Mr. Roger Murray:

Regarding what Senator McDowell said about the inquisitorial nature of the inquiry, as commented on by Professor Cusack, it is vitally important to understand this aspect. In our civil law system, which is adversarial, there is a contest. In the criminal courts tomorrow, for example, there will be those acting for the accused and those acting for the prosecution. It is a contest between two skilled teams of lawyers. The truth can quickly get lost in that situation. Similarly, in a civil case, there is a plaintiff and a defendant and people are trying to score points off each other in the context. In an inquest, however, the process is inquisitorial. The coroner is the person who holds the ring and decides on the witnesses to be called, based on the evidence. The truth remains central to that process.

Professor Cusack referred to the consistency of the figures in this regard. Approximately 2,000 deaths annually are the subject of an inquest. The importance of those proceedings to society cannot be underestimated. Turning to the cost to the State in respect of getting answers, repeated studies by academics, including Boothman et alfrom 2014, show that the reason people go to lawyers in the first instance after an adverse medical event is not to seek compensation but to get answers. Therefore, the State could save itself considerable amounts of money by investing in the coronial service to ensure in a medical context, where there are unanswered questions around a death, that a properly run and resourced inquest can address and answer all those queries. Compensation might be the very last thing on the family's mind thereafter.

Regarding the question raised by Deputy Kenny concerning the structure or umbrella the coronial service should fall under, the recommendations Professor Cusack referred to suggested, and I refer to this in my submission as well, that the coronial service should be attached to the Courts Service and that a new statutory agency should be established to be known as central coroner services to reflect the core concept of service. In this regard, an important Venetian saying comes to mind, namely, the dead open the eyes of the living. It is crucial to emphasise the public importance of the lessons that arise from a properly run inquest. It was also recommended that the central coronial service should have the logistics to support the undertaking of functions such as salaries, expenses and organisational set-up, training and development of a high-quality service and best practice procedures and information dissemination. That latter point is something to which my colleague and co-author, Ms O'Mahony, has repeatedly referred. There is also the importance of ensuring information available to the public. My colleagues from the Irish Council for Civil Liberties, ICCL, and the report by Professor Phil Scraton and Dr. Gillian McNaull, made particular reference to the dearth of information available to people. It was also suggested there should be a national information system for coroners and that an annual report or presentation on the coronial service be produced. The saving to the State of having a properly resourced and run coronial service will have a significant knock-on effect in respect of addressing societal concerns and suspicions, especially concerning medical deaths.