WHAT HAPPENS WHEN a loved one dies in tragic circumstances? While bereaved families and friends look to our communities for comfort and support, they also look to the State for an appropriate investigation and explanation of what has happened.

The coroner’s inquest can play a central role in this process and can provide answers to questions about how and why our loved one died. An inquest should also help society to learn lessons from unexpected deaths and prevent similar avoidable deaths in the future.

But in Ireland today this investigatory process is not functioning as it can or as it should. Ireland’s system of investigating deaths in suspicious or unnatural circumstances is under-funded and our coroners are not adequately empowered or equipped to fulfil these crucial public functions to their full extent.

• Read more here on how to support a major Noteworthy investigative project to examine if the coroner process of investigating tragic deaths is failing families. 

In 2000 – twenty-two years ago – an independent review group recommended root-and-branch reform of the coroners’ system. Exactly one year ago, the Irish Council for Civil Liberties (ICCL) published a research report which showed that, in the twenty-one years since that first report, very little had changed.

A year on from the publication of our research, and 52 recommendations for concrete reforms, still nothing has changed.

Our report included interviews with bereaved families and people working in the system and found that, for many families, the inquest process can compound and aggravate their grief. At the inquest, grieving families described finding themselves with no waiting areas, no private space, and often being without support.

One family who spoke to us told us the professionals present “had coffees and pastries but there was nothing for the family who are grieving, we were left in the corridor.”

Families spoke to us of a lack of basic information about how the process worked and of not being able to access legal advice.

Many remembered being stonewalled by state agencies as they tried to get to the truth of how their loved one died. Families were left feeling like a problem those working in the system hoped would just go away.

Delays prolong trauma

Chronic delays in the process prolong families’ trauma. These delays also mean crucial information on how to prevent deaths in similar circumstances is not disseminated on time.

Researchers can’t get reliable data on the number of deaths by suicide, deaths among people experiencing homelessness, or deaths from road traffic accidents. This lack of data means little to no hope of developing robust policy to prevent avoidable deaths.

Today, the Irish coroners’ service is a network of mainly part-time, under-resourced coroners operating largely independently of each other. Inconsistencies between districts mean that an inquest into a death in Dublin is not the same as an inquest into a death in Kerry.

Despite the work of An Garda Síochána often falling under investigation at an inquest, the coroners’ system relies on gardaí to carry out its investigations. There is no system for following up on recommendations made by coroners and no guarantee that they will be implemented.

So what are the solutions?

How can we put in place a modern coroners system that is fit for purpose? The good news is that much of the path to reform is already known, from the Government’s own report from 2000, from several partial attempts to reform the system over the intervening years, and from ICCL’s most recent report.

What is needed is a political commitment to fund a national coroners’ service; and to design a coroners’ system with the needs of families in mind.

The system must be based around adequately paid and trained full-time coroners throughout the country. Coroners must be entirely independent of An Garda Síochána with their own investigatory staff.

Information about the process must be made available to families. Counselling and legal aid for families should be a guaranteed by law. Delays must be addressed and recommendations arising from inquests about preventing future deaths must be followed up.

If there was any doubt about the inadequacy of our current system, the fact that fresh inquests are only now being initiated again with respect to the Stardust tragedy of 1981 proves the case for radical change now.

Tinkering around the edges will not address these systemic failings. The State owes bereaved families the truth and it owes them dignity through the process of getting to the truth. For all of society, we need to have confidence that lessons will be learned when tragedies occur.

Liam Herrick is the Executive Director of the Irish Council for Civil Liberties. 

PROLONGING GRIEF Investigation

Do you want to find out if the coroner process of investigating tragic deaths failing families?

The Noteworthy investigative team want to speak to families about their experience of this service and also examine the resources allocated to coroners around the country.

Here’s how to help support this proposal>