of the body.
I think you can add that. That is the provision in sub-section (2) of Section 13:
" (2) A coroner may at any time after he has viewed a body upon which he decides to hold an inquest by order under his hand authorise the burial of the body, and shall give the order to the relative or other person to whom it is required by the Registration Acts to be given."
The next section deals with cases in which there is a disagreement of the jury. At present the law is that you must summon at least 12 and the practice is to summon up to 23. There has to be an agreed verdict from at least 12. There may however, be only 12 on the jury and there is no reason why a couple of cranks should be capable of spoiling an inquiry.
The cranks are often honest men.
I suggest that we should adapt the section in the English Bill in regard to this, which reads as follows:—
" 14. (1) If the jury at an inquest fails to agree on a verdict, and the minority consists of not more than two, the coroner may accept the verdict of the majority, and the majority shall, in that case, certify the verdict in accordance with the requirements of sub-section (3) of Section 4 of the Coroners Act, 1887."
That would prevent an unnecessarily large number being summoned. I have seen inquests with 21 and 22 jurors—a number that was quite unnecessary.
This section we are dealing with now will not limit the number.
But it will help the coroner. He can limit the number to 12 if he wishes.
Do you propose to do anything in regard to the manner in which juries are summoned?
That is still done under the old Act of 1846. The coroner issues what is called a precept to the Civic Guard and they go out and get " good men and true " who are householders. That is what they are supposed to do.
Sometimes they merely go outside in Store Street and " nab " persons who are passing.
The sub-section I have read gives the coroner the right of taking a majority verdict if there is a sufficient majority. There is another sub-section which I suggest:
(2) In any other case of disagreement the coroner shall discharge the jury and issue his precept for summoning another jury and thereupon the inquest shall proceed in all respects as if the proceedings which terminated in the disagreement had not taken place, except that it shall not be obligatory on the coroner to view the body again."
There is another point that should be considered. At present the jury must be called from the district where the death took place. In the case of an accident in a factory you have a number of the workers in that factory summoned, and they have to come to view the body of one of their own fellow-workers.
There is a number of disqualifications in the case of jurors. If a man dies in hospital or prison the doctor of the hospital cannot be examined as a witness, except as to the mere cause of death, and in the case of the prison a warder is not allowed to act on the jury.
I was referring to the case of persons employed in a factory in a country district.
I remember a case where one of my employees was killed, and the jury consisted of a number of fellow-workers. They were in an awful quandary as they did not like to be sitting in judgment on me.
I think it would be desirable to have a jury outside the district.
I tried to make them get another jury, but they could not.
In England, where the villages are large, they would not have to go outside the village, but take the case of a small village in Ireland, where you cannot, perhaps, get a jury if you exclude the place of employment. You could get a jury who would have no interest in the case by going a little further.
Would the idea be to disqualify any person in the same employment as that of the deceased?
I would not have anything so hard and fast. Of course, there are very exceptional cases.
At present jurors must be householders living in the district. Formerly they had to be rated " for the relief of the poor in a sum not less than £4." That has been changed. The valuation of the house has been abolished.
And they should be summoned in writing. I think that is right.
The next section we might adapt is that giving power to hold a post-mortem examination without an inquest. As the Chairman told us, the present law is that the coroner can order a post-mortem examination only when the inquest is held. This gives him power to have a post-mortem examination and to avoid an inquest where it is not necessary. As adapted, the section reads:—
" (1) Where a coroner is informed that the dead body of a person is lying within his district and there is reasonable cause to suspect that the person has died a sudden death of which the cause is unknown, if the coroner is of opinion that a post-mortem examination may prove an inquest to be unnecessary, he may cause such an examination to be made and the result to be reported to him and for the purposes of the examination the coroner and any person authorised by him to conduct the examination, shall have the like powers, authorities and immunities as if the examination were an examination directed by the coroner at an inquest upon the body of the deceased.”
Then it goes on in two other sub-sections:—
" (2) If as a result of such an examination as aforesaid the coroner is satisfied that an inquest is unnecessary, he shall send to the Registrar of Deaths whose duty it is to register the death, a certificate under his hand stating the cause of death as disclosed by the report, and the Registrar shall make an entry in the register accordingly.
" (3) Nothing in this section shall be construed as authorising the coroner to dispense with an inquest in any case where there is reasonable cause to suspect that the deceased has died either a violent or an unnatural death or had died in prison, or in such place on in such circumstances as to necessitate the holding of an inquest in accordance with the requirements of any Act, other than the Coroners (Ireland) Act, 1846."
I think that is a necessary proviso, because that limits his power. He is entitled to have a post-mortem examination, and if the post-mortem shows that it is a natural death he can dispense with the inquest, but he cannot dispense with it in a case where it is unnatural or violent.
These are all the sections that I think might usefully be introduced. A lot of other suggestions have been made, and I think the Clerk has got a letter in connection with some of these. Some of the coroners are anxious to come here and give us their opinions. Mr. J. J. Horgan, who is Coroner in Cork, and who is a very useful man, is very anxious to give us his views. This is a letter from Mr. Horgan, dated last May. It is addressed to Mr. De Loughry, who was responsible for the Bill:—
" Dear Sir,—I see by the Press that your Bill concerning the holding of inquests has been referred to a Special Committee of the Senate, and I desire to point out from my considerable personal experience that there are two matters connected with the practice in Coroners' Courts which urgently require alteration, and venture to hope that you will be able to embody them in this Bill.
" The first is the practice of requiring the jury to view the body of the deceased person, in every case perfectly useless, and in most cases an extremely repulsive task. It is, I presume, a relic of the dark ages when medical evidence was neither exact nor readily procurable. Under modern conditions, where the doctor's evidence is always conclusive, the coroner should be given complete power to dispense the jury from seeing the body, or better still, the practice should be completely abolished.
" The second matter requiring attention is the necessity for summoning a jury of twelve in every inquest, no matter how unimportant. I enclose a copy of section 7 of the English Juries Act of 1918, which dispenses with coroners' juries altogether, save in cases of death in prison or murder or manslaughter. This was brought into force during the war, and has worked so well that it has since been continued. I need scarcely point out that in remote country places the present system imposes a great deal of work on the Civic Guard in collecting a jury, and often compels people to neglect their work and travel considerable distances in order to attend. The section in the English Act in no way prevents the coroner from summoning a jury in such cases where he considers local knowledge to be of use.
" I trust you will favourably consider these suggestions, which are the result of much anxious consideration and practical experience, and which have the support of other coroners with whom I have discussed them. If necessary, I shall be glad to give evidence before your Committee on these matters. I brought them before the Minister for Justice in January, 1924, but at that time he did not think it was opportune to deal with them."
I think we have embodied all the points that he raised.
He has anticipated everything.
And we have anticipated him, too. I wonder if Dr. O'Sullivan would like to attend to give evidence? Mr. Horgan probably never anticipated that all his points would be met. At the same time, if he would like to attend we could invite him.
Dr. O'Sullivan is a member of the Seanad.
He is not a member of the Committee.
I fancy we have covered all the points.
Mr. O'Sullivan, our Clerk, informs me that Mr. Horgan told him that he would get the Coroners' Association to meet prior to his appearing before us, if invited, and that they would then decide the general lines of his evidence.
We are now in a position to hear them because we know what is the matter.
That is the purpose of our meeting—first, to get an idea of what the law is at present and, secondly, to have our minds made up as to the amendments that are to be introduced. Then we can see if there are any other amendments of a useful kind that may be suggested to us. We can fix a date and invite the Coroners' representative to attend on that day. We would then have all these suggestions before us.
It was accordingly agreed that the Clerk should request Mr. J. J. Horgan and Dr. O'Sullivan to attend the next meeting of the Committee for the purpose of giving evidence.
The Committee adjourned at 4.5 p.m. till Wednesday 24th, March, at 11 a.m.