Dr. Tony Holohan:

I am not dodging the question in any way by saying the Senator will be aware the coronial process and the legislation are the responsibility of the Department of Justice and Equality. We have our own views on some of these matters and will be working with the Department of Justice and Equality, which I know has been considering this area in recent years. We know there is a variation in practice between different coroners. There is no standard of the kind that the Senator speaks of. The variation in practice is such that in some areas coroners' inquests are carried out quite quickly relative to the events while, in other areas, coroners might save up a number of events and hold a single set of hearings in a short space of time, the result being that it takes a very long time before the holding of inquests in respect of certain incidents. That contributes significantly to the harm. We have our own experiences and have heard directly from patients about the trauma of being part of an adversarial inquest, with staff members being significantly represented by counsel and senior counsel, etc. Patients may go through the process feeling quite vulnerable and unsupported. We want to ensure this is borne in mind in any review of the coronial process. We would like to work with our colleagues in the Department of Justice and Equality on this. We would like to see a process that is much more patient centred if this is to be an important part of our response regarding incidents and when they occur.

There is probably a lot of knowledge gleaned from inquests right around the system but we need to be much better at pulling that knowledge together from separate coronial processes conducted in each of the different jurisdictions with a view to learning from it and using it to inform our activity to prevent the kinds of cases that arise on coroners' desks.