Barrister Doireann O’Mahony has accompanied many distressed families to inquests held into the deaths of their loved ones. Often, she says, they emerge asking: “What was the point of that?”

Some families feel they are “stifled, silenced or gagged”, unable to ask the questions they want to or not allowed to read out statements they wish to have heard in public.

“The service should be made more professional, more unified,” says O’Mahony. “From having done inquests in different parts of the country, I think there is an unacceptably high variation in the standards across the districts.”

O’Mahony is a co-author, with fellow legal professionals Roger Murray and David O’Malley, of Medical Inquests, a book exploring practice and procedure at such hearings.

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

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The Minister for Justice exercises control and funds the coroners service in Dublin, where things work “very smoothly”, she says, with a five-day service. Outside the capital, the service is funded by local authorities and, she says, is more “ad hoc”, with many coroners serving part-time.

“The system needs to be modernised and humanised. It does not seem right, no matter where you are, or who you are, at the time of death, it should not be a postcode lottery.”

She favours the system being unified and controlled by a chief coroner, with proper training provided for coroners and “more openness and transparency and accountability around the entire service”.

[ The Living and the Dead: A day in the coroner’s court in CastlebarOpens in new window ]

[ The Living and the Dead: ‘There is concern the system is failing families seeking truth and justice’Opens in new window ]

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

People dissatisfied with a coroner’s decision only have the option of going to the High Court to challenge it, but many are “terrified” of doing so because of the costs, says O’Mahony. A better and cheaper option would be a review board, she believes.

Inquests are inquisitorial rather than adversarial and O’Mahony disagrees they are increasingly being approached by lawyers for some bereaved families as “dry runs” for future litigation.

She is adamant that all necessary information should be available for examination. Her concerns include that internal and external investigation reports into hospital deaths have been ruled out by coroners, even when they feature “good evidence”.

In relation to decisions by coroners excluding certain evidence of families for legal reasons, she says it is very upsetting for the bereaved and difficult for them to accept.

“HSE lawyers would come in and say they take issue with sections of the mother or the widower’s deposition and want it completely redacted. That is traumatising for the person, they just want to read it out,” she says.

“Inquests cannot be so narrow that families wonder afterwards what was the point of all that, all it has done is re-traumatise us.”

Most coroners, O’Mahony says, do their best to be very sensitive to the feelings of the family, and gardaí in coroners’ courts are very helpful but the service needs more resources, especially bereavement officers to assist families through the process.

Recommendations made by coroners are too often ignored, she adds. Some have been made repeatedly, including a call that defibrillators should be installed in every Garda station and emergency vehicle.

So far, An Garda Síochána’s answer is that it does not have enough money to do so. “Is that a good enough response?” O’Mahoney asks, adding that there should be a system to ensure recommendations are acted upon and agencies put under pressure when they fail to do so.

Cork city coroner Philip Comyn agrees there should be a system for checking recommendations are followed up on, but says coroners should retain discretion on whether they make recommendations or not. He has had some successes where calls he made during inquests for road improvements after fatal crashes were followed up by Cork City Council, although without any communication from the council to him about the matter.

The councils and State agencies can do better in how they respond to such recommendations, he says. “There should be a system where the relevant body should at least acknowledge they have got the recommendation and say what they are going to do about it.”

Comyn’s efforts to improve education in schools around drugs after an inquest into the death of a young man who had taken an excessive amount of a potent street drug were less successful. “I wrote to the three teaching bodies, but got no acknowledgment.” Letters to the Departments of Justice and Education were at least acknowledged, he adds, but he was given no indications of any follow-up actions.

He believes “a lot of good has come out of” media reporting on the issues raised and recommendations made at inquests.

Mayo County coroner Pat O’Connor believes the handling of medical litigation in the courts in general needs to be “seriously addressed”.

“It is horrendously expensive, even at coroner level,” he says. “There are ways of saying sorry without admitting liability, that’s a legal fiction that has been fanned by individuals, companies, insurers to fan their own particular interests.”

O’Connor observed at first hand the emotional cost to families of the deaths of loved ones during the Covid-19 pandemic.

“When you have a double-wrapped body and can’t open the coffin and have a wake – part of the fabric of rural society – that is very difficult. All deaths during Covid were difficult for families,” he says.

“If someone died having contracted Covid or with Covid, medical people would certify the medical cause of death as Covid. That took out the necessity for postmortems but it had a huge effect on bereaved families.”

Inquests were not held in person at the height of the pandemic, while pathologists and morticians were often reluctant to carry out postmortems. O’Connor resumed hearings in June 2020 but other districts had longer delays for reasons including lack of available venues.

He strongly favours bereavement officers being appointed by the HSE to which coroners can refer families. He would also like to see them in hospitals. His local hospital, Mayo University Hospital in Castlebar, runs “a fine show” but deals with up to 500 deaths a year, and staff, nurses and morticians are not trained to deal with those affected.

“A lot of the difficulties and anxieties of families would be alleviated if somebody just listened to them and addressed their issues,” says O’Connor.

During his 33 years as coroner, O’Connor has seen “a steady stream” of suicides. “There are more males than females, maybe two-thirds male, they fall generally within the 22-32 age group but there are some older people.”

He is personally sceptical whether the creation of a new coroners service, with its own chief executive and staff, would bring much added benefit. He estimates such a service would cost €100 million-€150 million a year, compared with €20 million-€25 million for the existing service.

He stresses the coroners society of Ireland, for which he is the public information officer, supports a new model and he agrees there must be rationalisation and reform.

Coroners’ remuneration has not increased in 15 years, with cuts imposed during the financial crisis never reversed, he points out. O’Connor’s own legal receptionist doubles up as a secretary for his coronial work. “I feel coroners are taken for a bit of a ride by the Department of Justice; the services they provide are not properly recognised.”

Speaking in one of the two cramped offices he shares with two staff opposite the courthouse on Washington Street in Cork, with little space to move between boxes of documents piled up on the floors, Comyn says the Cork city coroners service needs an urgent injection of resources.

“Dublin deals with about 6,000 deaths a year, we deal with nearly 1,400. Dublin has 24 staff, we have two. We are understaffed, the local authority pays for one of my staff, I pay for the second,” he says.

He gets €300,000 a year from Cork City Council to run his office, including the wages of one staff member. He has sought extra staff for several years with no success. “It will come to a head soon,” says Comyn.

On call 24/7, Comyn, when informed of a death, has to decide whether to treat it as natural, meaning he has no further involvement, or to order a postmortem, normally carried out within a day or two. There can then be a wait of up to six months for postmortem results, mostly because the findings of toxicology tests can take up to five months to come back from the State laboratory.

Comyn says there are not enough pathologists and some of those coming through are not interested in doing coronial work for contractual and other reasons. “Some don’t want to go to court for inquests for reasons including the stress of it.”

Families may opt for narrative inquests, based on documents, or, in more complex cases, inquests involving witnesses and reports. Some, especially in suicide cases, opt for a documentary inquest, where no witnesses are called, where the coroner reviews files and statements and issues a verdict.

Like his Mayo colleague, Comyn remembers the pandemic with sadness and says it placed major strain on the coroners service with a “huge” number of nursing home deaths recorded in Cork.

“I had 105 deaths in one month and was dealing with very upset families. Because people died alone and families had no proper grieving process and were not able to say goodbye, that leads to more queries.”

Whether during a pandemic or not, he says families need the same things: clear, accurate information and compassion from those they deal with in the coroners service, hospitals and State agencies.

Communications between hospitals and families could at times “be better”, a point he underlines when delivering talks to hospital staff.

“Hospitals should be able to apologise without it attracting any legal consequences, that would go a long way towards assisting families.

“Grief affects people differently so you have to try to help them and explain the process. We have leaflets and send out letters explaining the process, there is also a coroners website. Some people need to hear it directly,” he says.

“It’s often that they don’t understand what is happening. Sometimes anger over a death can transfer to the office and the authorities. Litigation can be another factor; it can make an inquest more adversarial than it is designed to be.”

His staff are the primary source of contact between his office and bereaved families and he believes they generally deal with families very well “but we are limited by the resources we have”.

It is “inevitable” some families will be unhappy after inquests, he says. “There are times we could do things better. I feel that in most of the inquests we deal with, the family are happy at the end of it or at least they have closure and an understanding of what has happened. That is the best we can do.”