THE OFFICE OF CORONER AND THE CORONER’S COURT
HISTORY The office of coroner is one of great antiquity while the court of the coroner is the oldest in the British and Irish Isles. Some historians indicate that the office was established with that of sheriff so as “to keep the peace when the Earls gave up wardship of the County” in the twelfth century. It has been suggested that the office was more ancient than the division of England into Counties by King Alfred and that it is visted at the time of the Romans.
The position of coroner did exist at the time of King Alfred and is mentioned in the charter granted by King Athelsten to the monastery of St. John of Beverly in 925 A.D. In the reign of King Richard I the coroner was referred to and also in the Magna Carter and subsequent statutes.
First record of an Irish coroner was in 1302. The first coroner’s clerk was appointed in Dublin in 1732 at an annual salary of £10.00!
THE CORONER The coroner is an independent official with responsibility in law for the investigation of some deaths. The coroner, must in accordance with the law (the Coroner’s Act 1962 as interpreted by a number of High Court and Supreme Court decisions), enquire into the circumstances of sudden, unexplained, violent and unnatural deaths.
The coroner’s obligation is concerned to establish whether or not a death was due to natural or unnatural causes. If the death was due to unnatural causes then an inquest must be held by the coroner.
THE DEATHS THAT ARE REPORTED TO A CORONER All deaths that are sudden or occur unexpectantly or are due to some unnatural cause must be reported to the coroner. On the other hand where a person dies from natural illness or disease a doctor will issue a medical certificate of cause of death.
RESPONSIBILITY TO REPORT A DEATH TO A CORONER There is a legal responsibility on a medical doctor, a registrar of deaths, funeral undertaker, householder and every person in charge of any institution or premises in which a person who has died was residing at the time of his or her death to report such a death to the coroner where it is sudden, unnatural or violent. Generally speaking it is the Garda Siochana to whom a report is made who then notify the coroner of such a death.
DEATHS WHICH MUST BE REPORTED TO THE CORONER There is a long list of deaths that are reportable to a coroner whether they be in the person’s home, a place of residence, hospital, Garda station, prison, or as a result of a road traffic accident, accident at work or self inflicted (suicide).
WHEN A DEATH HAS BEEN REPORTED TO A CORONER WHAT HAPPENS? The coroner will enquire into the circumstances of a death reported to him and will find out whether or not a doctor is prepared to certify the cause of death. Subject to certain conditions, which time will not permit me to go into this evening, the coroner will more often that not permit a doctor to complete a medical certificate as to the cause of death.
If a medical certificate of the cause of death is not completed by a doctor then the coroner will direct that a post mortem examination be carried out by a pathologist. Regretfully it may take up to 2 months, and sometimes longer, before a post mortem examination (often referred to as autopsy) is received by the coroner. A death cannot be registered until the report is received.
Depending on the circumstances outlined in the report it may be necessary to hold an inquest.
INVOLVEMENT OF AN GARDA The Gardai act as officers for a coroner in addition to their reporting obligations in law. The Gardai generally arrange the formal identification of a body and have the difficult task of meeting with the relatives of a person who has died suddenly.
THE INQUEST An inquest is an enquiry in public by a coroner, sitting with or without a jury, into the circumstances surrounding a death. An inquest must be held by law when a death is due to unnatural causes.
The inquest establishes the identity of the person who has died, and “how, when and where the death occurred”.
Questions of civil or criminal liability cannot be considered or investigated at the inquest – Section 30 of the Coroner’s Act 1962.
The purpose of an inquest therefore is simply to establish the facts surrounding the death and to place those facts on the public record and to make findings on the identification of the deceased, the date and place of death and the cause of death. A verdict will be returned relating to the means by which the death occurred. A range of verdicts open to a coroner or jury include accidental death, misadventure, suicide, open verdict, natural causes and in some circumstances unlawful killing.
INQUEST WITH A JURY There are some circumstances where a jury is required. The coroner has a discretion in relation to having a jury in relation to the means by which a death has occurred for example self inflicted homicide / suicide does not require a jury.
OTHER MATTERS I will not go into the procedure, the evidence given at an inquest, witnesses and those entitled to be represented and or asked questions at an inquest.
THE VERDICT OF SUICIDE A verdict of death by suicide was historically available to the coroner although in the past, for religious and social reasons, it was not often recorded. For example a person who was deemed to have died by their own hand / suicide was not permitted to be buried in consecrated ground by the Catholic church until relatively recently.
According to my colleague Dr. Brian Farrell in his book (Coroners: Practice and Procedure) “an examination of coroners’ records at the Coroners’ Court, Store Street, Dublin which cover a period of over 150 years, shows that the verdict of suicide was infrequently returned (at least in Dublin City).”
The legal position changed as a result of Section 30 of the Coroner’s Act 1962 in a case entitled McKeown v Scully (1986)I.L.R.M., 133 wherein Judge O’Hanlon stated “it was obviously intended by Section 30 of the Act 1962 that it should not be open to a coroner’s jury to bring in a verdict that a named person had unlawfully killed the deceased and, an analogy, I would hold that it was not intended that it should be open to them to find that the deceased had unlawfully brought about his own death by suicide”.
Judge Murphy in the High Court in 1991 stated that a verdict of “self inflicted drowning “ was the same as suicide.
Of major significance in the Irish legal context was the decriminalisation of suicide by the Criminal Law (Suicide) Act 1993 Section 2(I) of which provides “suicide shall cease to be a crime”.
The section goes on to indicate that any person who “aids, abets, counsels or secures the suicide of another shall be guilty of an offence”.
Accordingly a person who attempts suicide is not guilty of any crime but a person who supplies another with a drug knowing it to be used to commit suicide may be guilty of an offence under the 1993 Act.
The suicide pact survivor is also guilty of an offence in encouraging the suicide of another. It has been suggested by writers that an offence under Section 2 of the Criminal Law (Suicide) Act 1993 can be found as an alternative verdict to murder or manslaughter.
The Supreme Court judgement in the 1995 case of Green v McLoughlin has created difficulties for coroners in returning verdicts of suicide. That case has been cited by legal representatives wishing to restrict the scope of an inquest. It has been suggested that the judgement of the court turned on the facts of the case at the time when suicide was a criminal offence.
Suicide can never be presumed by a coroner or a coroner sitting with a jury but must be based on the evidence that the deceased intended to take his or her own life. The test of sufficiency of evidence to prove such intention has been stated to be “where other possible explanations were totally ruled out”.
Judge Johnson, as he then was (now president of the High Court) in the Green v McLoughlin case in 1991 stated that “quite clearly Section 30 of the Act was intended to limit in many ways the capacity of the coroner to investigate certain deaths and the criminal or civil liability attaching thereto. … it does not question the investigation of certain facts”.
CORONERS, INQUESTS AND THE MEDIA All inquests are held in public. Journalists and reporters are very often present as they are entitled to be. While a minority of inquests are reported in the national media the majority of them are reported in the provincial newspapers though not on local radio, as far as I am aware.
Coroners are aware of the tragic circumstances leading to a sudden death and always try to treat the family and bereaved sympathetically. It is my experience, having been coroner for almost 20 years, and holding inquests as coroner and deputy coroner for more than 25 years, that the media, particularly the papers, treat sudden death by self infliction (suicide) with sympathy and understanding.
The existence of a suicide note will be acknowledged in the course of an inquest but the contents will generally not be read out, unless there is a specific request by the next of kin and or the legal representatives, in court. This is then only done at the discretion of the coroner.
Every attempt is made to ensure that an inquest is not duly intrusive of the families concerned.
The Press Council of Ireland has held a public consultation on the reporting of suicide. National and regional newspapers and magazines published advertisements inviting submissions from organisations and members of the public. The Press Council of Ireland’s report deals with the response to those recommendations. While the “jury is out” on the extent of reporting on suicide it is my experience that the media in general do adopt a responsible, understanding and sympathetic approach to the reporting of such tragic events.
In my coronial district, which in geographical terms is relatively small, more than 70% of the deaths that occurred in the last 3 years were self inflicted. In some cases I did not record a verdict of suicide as there was insufficient evidence to establish the intention of the deceased at the time of death.
My own view is that guidelines on the reporting of suicide and self inflicted deaths would be beneficial to journalists and reporters. I do not think they should be too detailed or prescriptive.
There is, as set out in the report of the Press Council of Ireland, a general “measure of agreement… that detail the means employed by individuals when taking their own lives should generally be excluded in the light of research which strongly suggests the risk of imitation”.
I believe that alcohol and drugs, may be a substantial contributing factor in a persons ultimate decision to end their own life. What can be done about it ? I am not certain. Education and understanding may help to reduce the incidents of suicide in Ireland but regretfully, in my view, it can and will never be eliminated entirely. That is just the way life is.
CONCLUSION The coroner has an important and legal role in enquiring into the circumstances of unexplained and unnatural deaths such as suicide. An inquest, where necessary, should be held as soon as possible so that the bereaved family and friends can come to terms with their great grief and have an understanding, in so far as it is possible, of the death that has occurred. Regretfully some agencies of the State do not carry out their investigative roles as quickly as possible and hence coroners are often frustrated in endeavouring to bring an inquest and the findings thereof to a conclusion. The Coroners Bill 2007 has been many years in gestation. The sooner it is enacted the better the coronial service in Ireland will be however sin sceal eile!
3rd December 2008 Patrick O’Connor B.C.L., LL.B., TEP., Coroner / Solicitor / Notary Public Swinford, Co. Mayo Coroner for Mayo East
I am indebted to my colleagues Dr. Brian Farrell (Dublin City Coroner) and Mr. Paul Morris (Coroner for County Tipperary) for permitting me to use some of their published material in the preparation of this paper.
Some useful Publications relating to Coroners in Ireland 1. The Coroners Court – The Law Society – Irish Medical Organisation Joint Seminar Papers – Denis A Cusack, Paul T Morris, Pat O’Connor and Bartley Sheehan (1997) 2. Handbook for Coroners in the Republic of Ireland – Patrick O’Connor (1997) 3. Coroners Law and Practice in Northern Ireland – Leckey and Greer (1998) 4. Sources of Coroners Law – Knapnan and Powers (1999) 5. Suicide Awareness – The Office of Coroner – Paul Morris – 22nd October 2001 6. Suicide In Ireland – A Global Prospective and a National Strategy – AWARE (1998) 7. Media Guidelines on Protrayal of Suicide – The Samaritans – The Irish Association of Suicidology (1998) 8. Coroners: Practice and Procedure – Brian Farrell (2000) 9. Coroners Bill (2007)