The Living and the Dead: ‘There is concern the system is failing families seeking truth and justice’

People should be looked after in death as much as when they are alive but the work of the State’s coroners is not properly recognised as important, says Dr Eleanor Fitzgerald, president of the Coroners Service of Ireland (CSI) and coroner for north Mayo.

The coronial service is not properly resourced and coroners are subsidising the service through their own work as solicitors and doctors, Fitzgerald says. “The work we do is not properly recognised as important, that is disrespectful by the Department of Justice.”

“I wonder about the priorities. It’s a matter of principle. People should be looked after as much as in death as when alive, Irish people are very concerned with deaths and inquests, and it is important to recognise that. Being a coroner is a serious job.”

Deaths by natural causes account for the vast bulk of the work of Ireland’s 32 coroners and most bereaved families can get on with the natural process of grieving.

Inside Ireland’s Coroners’ Courts: ‘No matter where you are, or who you are, at the time of death, it should not be a postcode lottery’

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The Living and the Dead: ‘Families are very much isolated from the process unless they are proactive’

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The Living and the Dead: A day in the coroner’s court in Castlebar

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[ The Living and the Dead: ‘Families are very much isolated from the process unless they are proactive’ ]

[ The Living and the Dead: A day in the coroner’s court in Castlebar ]

For the less fortunate, those who experience sudden, violent or unexplained deaths of a loved one, there may be investigations, postmortems and inquests. Covid-19 added even more layers of complexity and grief, depriving people of last moments with loved ones and comforting rituals such as wakes which traditionally surround death in Ireland.

The workload of coroners is rising for reasons including population increase but coroners and supporters of reform say the added burden is not matched by the necessary resources.

Issues that must be urgently tackled, Fitzgerald says, include an insufficient numbers of pathologists and histologists, delaying postmortems and inquests; appointment by the HSE of bereavement officers to help families navigate the system; increased funding of the service and a reversal of cuts to coroners fees imposed in 2009.

The Cork City Coroner was so frustrated with the failure to sanction six more staff by 2019 that, following several warnings, he advertised in recent weeks for two more staff and warned of legal proceedings if the council refused to pay for them

Documents obtained by The Irish Times from Cork City Council under the Freedom of Information (FOI) Act show that Philip Comyn, the Cork City Coroner, accused the council over several years of failing to address a “crisis” in the coroners service there.

The failure to have a strategic plan for the service and to appoint more staff “is causing severe and unnecessary hardship for families of deceased persons and cannot continue”, he told the council CEO, Ann Doherty, in a letter last October.

The “gross understaffing” of his office creates many problems, including delays issuing death certificates and regarding cremations, delays holding inquests and postmortems and releasing bodies of deceased persons who live outside Ireland for burial, he told the council in several letters from 2018 to November last.

In a business case to the council, Mr Comyn outlined that the staff shortages mean the response from his office to complex cases is “not occurring in a timely fashion”. He particularly referred to cases involving deaths of children, hospital deaths, deaths by suicide/drugs, deaths with international dimensions and deaths in care facilities, including nursing homes and psychiatric hospitals.

The business case contrasted the resources of his office with those of Dublin, the only coronial district both controlled and funded by the Department of Justice.

Cork and all other districts are answerable to the Department but are funded by their local authority.

Cork City has one full-time coroner sitting in court one day weekly and two full time clerical staff for an area of some 125,000 people while Dublin has four full-time coroners sitting in court five days weekly and 24 staff for an area of some 550,000 people, he said. The Dublin office had 12 times the level of resources available to Cork to conduct an average of five times the amount of comparative work in the period 2018 – 2021, he said.

“It is accepted the Dublin office is currently understaffed. It must also be accepted the Cork Office of the Coroner has an inequitable level of resource and is grossly understaffed.”

He was so frustrated with the failure to sanction six more staff by 2019 that, following several warnings, he advertised in recent weeks for two more staff and warned of legal proceedings if the council refused to pay for them.

He also asked Cork Lord Mayor Deirdre Forde to permit him to address a full meeting of the council about resourcing his office.

According to the business case, the Cork City coroner inquired into 917 reported deaths in the city in 2014 and completed 192 inquests. In 2021, there were 1,337 reported deaths, an increase of 35 per cent on 2014, leading to 290 inquests, with another 113 inquests pending.

The Covid-19 pandemic had a major impact on the number of inquests pending since 2019, the business case notes.

Mr Comyn said the absence of a strategic development plan for his office has resulted in a lack of strategic attention paid by responsible bodies for the required provision of resources to deliver on the expectations of “this critical role in society”. It also resulted in the loss of the essential histology services within the region, resulting in a potential nine-month delay in the completion of a postmortem and subsequent inquest, he said.

Back in February 2019, the coroner told Ms Doherty the position in his office was “critical” and he copied the letter to then minister for justice Charlie Flanagan and then minister for local government, Eoghan Murphy

In response to the correspondence, the council has denied breach of its obligations and referred to discussions among local authorities about improving efficiencies in coroners services.

It supported Mr Comyn’s view the Cork service should be funded by the Department of Justice, noted the Department is reviewing the Coroners Act 1962 and had recognised that needed to be updated.

In July 2019, a council official denied Mr Comyn’s allegations the council was in breach of its statutory obligations regarding the coroner’s office. She said the council paid €330,318 in 2019 to support the coroner’s office, including a €44,000 retainer for the costs of the office, some €35,000 for an employee, €250,000 in fees per item such as postmortem reports and death certs. The council was paying additional administrative costs and cannot provide further funding, Mr Comyn was told.

A report by the Irish Council for Civil Liberties (ICCL) said the failure of successive governments to implement reform is causing ongoing human rights violations,

Moves to achieve reform of the coroners system date back more than 20 years but progress has been slow. In 2000, a working group appointed two years previously by the Department of Justice to review the system recommended a full and radical overhaul. A Coroners Bill introduced in 2007 fell with the dissolution of the Dáil and lapsed as Ireland was engulfed by a financial crisis.

It took until 2019 to introduce the Coroners Amendment Act, providing for limited changes to the 1962 Coroners Act – a requirement for inquests to be held in all cases of maternal death and civil legal aid for families whose loved ones died in custody, in prison or as an involuntary patient in a mental health institution.

The demand for more comprehensive reform has intensified and the Oireachtas Justice Committee, which heard last summer from proponents of reform, including retired Kildare coroner Denis Cusack, who headed the 1998 review group, is due to report in the coming months.

Cusack described the service as not fit for purpose and set out the measures necessary to achieve a more professional and streamlined service, including reorganisation of coronial districts within a larger coronial structure, the appointment of a chief coroner and deputy chief coroner, coroners’ investigation officers and support service arrangements.

The service is “for the living as well as the dead” and must balance the legal format with compassionate sensitivity, he urged.

A report put before the committee by the Irish Council for Civil Liberties (ICCL) said the failure of successive governments to implement reform is causing ongoing human rights violations, the service is “seriously under-resourced” and the delay in holding inquests is “unacceptable”.

It set out 52 recommendations for an independent professional coroner service, including structural reform, a significant increase in funding and a new coroner agency and inspectorate.

Doireann Ansbro of the ICCL told The Irish Times that a priority is the development of a ‘charter for the bereaved’ outlining the rights of families and placing them at the centre of the system. “There is a real concern that the system is failing families in seeking truth and justice.”

The ICCL sought families to participate in the research and, of 25 families who did, many reported a negative experience with the coroners system with delays in hearing/finalising inquests a particular source of frustration.

Many want a system ensuring inquest recommendations are acted upon, Ansbro said. “They did not want other families to go through this.”

“The report is about criticising the system, not coroners. We recognise some coroners provide really excellent support and a compassionate response, the concern is about ensuring a professional system. All the significant actors agree the system is broken and in need of reform.”

Fitzgerald says, when it comes to reform: “We have to think about what is achievable, practical and realistic.”

She would like to see all coronial districts controlled and funded by the Department of Justice. The Dublin district, with four full-time coroners running inquests five days weekly, a staff of 24, a comprehensive website, three dedicated courtrooms, and its own mortuary is the envy of many coroners.

“The councils are strapped for cash and sometimes they don’t understand what costs are involved for us. It would be better to have a more streamlined service,” says Fitzgerald.

Her retainer from Mayo County Council to run the north Mayo service does not cover the costs of a county clerk and a secretary four days a week, which she pays for herself, she says.

Coronial districts, together with secretarial and other supports, could be amalgamated as coroners retire but she has concerns that having full-time coroners could “depersonalise” the service and mean, for example, having just one coroner in the West of Ireland and “more layers of bureaucracy for people to deal with”.

“One coroner per county perhaps might be a better option.”

A separate coroners investigation service would mean duplication and more costs but that may be a different issue in Dublin which deals with a lot more fatalities, she says.

Fitzgerald believes the negative experiences of the service reported by the families who participated in the ICCl research is “not representative of the experience of the majority of coroners in dealing with families” but stresses that proper communication is essential.

Coroners are actively trying to improve communication links with people but there can be “gaps” in the information provided to families and confusion, especially about why results of postmortems or toxicology have not come back. Cytology sent to Dublin or London for testing can take between three and six months, causing more anxiety for people, she notes.

Having a set of coroners rules and a rules committee could address that, she says.

The input of coroners who are GPs is valuable, she says. “Without GPs, there could be more inquests and more unnecessary witnesses. It is very legalistic now. The best of both worlds of course would be a coroner who is both a lawyer and a GP.”

Inquests are “only a small part of our work”, she stresses. “We are confined to facts and evidence and rely on the gardaí. More questions are being asked about deaths, we are becoming more litigious. I think that affects GPs a lot, if they are not 100 per cent sure of the cause of death, they will look for a postmortem, hospitals too are under the spotlight.”

When an inquest goes beyond inquiry into “accusations”, that can be “defamatory, intimidating and demoralising”, she says. “Most GPs operate in accordance with best standards but they do not have access to every diagnostic tool and are under a lot of pressures.”

There is an issue, she believes, as to whether fear of making decisions “may paralyse medicine”.

She stresses that deficiencies have to be pointed out in the public interest and she believes recommendations made at inquests can form part of a learning process.

Recommendations for road safety improvements are often followed up but other recommendations can “end up on a shelf”, she says. “Coroners do not have powers to enforce them, it’s really up to government. I would like to see more recognition of what coroners say at inquests, especially about addressing trauma.”

Fitzgerald presided over the inquest in Belmullet last June into the deaths of all four crew members of the Irish Coast Guard Rescue 116 helicopter after it crashed off the north Mayo coast in 2017.

The jury returned verdicts of accidental death in relation to all four. The bodies of Captain Mark Duffy and Captain Dara Fitzpatrick were recovered but the remains of their colleagues, Winchman Ciarán Smith and Winch Operator Paul Ormsby, were lost at sea.

“I met the families at the opening of that inquest, times like that bring home to you the trauma that people undergo,” says Fitzgerald. “The families were welcomed and cared for by the local community. The inquest was important for them, it was very poignant and emotional to hear the evidence from start to finish and the questions asked, and answers given. The jury was well informed, I hope lessons will be learned.”

Suicides are the “most harrowing” inquests to preside over. “The deceased are often young adults and teenagers, parents are very affected. Garda liaison officers are on site, I always tell the families that. We get a lot of positive feedback from people.”

A spokesman for the Department of Justice said the coroner service “provides an important service to next of kin and society in general”. Investigations can be “a difficult and painful experience” for next of kin but the Minister “is confident that Irish coroners endeavour, as far as possible, to show great sensitivity towards bereaved families and to accommodate their concerns”.

Delays can arise, for example, in receiving postmortem reports, toxicology or other test results, or in the availability of witnesses and this can lead to delays in holding inquests, he noted. The Department has no role in the conduct of death investigations or inquests, he added.

Work is ongoing within the Department on preparing for a review that will deliver “a comprehensive service improvement plan to address identified issues in the coronial system”.

“The priorities for reform are driving innovative change, enhancing customer service and improving the interaction with pathology services.”

The fees restoration sought by the CSI will require consultation between the department and other government departments and local authorities, he added.