Coroner’s Inquests

Table of Contents

Purpose of Inquest

The coroner may hold an inquest to establish the cause of death and in other circumstances at his or her discretion.

The purpose of an inquest is limited to identifying the facts of death. Blame may not be attributed. An inquest may require a jury who will reach a verdict on the question.

The purpose of an inquest shall be to establish:

the identity of the person in relation to whose death the inquest is being held,
how, when and where the death occurred, and
to the extent that the coroner holding the inquest considers it necessary, the circumstances in which the death occurred.

The inquest should make findings in respect of these matters and return a verdict.

If, at an inquest, the coroner or, where he or she is sitting with a jury, the jury is unable to make findings in respect of any of the matters specified, the coroner may adjourn the inquest for such period as he or she thinks proper. If, on the resumption of an inquest so adjourned the coroner or, as the case may be, the jury remains unable to make findings in respect of any matter specified, the coroner shall record any findings and the verdict returned and shall close the inquest.

Notice of Inquest

The coroner shall give notice of the inquest by post or other means at least 14 days in advance to:

a family member of the deceased person;
a person required to attend at the inquest as a witness;
another person who, in the opinion of the coroner, ought to receive such notice.

The coroner may hold an enquiry without giving that notice if he is satisfied that to do so does not unfairly prejudice the interests of a family member of the deceased person concerned and that it is appropriate to hold the inquest on an earlier date—

due to the circumstances of the death of the deceased person, to facilitate the attendance of witnesses whose evidence would, in the opinion of the coroner, be of assistance at the inquest, or
where the body of the deceased person is being repatriated to a place outside the State, to facilitate the repatriation of the body.

Where Coroners are Prevented from Holding Inquest

Where a coroner inquest cannot be held due to the coroner or deputy coroner being absent, ill, incapacitated or disqualified, a member of An Garda Siochana of the rank of inspector or above may request the Minister to direct another coroner to hold the inquest. The Minister may do so if he thinks proper.

Where the bodies of two or more persons whose deaths appear to have been caused by the same occurrence are lying within the districts of different coroners, the Minister may, if he so thinks proper, direct that one of those coroners shall hold an inquest in relation to all of the deaths.

Inquests Without a Body

Where the body of any person upon which it is necessary to hold an inquest has been buried and it is known to the coroner that no good purpose will come of exhuming the body for the purposes of an inquest, he may proceed to hold an inquest without having exhumed the body.

Whenever a coroner has reason to believe that a death has occurred in or near his district in such circumstances that an inquest is appropriate and that, owing to the destruction of the body or its being irrecoverable, an inquest cannot be held, the Minister may, if he so thinks proper, direct an inquest in relation to the death to be held by that coroner or another coroner. The coroner so directed shall hold an inquest in relation to the death in like manner as if the body were lying within his district and had been viewed by him.

Inquests on Order of Attorney General

Where the Attorney General has reason to believe that a person has died in circumstances which in his opinion make the holding of an inquest advisable he may direct any coroner to hold an inquest in relation to the death of that person. That coroner shall proceed to hold an inquest whether or not he or any other coroner has viewed the body, made any inquiry, held any inquest in relation to or done any other act in connection with the death.

Adjournment During Criminal Proceedings

Where, at an inquest in relation to a death—

a member of An Garda Síochána not below the rank of inspector;
a member of the Defence Forces not below the rank of commandant in a case of the death of a person who is subject to military law under the Defence Acts 1954 to 2015; or
a designated officer of the Ombudsman Commission in a case where there is a relevant Ombudsman Commission investigation,

requests the coroner to adjourn the inquest on the ground that criminal proceedings in relation to the death are being considered, the coroner shall adjourn the inquest for such period as he or she thinks proper, and shall further adjourn the inquest for similar periods so often as is so requested if the same grounds apply.

The same parties (senior Gardaí, Defence Force officers and Ombudsman Commission members) may request the coroner to adjourn the inquest on the ground that criminal proceedings in relation to the death have been instituted. In this case, the coroner shall adjourn the inquest until such proceedings have been finally determined. It shall not then be obligatory on the coroner to resume the inquest unless he thinks there are special reasons for so doing.

It is be the duty of the clerk or registrar of any court, at the conclusion of criminal proceedings in that court in relation to the death of a person, to inform the coroner holding an inquest in relation to the death of the result of such proceedings.

When adjourning an inquest a coroner may discharge the jury (if any) summoned therefor. Where a coroner resumes an inquest and the jury for which has been discharged, he shall proceed in all respects as if the inquest had not been begun.

Summoning of Witnesses

Witnesses may be called and give evidence. Only the coroner may call witnesses. A coroner may, at any time before the conclusion of an inquest held by him, cause a summons in the prescribed form to attend and give evidence at the inquest to be served on any person (including in particular any registered medical practitioner) whose evidence would, in the opinion of the coroner, be of assistance at the inquest.

A person who, having been duly served with a summons requiring him to attend an inquest as a juror, fails without reasonable excuse to attend on the date and at the time and place specified in the summons shall be guilty of an offence and shall be liable on summary conviction to a fine not exceeding €500.

A person who, having been duly served with a summons requiring him to attend an inquest as a witness, fails without reasonable excuse to attend on the date and at the time and place specified in the summons shall be guilty of an offence and shall be liable on summary conviction to a fine not exceeding €3,000 or to imprisonment for a term not exceeding 12 months or to both.

Where a person who, having been duly served with a summons requiring him or her to attend an inquest as a witness, fails without reasonable excuse to attend on the date and at the time and place specified in the summons, the High Court may, on application to it in that behalf by a coroner:

order the person to comply with the summons, and
make such other order (including an order as to costs), if any, as it considers necessary and just to enable the order to have full effect.

Powers re the Taking of Evidence at Inquests

A coroner in position is inquisitorial rather than adversarial. The coroner will generally seek to enquire into the time, place, circumstances and manner of death.

An inquest is usually held in public. It may be held in the courtroom in the coroner’s court.

The Coroner has the power to require persons to produce documents or things necessary for the proper conduct of the inquest and to direct a witness to answer questions. Where a person fails or refuses without reasonable excuse to comply with such a direction, the coroner may apply to the High Court for an order compelling the person to comply with the direction. It shall be an offence for a person to knowingly give false or misleading evidence at an inquest. A witness at an inquest shall be entitled to the same immunities and privileges as if he or she were a witness before the High Court.

A coroner may direct that evidence be taken from a person, or documents or things produced by a person, before the inquest if the person concerned is likely to be absent from the State during the inquest itself.

Evidence can be given verbally or in writing. The coroner may question witnesses. Witnesses answer questions under oath.

Submissions may be made from interested parties regarding which witness might be called. However the coroner has sole discretion whether or not to call a witness.

It is contempt of court to refuse to answer questions, refuse to take an oath or refuse to attend. The High Court may deal with the matter in the same manner as contempt of court.

A witness who testifies in the coroner’s court is in the same position as a High Court witness. He is entitled to all the protections and privileges that would be applicable in giving evidence. He is not obliged to answer questions regarding matters which are legally privileged.

A person who wishes to testify may indicate his desire to give evidence and the coroner may choose to call him if he considers it relevant. Testimony must be confined to relevant matters.

Juries at Inquests

The Coroner’s jury consist of between six and 12 members. They’re empanelled and sworn in. They must reach a verdict. If they cannot do so, the coroner may discharge them and hear the matter with a new jury. The coroner will accept a verdict by the majority of the jury.

The coroner has discretion as to whether to empanel a jury. In some cases, he must empanel a jury where he believes that:

the death was as a result of murder, manslaughter or infanticide;
the death occurred in circumstances where other legislation requires an inquest;
the death of the deceased was caused by accident, poisoning or disease of which, under provisions in that behalf contained in any other enactment, notice is required to be given to a Minister or Department of State or to an inspector or other officer of a Minister or Department of State, or;
that the death of the deceased occurred in circumstances the continuance or possible recurrence of which would be prejudicial to the health or safety of the public or any section of the public.

Where a coroner, before commencing or resuming an inquest in relation to any death, is informed by a member of An Garda Síochána not below the rank of inspector, a member of the Defence Forces not below the rank of commandant or a designated officer of the Ombudsman Commission that he or she will request an adjournment of the inquest on the ground either that criminal proceedings in relation to the death are being considered or have been instituted, every (if any) obligation to hold the inquest with a jury shall be deemed to be suspended unless and until the full hearing of the inquest takes place.

Powers re Witnesses

There may be disputes as to facts in certain cases, or as to how they are to be interpreted. The parties at inquest are entitled to have legal representatives to ensure due process.

Witnesses may be examined by interested parties or their representatives. Persons who may be interested include:

relatives and next of kin
those responsible or alleged to be responsible for the death.
insurance companies
employers
trade union representatives in the case of death at work
other persons accepted as having an interest by the coroner

The coroner records the names and addresses of witnesses and details of depositions. Post-mortem results and verdicts returned are recorded.

The coroner is not obliged to give a written judgement or report. The Coroner is obliged to settle statements and documents among the interest of parties. In some circumstances they may be withheld where there is good reason.

Verdicts

Once evidence is heard or a report submitted, the coroner or the coroner and jury give a verdict. Neither the verdict, any rider to the verdict at an inquest or any findings made at an inquest shall contain a censure or exoneration of any person. Recommendations of a general character that are designed to prevent further fatalities or are considered necessary or desirable in the interests of public health or safety may be appended to the verdict at any inquest.

Verdicts include the following:

Accidental death
Death by misadventure
Suicide
Want of attention at birth
Unlawful killing
Occupational disease
Death by natural causes
Open verdict

Death by misadventure is death as a result of a non-intended outcome of an intended action. An open verdict is one where there is no sufficient evidence to reach on any other conclusion.

Directions of High Court

A coroner may, whenever he or she considers it appropriate to do so, apply to the High Court for directions on a point of law regarding the performance of his or her functions under this Act in relation to the death of any person. The High Court shall determine an application by giving such directions and making such orders as it considers appropriate.

The High Court may, on application to it in that behalf, hear an application otherwise than in public if satisfied that it is appropriate to do so because of:

the subject matter in relation to which directions are sought,
a risk of prejudice to criminal proceedings, or
any other matter relating to the nature of the evidence to be given at the hearing of the application.

The High Court shall give such priority as it reasonably can, having regard to all of the circumstances, to the disposal of proceedings in the Court. An appeal shall lie by leave of the High Court to the Court of Appeal from a determination of the High Court of an application.

The Coroner’s documentation is public and may be inspected.

Recommendations by the Coroner

The Coroner may make recommendations where he believes it is necessary to avoid the repeat or recurrence of circumstances or avoidable accidents. This may relate to a practice or to the condition of particular works or a place or road.