Professor Denis Cusack:

I thank the Cathaoirleach and members of the committee for the kind invitation to present to and assist the committee in this discussion on the topic of the examination of operation of the Coroner Service. I am addressing the committee both in my individual professional capacity as senior coroner for the district of Kildare and on behalf of the president of Coroners Society of Ireland. There are a number of matters on which I am happy to elaborate at a later stage.

The coroner’s forensic and medico-legal death investigation, including post mortem examination and inquest hearing, is carried out in accordance with the provisions of Bunreacht na hÉireann, common law and the provisions of the Coroners Acts, together with other relevant statutes, including the European Convention on Human Rights Act 2003. I was privileged to serve on the Department of Justice’s review of the Coroner Service working group which produced the report of 2000. That report included 107 recommendations of a wide-ranging nature for reform of the Coroner Service in Ireland. I stress that it is the Coroner Service and the coroners themselves who have been driving and pushing reform in those 20 years. At page 2 of that report, under the heading of "Ethos of the Irish Coroner Service", it was stated that the investigation of sudden and unexplained death takes many forms throughout the world. There is a relatively wide range of unexplained deaths. Our work reflects the essential value placed by our Constitution on life itself. I stress that this is about compassionate sensitivity with legal formality and humanity.

The Coroner Service is for the living as well as the dead. It must be a service which balances that legal formality with compassionate sensitivity. There is an overemphasis on inquests, which only occur in a minority of coroner's inquiries. An inquest is a public inquiry and the coroner is the judicial officer of the State investigating certain categories of deaths, with more than 80% of all deaths in the State in 2021 being reported to the Coroner Service. I refer the committee to section 18A of the Coroners Acts of 1962 to 2020. I will refer later to recommendations of a general character designed to prevent further fatalities.

There have been many significant legislative reforms of the coroner’s role in the intervening period since the report of 2000. Senator McDowell is familiar with the coroner's rules and the Bill he introduced as Minister for Justice. The reforms in investigation of maternal deaths and in civil legal aid are two important issues. For various reasons, other reforms have not been followed through with regard to Part 2 of the Coroners Bill. The structure, organisation and financing of the Coroner Service no longer meet the needs of a modern, forensic and medico-legal death investigation service and have not done so for some time. The structure, organisation and financing are not fit for purpose in this modern era. It is time to drive innovative change.

I have, in my submission to the committee, listed seven headings for reform. Those relate to the reorganisation of districts within a larger regional structure, with shared operational, office, administrative, investigative framework and support; support service arrangements for pathology, post-mortem examination, toxicology and histopathology; an appointment system and terms and conditions for coroners with more full-time coroners as districts are amalgamated; the appointment of coroner's investigation officers on a regional and shared basis; importantly, the appointment of a chief coroner and deputy chief coroner to enhance leadership and consistency in practice; the establishment of a structured Coroner Service agency with an agency director; and the establishment of a Corner Service advisory committee. I have also included methods of death investigation but I am not going to go through them unless asked to do so by the committee at a later stage. I thank the committee members for their attention.