A loved one’s death in unexpected or contested circumstances is faced daily and randomly by families in our communities.
Without knowledge or preparation for the processes of inquiry which come to dominate their lives, bereaved families assume that the truth regarding how and why their loved one died will be revealed. In this process they expect compassion and understanding. It affects us all — today ‘them’, tomorrow ‘us’.
It is 21 years since an influential, independent working group published detailed findings recommending root and branch reform of Ireland’s coronial system. ‘Radical reform and major reconfiguration’, delivered over two decades by a ‘clear strategy for change’ were considered imperative.
Our research, conducted for the Irish Council for Civil Liberties and published today, establishes no significant reform has occurred in policies or practices regarding death investigation or inquests.
We interviewed families bereaved in a range of contested circumstances, solicitors who regularly appear at inquests and senior coroners.
We conclude, particularly in contested cases, the rights and needs of bereaved families and the duty to serve the public interest are consistently failed. Delivering 52 detailed recommendations fundamental to prioritising a long overdue ‘clear strategy for change’, we also detail a seven-point
Last Thursday, April 15, was the 32nd anniversary of the Hillsborough Disaster. 96 men women and children died as a consequence of a dreadful crush on the terraces at an FA Cup semi-final between Liverpool and Nottingham Forest. Hundreds more were injured, thousands traumatised, lives changed forever.
The disaster unfolded in plain sight, on CCTV and on television. A hostile media, supported by police and politicians’ commentaries condemned Liverpool fans for arriving late at the stadium, many without tickets, heavily drinking and forcing entry.
In the dominant narrative, fans were culpable.
Following the longest inquests in UK legal history the jury verdict was accidental death. For two decades bereaved families and survivors campaigned for new inquests.
In 2012, following publication of the Hillsborough Independent Panel report, of which I was the principal author, the attorney general quashed the verdicts and ordered new inquests.
Bereaved families were fully represented and, in April 2016, the jury returned a unanimous verdict. Hillsborough was not an accident. Those who died had been unlawfully killed.
Multiple findings were delivered against the authorities involved, the majority directed towards the police.
The jury concluded that fans’ behaviour played no part in the disaster.
A lengthy judge-led tribunal attributed ‘probable’ responsibility to an unknown arsonist with an unknown motive. In September 2019, following the bereaved families’ a campaign spanning four decades, the attorney general made a direct comparison to Hillsborough and ordered new inquests. His decision was ‘in the public interest’ and ‘in the interest of justice’.
Two high profile inquests into multiple deaths. They are so well-known that ‘Hillsborough’ or ‘Stardust’ are instantly recognisable for the scale of loss and injury involved, but also the institutional failure of the State to inquire thoroughly into the circumstances and causes of the deaths.
Yet, it has been campaigns by bereaved families, challenging the outcomes of the initial inquiries, that has resulted in new inquests. They have raised the profile of how the State investigates deaths in contested circumstances, the role of the coroner and the function of the inquest.
Further, they highlight concerns regarding the rights of the bereaved to a thorough and exacting inquiry into the death of their loved ones.
Inquests have four objectives. They determine the identity of the deceased, where and when they died. Most significantly, they determine ‘how’ they died.
At the opening of inquests, coroners invariably remind the court and jury that liability for the death must not be attributed. For the lay-person, this is counter-intuitive to their understanding of ‘how’ the death occurred.
‘How’ a person died — be it in a motor collision, in hospital, in prison, during arrest, in a fire, in a crush — cannot be established without directing responsibility towards those who have a duty of care.
When bereaved families arrive at ‘their’ inquest, in which the circumstances of death will be explored and contested, they are in no doubt that liability is at stake.
We found the common theme was their feeling of exclusion from a process, that had often been delayed for years without explanation.
Further, across Ireland coroners’ investigations and hearings lacked consistency. Operating part-time and under- resourced, the service was inconsistent and regularly inconsiderate. Arriving for inquests, families were poorly accommodated, marginalised in overcrowded venues.
They received minimal support, realising that other families were also waiting.
While state agencies and other institutions involved are routinely legally represented this was not the case for many families. With liability at stake, the inquest becomes an adversarial wolf in inquisitorial sheep’s clothing.
Consistent concerns raised by bereaved families include dissatisfaction with the depth and breadth of inquiry, imbalance in the evidence presented and examined, defensiveness and protection of institutional interests, the scope of verdicts offered to juries and, accordingly, the verdicts delivered. Crucially,
no system is in place to ensure inquest recommendations, aimed at preventing recurrence of avoidable deaths, are implemented.
Reflecting coronial reform in England and Wales, the Irish Government must prioritise the radical reforms recommended by the 2000 review. While there are excellent coroners, they are poorly served by chronic under-resourcing and deficient powers.
Our report recommends immediate transition to an appropriately staffed, full- time service, consistent in its operation throughout Ireland. Other than necessary policing inquiries, it should be independent of An Garda Síochána.
Inquests should be held within reasonable time, juries randomly selected avoiding ‘sitting juries’, and inquest recommendations must be followed up.
Minor, peripheral reform is no longer appropriate to deliver a service to meet the complexity of cases that come before coroners. Minor modifications cannot arrest deficiencies inherent in a system that is undermined by persistent, discrepant, and discretionary decision-making in a context of minimal oversight.