Ms Doireann O'Mahony:

In and of itself, a verdict has no place in a forum where criminal or civil liability does not come into the fray. Perhaps, "findings of the coroner" would be more appropriate terminology going forward. The verdicts, in and of themselves, can be pretty meaningless to families. Alternatively, families might have high expectations or hopes of getting a particular verdict and may feel disappointed if that verdict is not returned by the coroner or the jury.

I will make a point while I have a chance. A moment ago, we were talking about how justice must be done and how it must be seen to be done in public. From my real lived experience of meeting many different people who have been through this process, I know that what matters to them is that their loved ones are not forgotten in the middle of it all. When things get heated and debates rage, the people at the centre of the matter can often feel forgotten. I have personally been told by family members that they have felt like furniture at inquests. Particularly in the case of hospital death inquests, there will sometimes be two or more sets of solicitors coming in for the hospitals and consultants. There will be multiple people and boxes of papers. The families feel their voices are not being heard.

I have been involved in inquests where members of the family have given statements or depositions to the coroner and then the hospital has tried to have those statements ruled out or redacted in large part. In other words, it makes families feel as if they are being gagged and as if their voices do not matter. That is something that is very important and that is why things could be made fairer if we were to have a set of coroners' rules and a review board or review panel. Reference was made to the prohibitive nature of judicial review. That is where somebody appeals a decision. It is terribly expensive and it takes an awfully long time. As I said, most people are frightened off by the idea of going to the High Court and they just do not have it in them. They are exhausted, broken down, grieving and the last thing in the world they want is to have to go to the High Court. If we had, as was recommended a quarter of a century ago, a review board or panel perhaps made up of a member of the Attorney General’s office, a coroner, a pathologist and a layperson, matters could be referred to that board or panel as they arise either in the lead up to or during an inquest and that would save time and costs and would mean people would not always have to resort to a judicial review.