Charles Flanagan (Laois, Fine Gael) | Oireachtas source

That Bill addressed the findings of inquests and inquiries in several high-profile cases that caused great public unease. Some maternal deaths occurring in hospitals that should have been reported to coroners because they raised issues of medical error and were unnatural deaths under the Coroners Act 1962 were not so reported. Bereaved families and, in some instances, even coroners experienced considerable difficulty in obtaining basic information that should have been provided to them. This was, and is, unacceptable. I am introducing these provisions to significantly strengthen the powers of coroners so that will not recur.

Deputy Clare Daly's Bill received broad support from all sides in the Dáil. The Government agreed that I and my officials would work with Deputy Daly to progress the legislative proposals. The Bill I am introducing today, therefore, incorporates all the amendments sought by Deputy Clare Daly in respect of maternal deaths. The Bill will require mandatory reporting to a coroner, mandatory post-mortem examination and mandatory inquest in all cases of maternal or late maternal death. It will also extend the applicability of the legal aid scheme for family members at certain inquests to cases of maternal or late maternal death.

As well as addressing the issue of maternal deaths, my Bill provides for mandatory reporting to a coroner of all stillbirths, intrapartum deaths and infant deaths. As I mentioned, this responds to similar public concerns that have arisen in several cases involving perinatal and infant hospital deaths. I wish to emphasise that we are not proposing mandatory post-mortem examination or inquest in these particularly sensitive cases. Post mortem and inquest in such cases will remain, as currently, at the discretion of the coroner.The wishes of the bereaved parents are a key consideration for coroners in such cases.

The Bill also introduces, for the first time, a statutory basis for a coroner to inquire into a stillbirth where there is cause for concern, for example, arising from matters raised by the bereaved parents. These provisions fit logically into the overall purposes of the Bill, which sets out in a more comprehensive, clear, specific and stringent manner the legal framework for reporting and investigation of certain deaths. The Bill specifies much more clearly and comprehensively the situations in which a death must be reported to the coroner. These include any death that appears to be violent or unnatural, where the circumstances may in the public interest require investigation, or simply where the death is unexpected and the cause is unknown. The Bill also inserts a new schedule setting out specific types of death that must be reported to the coroner, including, for example, all maternal or late maternal deaths and all infant deaths.

Moreover, the legislation specifies more clearly and comprehensively the range of persons who are legally responsible for reporting a mandatory reportable death to the coroner and provides for updated penalties where this is not done. I should emphasise that in the majority of cases mandatory reporting does not result in a post-mortem examination and even fewer result in an inquest. Most reported deaths are quickly cleared from further investigation by the coroner, as the circumstances of death are well known and a death certificate can be signed and issued. However, mandatory reporting does ensure that in situations of concern or doubt, coroners have the necessary information to assess whether the death is one that requires further inquiry. In a limited range of situations, which I will outline shortly, the Bill does provide for mandatory post-mortem examination, mandatory inquest or both.

Regarding post-mortem examinations, the Bill sets out in a clearer, more comprehensive and more stringent manner a limited range of situations in which a post-mortem examination is always required. These include deaths which following inquiry by the coroner, appear to be violent or unnatural, or where the death is unexpected and the cause is unknown. They will also include, specifically, any death occurring in State custody or detention, and any maternal death or late maternal death, as well as certain deaths where a post-mortem examination is already a statutory requirement. The coroner also retains a discretion to direct a post-mortem examination in other cases.

Regarding inquests, the Bill amends the 1962 Act to expressly set out the situations in which an inquest is required by law. These include where the death appears to be violent or unnatural, or to have occurred unexpectedly and from unknown causes, or in certain situations where an inquest is a statutory requirement. The Bill also specifies that an inquest must be held into any death occurring in State custody or detention and into any maternal death or late maternal death. The coroner retains a discretion to direct an inquest in other cases.

The Bill introduces other important reforms. It strengthens the coroner’s powers to summon witnesses to an inquest, direct production of appropriate material, or enter premises and take possession of relevant documents. The Bill updates sanctions for a person obstructing an inquest, provides a modernised framework for post-mortem examinations, taking account of forensic developments, and requires family members to be informed regarding post-mortem examinations or inquests. In the light of the previous difficulties that have arisen, the Bill provides an important new power for the coroner to direct a hospital or other health institution, or a medical practitioner, to make available forthwith relevant medical records of a deceased person for the purposes of a post-mortem examination.

I should also mention a series of amendments relating to any case where the death that is the subject of the coroner's inquiry is also being investigated by the Garda Síochána Ombudsman Commission, GSOC, under the Garda Síochána Act 2005. Typically, a GSOC investigation will arise if a person dies in a vehicle collision following pursuit by a Garda vehicle, or after discharge of a Garda firearm or while in Garda custody. In such cases, the amendments recognise GSOC, rather than the Garda Síochána, as the lead criminal investigating agency. They also provide that the assistance to the coroner normally provided by the Garda Síochána in matters such as taking witness statements and producing forensic exhibits at the inquest will instead be provided by GSOC designated officers. This reflects the existing practice. It is clearly preferable for all stakeholders concerned in the interests of ensuring a visibly independent and transparent coroner’s inquiry.

The Government has agreed to priority drafting of a number of further amendments. These are being finalised and I intend to bring them forward on Committee or Report Stage. They include provisions for a coroner to seek directions from the High Court on a point of law relating to his or her functions - a consultative case stated provision. Another proposed amendment is subject to the Attorney General's advice, setting overall rules, and empowering me to make detailed regulations to guide the best conduct of a post-mortem examination for coronial purposes, and the proper and respectful storage and ultimate disposal of human tissue or organs removed for the purposes of the post mortem and retained for the inquest. Such disposal arrangements could include return to a family member for burial or cremation, if requested and appropriate. The detailed regulations will be developed together with the Minister for Health and appropriate stakeholders.

Many of the Bill’s provisions build on an extensive review by my Department of the Coroners Bill 2007 which also proposed to modernise and strengthen coroners’ powers but had become, in some respects, outdated. Of course, the 2007 Bill also provided for a major administrative restructuring of the coroner system. Due to the major challenges then confronting public finances, this aspect of the 2007 Bill was not progressed following Second Stage in the Seanad and now needs significant updating. However, we must continue to examine the optimum organisation of the coroner service.

Further elements of the existing law and structures will require significant improvement. Such improvement might likely involve a move away from the current multi-jurisdictional county model to a more regional one. However, no decisions have been taken. In the meantime, the Bill makes provision for a small number of immediate and necessary administrative amendments to assist coroners in carrying out their functions. This primarily concerns the Dublin district.

I will now address the main provisions of the Bill. Section 1 is a standard provision.

Section 2 provides for a number of new definitions in the 1962 Act, including "family member", "post-mortem examination", "stillborn child", and a range of situations that are defined as "State custody or detention". It also defines "maternal death", and a number of related terms, in accordance with the internationally recognised World Health Organization, WHO, definitions.

Section 3 provides an express statutory power for a coroner to inquire into a stillbirth where there is cause for concern. This addresses the question whether references in the legislation to a "deceased person" can apply to a stillborn child who has never drawn breath independently.

Sections 4 to 6, inclusive, contain a number of updating technical amendments regarding administration of the Dublin coroner district. These are necessary following the transfer, in late 2017, of responsibility for the operation of the Dublin coroner district from the Dublin local authorities to the Minister for Justice and Equality.

Section 7 inserts into the principal Act a new part IIA on reporting of death. It consists of two proposed new sections, the first of which is section 16A, which sets out comprehensively the general types of deaths which must be reported to coroners. It should be read in combination with the new Second Schedule contained in section 34, which sets out a list of concrete examples of mandatory reportable deaths. This list expressly includes any maternal death or late maternal death and any death of a stillborn child, intrapartum death or infant death. There is a power for the Minister to amend the list of reportable deaths by statutory instrument.

Secondly, section 16B sets out comprehensively the various persons who are under a duty to report a mandatory reportable death to the coroner. Reporting does not mean the death would automatically be subject to a post-mortem examination or an inquest. A doctor reporting the death to the coroner must indicate whether he or she is satisfied, in the circumstances, to certify that the death was due to natural causes. Where no cause for concern arises, such a certificate is sufficient under the Coroners Act. The proposed section also updates the penalties for failing to report a reportable death.

Section 8 updates section 17 of the principal Act to provide that an inquest is mandatory if the person has died in State custody or detention, and in all cases of maternal death or late maternal death.

Section 9 amends section 18 of the principal Act to provide that the coroner has a discretion to inquire into the circumstances of death - and, if the coroner thinks proper, to hold an inquest - if a medical certificate of the cause of death has been provided but the coroner considers that the certificate is not completed in a satisfactory manner.

Section 10 is a significant provision that extends the scope of the inquest to include establishing "the circumstances in which the death occurred". This is a key issue in certain inquests - for example, those occurring while the deceased was in State custody or detention - for strengthening our compliance with the European Convention on Human Rights, ECHR. However, it will remain the position that an inquest does not make any finding of civil or criminal liability.Section 11 requires the coroner to give at least 14 days’ notice regarding the holding of the inquest to family members and interested persons. Shorter notice is permitted in limited situations as an exception if the family will not be unfairly prejudiced, for example, where the deceased is a foreign national and the coroner is facilitating repatriation of the body.

Sections 12 and 13 are further technical amendments arising from the recent administrative changes regarding the Dublin coroner district. Along with sections 14, 19, 20, 21, 23, 24 and 26, section 12 also makes provision for a designated officer of GSOC to assist the coroner in place of a garda, or recognises GSOC as the lead investigating agency in place of An Garda Síochána, in a case where the death is also being investigated by GSOC, as I mentioned earlier.

Section 14 modernises the current provision for identifying the body of the deceased person.

Section 15 amends section 30 of the principal Act, to delete the restriction that an inquest shall be "confined to ascertaining the identity of the deceased person, and how, when and where the death occurred". This change flows from the new provision at section 10, widening the scope of the inquest.

Section 16 amends section 31 of the principal Act to include reference to the findings made at inquest in that section's prohibition of censure or exoneration and to add that general recommendations that are considered necessary in the interests of public health and safety may be appended to the verdict.

Section 17 amends section 32 of the principal Act to add a reference to the findings made at inquest in the record of the inquest’s conclusions.

Section 18 is a key section which provides for extensive reform of the Act’s provisions on post-mortem examinations directed by the coroner. It replaces sections 19 and 52 of the principal Act and amends section 33, which refers to the coroner’s discretion to direct that a post-mortem examination be performed. The section also proposes five new sections in the principal Act: sections 33A to 33E. Collectively, these provide for: a more detailed statutory framework where there is a mandatory post-mortem examination; a modern and more coherent process for the post-mortem examination to be performed by a pathologist under the direction of the coroner; requirements for a family member of the deceased person to be informed regarding the post-mortem examination and provided with a copy of the post-mortem report if requested; and a new statutory provision for the coroner to direct a further post-mortem examination of the body of the deceased if the coroner thinks it necessary.

Section 19 makes provision for a designated officer of GSOC to assist the coroner, in place of a garda, in a relevant death by serving witness or jury summons for the inquest.

Section 20 amends section 37 of the principal Act to provide that if a witness fails to attend the inquest without reasonable excuse, the coroner can seek a High Court order directing the witness to attend. The court can make such other orders as it considers just, including an order as to costs.

Section 21 amends section 38 of the principal Act to significantly strengthen coroners’ powers regarding a witness at inquest. It will empower a coroner to direct a witness to reply on oath or affirmation or to answer a question and to direct a person to produce to the inquest documents or objects in that person’s possession or control. It also allows the coroner to seek a High Court order that a person comply with the coroner’s direction and ancillary orders to give full effect to the direction. The offence of knowingly giving false or misleading evidence to an inquest is updated to carry a class A fine or imprisonment for a term not exceeding 12 months.

Section 22 provides for the coroner to take evidence before the inquest from a person who is about to leave the State, where that appears necessary.

Section 23 amends section 40 of the principal Act to remove the requirement that the coroner must sit with a jury in every road traffic death. This change has long been sought by coroners. Currently the jury requirement applies even in straightforward cases where no other vehicle is involved. Coroners advise that it is increasingly difficult to empanel juries for such a large volume of cases leading to unexpected adjournments and delays in many cases, distress to the bereaved families, and inconvenience to witnesses. The coroner would instead keep a discretion to empanel a jury in road traffic cases for which it is considered appropriate.

Section 24 is another section empowering a GSOC officer to assist the coroner in relevant cases, in this case in empanelling a jury for the inquest. Section 25 updates the sanctions under section 46 of the principal Act for obstructing the removal of a body to a mortuary or morgue. Section 26 is a further GSOC amendment and allows for a GSOC-designated officer to apply for exhumation of a body under section 47 of the principal Act in the same manner as a Garda inspector might. Section 27 provides a significant new power for the coroner, acting under a warrant from the District Court, to enter and inspect premises and to take copies or take possession of any documents or material relevant to the inquest. Section 28 is a new provision that the coroner may obtain advice and assistance from an expert, if he or she considers it necessary, on a particularly specialised subject relating to the death.

Sections 29 and 30 provide for further necessary updates regarding administrative matters following the transfer of responsibility for the Dublin coroner office. Section 31 extends the scheme of legal aid in the principal Act for a family member of the deceased at inquest, which was introduced in 2013 for certain categories of deaths, to cases of maternal death or late maternal death. Section 32 inserts a new provision such that, if a body corporate commits an offence under the Coroners Act, its officers may also be personally liable if they consented or connived in its commission. Section 33 is a further GSOC amendment. It inserts a new express provision in the Garda Síochána Act 2005 for GSOC-designated officers to assist the coroner in relevant cases. Section 34 provides for the new Second Schedule that sets out for the first time in statutory form a specific list of concrete examples of deaths that must be reported to a coroner.

Sections 35 and 36 are standard provisions.

It is my strong view that this important Bill responds to the demands of bereaved families, of interested parties, and of society in general. It will provide the coroner with a modernised and coherent legal framework and with significant new powers to ensure an effective death investigation. I hope that, with the co-operation of all sides, we can facilitate its swift passage through this House with a view to enactment before the summer recess. To this end, I ask Senators for their co-operation on this issue. I commend the Bill to the House.