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An inquest is an official enquiry, held in public and led by a Coroner (sometimes held with a jury)  to enquire into the cause of a sudden, unexplained or violent death.   In the case of some deaths an inquest is legally required.  In other cases an inquest is held at the discretion of the Coroner.  Here Roger Murray, Partner at CallanTansey Solicitors outlines some of the most common queries regarding inquests.

What is the Purpose of an Inquest?

1. To establish the identity of the person who has died;
2. To establish how, when and where the death occurred; and
3. To investigate the circumstances in which the death occurred and
4. To make findings and return a verdict.

 What is the role of a Coroner?

The Coroner examines the circumstances surrounding a death, investigates the medical cause of death and also the wider surrounding circumstances leading to the death.

What does a Coroner Do?

The Coroner’s job is to investigate all deaths reported to him or her.  If the death is natural, and a Medical Certificate can be procured so certifying, that is the end of the investigation.  Where the death is unnatural or where there is some doubt about the circumstances leading to the death, the Coroner will direct that a post-mortem takes place.  After the post-mortem report is available to the Coroner, he/she will then decide if a full Court Inquest is required.  A Coroner must hold an Inquest in relation to the death of any individual in State custody, (regardless of the circumstances) and it is also now mandatory for the Coroner to hold an Inquest where the death is a maternal death or late maternal death (within 12 months after birth taking place).  In all other circumstances, the holding of an Inquest is at the discretion of the Coroner.

Who reports the death to the Coroner?

Persons obliged to report death to the Coroner include the following:

1. Any Medical Practitioner, Nurse or Midwife who had responsibility for, or involvement in, the treatment or care of the person who has died in the period immediately before his/her death or who was present at his/her death.
2. Any Medical Practitioner who examines the body of a Deceased after death.
3. Any Paramedic or Advanced Paramedic who had responsibility for, or was involved in, the care of the Deceased in the period immediately before his/her death or who was present after his death.
4. The Funeral Undertaker responsible for the disposal of the body of the Deceased person.
5. The person in charge of a mortuary.
6. The occupier of a house or other dwelling including a mobile dwelling in which Deceased person was residing at the time of the death
7. The person in charge of any public or private institution or premises in which the Deceased was residing or receiving treatment.
8. A person who had care of the Deceased immediately prior or before his/her death
9. Where the Deceased person was in State custody or detention the person who has responsibility for the Deceased person
10. The person in charge of an aircraft, ship or other vessel landing or arriving in the State on which the Deceased person was travelling at the time of his/her death.
11. The Registrar of Deaths in the District.

Unless that person has reasonable grounds for believing that the death has already been reported to the Coroner by another person specified in the list above.

In the context of a stillborn child or a death during birth any medical practitioner, nurse or midwife who had responsibility for, or involvement in, the treatment or care of the woman concerned in the period immediately before or after the delivery of the stillborn child or was present at the delivery is required to report the death of the baby.

The obligation to report is discharged if the person reports the death as soon as practicable after becoming aware of it to a member of An Garda Siochana.

What Categories of Deaths Must be Reported to a Coroner?

1. Maternal Deaths and Late Maternal Deaths
2. The death of a stillborn child or of a child during its first year of life.
3. Any death which occurred or may have occurred either directly or indirectly:
   1. In a violent or unnatural manner or by unfair means;
   2. By misadventure or accident;
   3. Unexpectedly and for unknown causes or in an unexplained manner;
   4. As a result of negligence, misconduct or malpractice on the part of others, or
   5. In such circumstances as may, in the public interest, require investigation.
4. Death by suicide or by assisted suicide
5. Death by notifiable disease
6. Death by drug reactions or overdose
7. Death by prion disease
8. Deaths that may be healthcare acquired infection
9. Any death occurring in a hospital or other health institution
   1. That is unexpected
   2. Within 24 hours of presentation or admission whichever is the later
   3. Of a person transferred from a nursing home
10. Any child who dies during birth.
11. Any death occurring in a hospital or other health institution that is directly or indirectly related to a surgical operation or anaesthesia (including recovery from the effects of anaesthesia) or to any other medical, surgical or dental procedure, regardless of the length of time between the procedure and death
12. Any death where an allegation is made, or a concern has been expressed regarding the medical treatment provide to the Deceased person or the management of his or her healthcare.
13. Any death which may be as a result of an unconventional medical procedure or treatment

What is a Coroners Court?

The Coroner’s Court occupies a “unique” position in Irish law.  It has many powers and functions which point to the administration of justice such as: the power to summon witnesses under Section 26 and to compel their attendance under Sections 36 and 37.  A person may be found guilty (section 38) of contempt at an Inquest and be brought before the Court.  A new Act (The Coroner’s (Amendment) Act 2019) came into force in February, 2020 which has given Coroners much greater powers and will help families get answers.

The Coroner’s Court has now the capacity (albeit with the assistance of other Courts) to penalise reluctant witnesses, people who deliberately mislead the Court, and/or those who obstruct the Court in its investigative powers.  Its investigative powers have been significantly strengthened.  Now it has the power to seek discovery of records and obtain search warrants to search buildings and seize documents and equipment.

Section 16 also proposes to amend Section 31 of the 1962 Act.  This gives investigative powers to the Coroner’s Court in relation to determining how a death occurred.  For example, if the HSA has concluded that a company is guilty of corporate manslaughter, the Coroner now has the power to investigate any individual who is responsible and to determine if  such individual is “liable to be proceeded against and punished” and pass that finding to another Court.  The view that the Coroner’s Court is becoming a significant player in the Irish judicial landscape is strengthened by the extension of the Legal Aid Scheme to family members at Inquests.

What are the steps a Coroner takes once notified of a death?

Once notified of a death, the Coroner will ask the investigating member of the Gardai for all details relating to the Deceased including all of their personal details and full and detailed circumstances surrounding the death including the name of the registered medical practitioner who pronounced death and the name of any medical practitioner who may be in a position to offer a Medical Certificate of the cause of death.  In the vast majority of cases, deaths are usually reported by a Doctor directly to the Coroner or the local Garda Station.  Following receipt of the details, the Coroner will make enquiries in relation to the circumstances of the death.  Even if the death was sudden, if it is due to natural causes, the Coroner will contact a registered medical practitioner and ask him or her to issue a Medical Certificate of the cause of death.  This will only happen where it appears to the Coroner that the death is not due to any unnatural cause.  The registered medical practitioner must have seen and treated the patient within one month prior to the death and there should be no other circumstances which might require an Inquest to be held.  If allegations of one kind or another are in existence or there is some concern, the Coroner will not permit the doctor to issue a Medical Certificate and will proceed to direct a post-mortem examination.  It must be emphasised that the Coroner has legal possession of the body and has a statutory duty to enquire fully into all of the circumstances of certain deaths.  If the medical doctor is in a position to satisfy the Coroner, with regard to the cause of death, and no other matters arise or give the Coroner cause for concern, the Coroner will normally direct the medical practitioner to issue a Certificate and the death will be registered without an Inquest.  The fact that a death is reported to a Coroner for discussion does not necessarily mean that an autopsy will automatically be required.  However, once the Coroner is in possession of all of the relevant facts and has had a full discussion, the Coroner can make an informed decision as to whether or not it would be prudent in the circumstances to direct a post-mortem examination.  If there is any doubt in the matter, the better course of action is for the Coroner to so direct.  Where the post-mortem examination confirms or establishes an unnatural cause of death or where the circumstances surrounding the death give rise to concern, an Inquest must be held.  While awaiting a post-mortem report or prior to the Inquest being held, the Coroner’s Office may provide, on request, an Interim Certificate of the Fact of Death, which is acceptable to banks, insurance companies and other institutions to confirm that the death has occurred albeit that the circumstances have yet to be established.

What powers does a Coroner have?

• To direct a Post-Mortem examination of a Deceased person;
• To direct the holding of an Inquest;
• To direct that all relevant medical records be given to the registered medical practitioner conducting the post-mortem examination and to the Coroner;
• To get a High Court Order to direct that a person giving evidence comply with a direction given by the Coroner

Who acts as a Coroner?

1. Any registered medical practitioner or legal practitioner of at least 5 years standing.
2. A Coroner is allowed to hold office to the age of 70.
3. They must be appointed by the Local Authority for every district in whose area the district is situated.
4. Most Districts have Part-Time Coroners and Deputy Coroners, with the exception of Cork (full time Coroner) and Dublin City: full-time Coroner in addition to having an Assistant Coroner and two Deputy Coroners.
5. In all other cases, the people holding the position of Coroner have “day jobs” as practising lawyers or doctors.  Their position is as Coroner is part-time.

Does the Coroner have to keep the family of the deceased notified about Inquests and their findings?

Where a Coroner has directed a post-mortem examination, as far as practicable, he/she shall ensure that a family member of the Deceased person is informed of the fact and is informed that material may be removed from the body and retained for the purpose of a post-mortem examination.  A copy of the post mortem report may be furnished to members of the Deceased persons family if they so request.  There is no mandatory requirement to provide family members with the report.  The Coroner shall, if so directed by a family member provide a copy of the report to that family member but the Coroner does have a discretion not to furnish the report under the new Section 33 (E) 5 if the Coroner thinks that it is not proper to do so as it may prejudice criminal proceedings as are being considered or have been instituted.

How soon after death is reported is an Inquest arranged?

A death which is reportable to the Coroner as defined in the legislation must be reported “as soon as practicable”.  The Coroner will then see if a post-mortem is required and if a post-mortem is required, the results will generally be available within 6-10 weeks.  If the Coroner is then of the view that an Inquest is required, an Inquest will take place as soon as the opportunity to set a date for hearing for the Inquest.  This will depend on a number of factors including the number of witnesses, the complexity of the facts, whether documents are involved and whether witnesses are available.  For complicated Inquests, it is not unusual for them to take place a year or more following the death of a Deceased.  Inquests can generally be concluded within one day, but certain complex medical Inquests can go on for several days.

Who can go to an Inquest?

Inquests are heard in public and any member of the public can attend any Inquest.  Only properly “interested persons” may ask questions.  This would include family members of the Deceased or anyone involved in their death.  They are entitled to ask questions themselves, or appoint lawyers to represent them.  The proceedings at an Inquest are inquisitorial in nature:  it involves working together to try to help the Coroners Court gather evidence.

Are there different types of Inquest?

Inquests are essentially an Inquiry into the circumstances surrounding the death of the Deceased.  Some Inquests will, of course, be more lengthy and complicated than others.  If the immediate cause of death is clear and if there are no significant or lengthy background facts, then the Inquest can generally be determined in a number of hours.  If the case involves for instance complex medical treatment taking place over several days or weeks and involves many witnesses and medical records, then the Inquest may hear from many witnesses and may take place over several days.

What should you wear to an Inquest?

Because an Inquest is a formal event and takes place in a Court, formal/business wear is the norm.

What happens if I am called to be Witness at an Inquest?

If you are called to be a witness, you will first be contacted by the Gardai and you will be asked to provide a deposition.  That deposition can either be prepared in writing by you or with the assistance of the Gardai.  The written deposition is then submitted to the Coroners Court.  When the Inquest begins sitting you must then physically come to Court and read that deposition out.  Once the deposition has been read out and signed by the person giving evidence, then it becomes evidence.  When you are in the Coroners Court, and you are called to physically give evidence. You will have to speak in public under oath in the witness box.  You are liable to be asked questions by both the Coroner and any legal representatives present for any of the interested parties.

 Do you have to attend an Inquest if called as a Witness?

It is an offence to not answer a Summons to appear as a witness at an inquest where “no reasonable excuse exists”.  The Coroner has a new power to go to the High Court in respect of any person who has been served with a Summons and fails without reasonable  excuse to attend.The High Court can then:

1.  Order the person to comply with the Summons
2. Make such other or other Order as is necessary to enable the Order to be made
3. Make an Order for costs.

What kind of evidence might the Coroner expect from a witness?

The Coroner will expect a witness to read out his/her deposition and answer questions.  They Coroner may also:

1. Direct a witness to answer questions, even if the witness refuses
2. Direct the production of, by any person, any document, article, substance, or thing in its possession or control

In this regard “document” includes the following:

1. A book, record or other written or printed material
2. A photograph
3. Any information stored, maintained or preserved by means of any mechanical or electronical device whether stored, maintained or preserved in legible form
4. Any audio or video recording.

What happens if a Witness is not in the State at the time of the Inquest?

Where a Coroner is satisfied that a person is likely to be absent from the State during the time of an Inquest, the Coroner may direct that the evidence of that witness be taken or the production by them of any document or article at any time before the commencement of the Inquest.

Can I ask questions at an Inquest?

You can ask questions at an Inquest only if you are “an interested party” or are the representative of an interested party e.g. a family member.  Remember, this is a Court, and the strict formal rules of evidence apply.  You will be facing qualified lawyers and the Coroner who is trained in the law of evidence.  It is much better to be legally represented.

What questions can I ask at an Inquest?

 If you are an interested party, either you or a lawyer on your behalf can ask questions to assist the Coroner in establishing the circumstances surrounding a death.  A witness is not obliged to answer a question which will result in criminal or civil liability.  Questions such as “Was this negligent?” or “Was this criminal?” will not be allowed.  The purpose of an Inquest is not to establish guilt or innocence; it is to assist the Coroner in establishing all of the facts which lead up to the death of the Deceased and to try to prevent something like that happening again.

 What powers does a Coroner have to gather evidence?

A Coroner has the power to apply to the District Court for a warrant to enter a premises, if necessary by the use of reasonable force, to inspect, copy or take extracts from or, if necessary seize, documents the Court requires or to inspect or to if necessary to seize the articles, substances or things concerned in those premises.

If a Coroner considers that he or she requires the advice or assistance of an expert in respect of a matter for the purposes of his or her inquiry into a death, he or she may seek and obtain such advice or assistance from a person who has expertise in respect of that matter.   This is a significant power and recognises that some Coroners have appointed their own experts to review certain matters, including, in particular, independent Pathologists.

A Coroner can direct a second post-mortem examination be carried out “for the purpose of enquiring into the death of a person”.

What is a Coroners Report?

The Coroner will have a post-mortem report which will assist him/ her in coming to a decision about the cause of death.  At the end of a Court hearing of all of the evidence at an Inquest the Coroner (or the jury) will record a verdict.  This will relate to the identity of the Deceased person and how, where and when the death occurred.  The “how” includes not only the medical cause of death but all the circumstances leading to the death.  It will generally be a short neutral summary of the facts followed by a formal legal conclusion or verdict such as “Death by Misadventure”, “Death by Accident”.  In most instances involving medical care, there will be a “Narrative Verdict” which is effectively a short summary of all of the evidence encapsulating everything that was discussed.  Recommendations can also be attached to the Inquest verdict which are recommendations of a general character designed to prevent further fatalities or are considered necessary or desirable in the interests of public health and safety.

Who can get a copy of a Coroners Report?

The post-mortem report is a private part of the Coroner’s file.  Only family members or their lawyers can access it.  The record of verdict can be applied for by the next of kin of the Deceased or their legal representatives but it is  a document of public record and is available to anybody who makes the appropriate application to the Coroners Office.