Éagóir Nó Ceartas? Táithí na n-Íosportach I gCóras Corónach na hÉireann agus Moltaí D'Athchóiriú I Léith Chearta an Duine

AuthorBlánaid Ní Chearnaigh
PositionIarrthóir Sophister Sinsearach LL.B, Coláiste
Pages14-55
© 2020 Blánaid Ní Chearnaigh and Dublin University Law Society
ÉAGÓIR NÓ CEARTAS? TAITHÍ NA NOSPORTACH I
GCÓRAS CORÓNACH NA HÉIREANN AGUS MOLTAÍ
D’ATHCHÓIRIÚ I LÉITH CHEARTA AN DUINE
BLÁNAID NÍ CHEARNAIGH*
Réamhrá
Scríobh Voltaire tráth, ‘[D]líonn na beo ár meas, dlíonn na mairbh ár n-
ionracas.’
1
Le leathchéad bliain anuas, dhearnadh aon athchóiriú reachta
ná beartais ar an gcóras corónach in Éirinn. Ní ghabhann sé seo go cuí leis
na hathruithe ó bhonn a tharla sa tsochaí le linn an dara leath den fhichiú
haois,
2
ag cur isteach ar beagnach gach gné den saol, agus go deimhin, an
básgodtí an pointe ina bhfuil gá le hathbhreithniú cuimsitheach.
3
Mar fhreagra ar an gceist seo, b’fhéidir, bhí comhaontú ann sa
Dáil,4
4
agus tháinig Acht na gCróinéirí (Leasú) 2019 amach astu, gur ghá le
tograí athchóirithe maidir le hathchóiriú reachtach an chórais chorónaigh.
Agus sin ráite, tá éifeachtúlacht an Achta fós neamhchinnte, de réir mar a
dhéanfaidh an plé seo a iniúchadh.
* Iarrthóir Sophister Sinsearach LL.B, Coláiste na Tríonóide, Baile Átha Cliath agus
Reachtaire An Chumann Ghaelaigh. Tá an t-údar seo faoi chomaoin ag a hathair, Dr. Ciarán
Kearney, as a threoir, a chomhairle agus a léargas ar an alt seo. Gabhaim buíochas ó chroí
leis an t-Ollamh Ivana Bacik as a habhcóide le linn an t-alt seo a athdhréachtú agus don
Bhord Eagarthóireachta, go háirithe Sara Ní Lochlainn, le haghaidh tuairimí agus tacaíochta
sa phróiseas foilseacháin. Ar a scáth a chéile a mhaireann na daoine.
1
Tugtar an luachan do Voltaire gan tagairt d’aon obair shonrach. Is cosúil gurb é sa Letter
to M. de Grenonville (1719) go luaitear é is coitianta.
2
Tá luas d’athraithe shóisialta in Éirinn ag méadú go seasta le cúpla bliain anuas, mar a
léiríodh le linn an reifreann i 2018 ó thaobh ghinmhilleadh agus an reifreann i 2015 ar
mhargaí comhghnéis. Do thuilleadh eolais, féach ar John Dowling, ‘Yet again the pace of
societal change in Ireland has moved up a gear’ The Irish Independent (Independent.ie, 26
Bealtaine 2018) https://www.independent.ie/irish-news/abortion-referendum/yet-again-
the-pace-of-societal-change-in-ireland-has-moved-up-a-gear-36948146.html> faighte ar an
15 Feabhra 2020.
3
An Roinn Dlí agus Cirt, Comhionannas agus Athchóirithe Dlí, ‘Review of the Coroner
Service: Report of the Working Group’
> accessed 17 Samhain 2018. Dá ngairtear ‘Tuarascáil an Ghrúpa Oibre’ amach anseo.
4 An Bille Cróinéirí (Leasú) 2018.
2020] Éagóir nó Ceartas
15
(IN)JUSTICE FOR ALL? THE EXPERIENCE OF
VICTIMS IN THE CORONIAL SYSTEM AND PROPOSALS
FOR HUMAN RIGHTS BASED REFORM
BLÁNAID KEARNEY*
Introduction
Voltaire once wrote, ‘[t]o the living we owe respect, to the dead we owe
truth.’1
5
For half a century, the coronial system in Ireland has escaped
legislative or policy reform. This contrasts with what can only be described
as transformational changes in society throughout the second half of the
twentieth century,2
6
affecting almost every aspect of life, and indeed, death
to the point where a comprehensive review is warranted.3
7
Despite recognition and growing political consensus of the imperative
for modernisation and improvement, there has been a lack of reform within
the coronial system. Perhaps, in response to this, proposals for legislative
reform of the coronial system were introduced to the Dáil4
8
and have led to
the Coroners (Amendment) Act 2019, the effectiveness of which still
remains uncertain.
* Senior Sophister LL.B. candidate, Trinity College Dublin and President of An Chumann
Gaelach. The author is indebted to her father, Dr Ciarán Kearney, for his guidance, advice
and insight on this article. Sincere gratitude is also extended to Professor Ivana Bacik for
her counsel during the redrafting of this article and to the Editorial Board of the Trinity
College Law Review, in particular Sara Loughlin, for comments and support in the
publication process. Ar a scáth a chéile a mhaireann na daoine.
1The quotation is attributed to Voltaire without reference to any specific work. It appears to
be most commonly cited as his Letter to M. de Grenonville (1719).
2The pace of social change in Ireland has been steadily on the rise over the last few decades,
as evidenced through the 2018 referendum on abortion and the 2015 referendum on same-
sex marriage, to name but a few examples. For further information, see John Dowling, ‘Yet
again the pace of societal change in Ireland has moved up a gear’ The Irish Independent
(Independent.ie, 26 May 2018) news/abortion-
referendum/yet-again-the-pace-of-societal-change-in-ireland-has-moved-up-a-gear-
36948146.html> accessed 15 February 2020.
3Department of Justice, Equality and Law Reform, ‘Review of the Coroner Service: Report of
the Working Group’
> accessed 17 November 2019. Hereinafter referred to as the ‘Report of the Working
Group’.
4Coroners (Amendment) Bill 2018.
Trinity College Law Review [Vol 23
16
Lena linn sin, tá méadú tar éis teacht ar dhlí idirnáisiúnta um chearta
an duine de réir a chéile, a thugann soiléiriú ar dhualgais agus freagracht an
Stáit agus ar chearta na saoránach agus n-íospartach laistigh den chóras
corónach. Baineann tábhacht ar leith ina thaobh seo le hachtú an
Choinbhinsiúin Eorpaigh um Chearta an Duine in Éirinn sa bhliain 2003.5
10
Chuidigh reachtaíocht i leith chearta an duine dul i gcion ar a mbíonn
íospartaigh ag súil leis agus soiléiriú a thabhairt ar na cearta atá ag dul dóibh
maidir leis an gcóras corónach. Is é an bunús atá leis seo ná oibleagáidí an
Stáit a bheith curtha in iúl faoi Airteagal 2 den Choinbhinsiún, a eascraíonn
as ceithre chás i dTuaisceart Éireann.6
11
Cumhdaíonn Airteagal 2 den
Choinbhinsiún roinnt dualgais éagsúla, ach a bhfuil nasc éigin eatarthu,
chun cosaint na mbeatha a chinntiú mar seo a leanas: (i) dualgas an Stáit
forálacha éifeachtacha dlí choiriúil a chur i bhfeidhm chun coireanna a
chosc i gcoinne an duine, arna dtacú ag córas um fhorfheidhmiú an dlí chun
sáruithe ar fhorálacha den sórt sin a chosc, a thoirmeasc agus a phionósú;
(ii) dualgas an Stáit gan duine a chur den saol mura bhfuil an fórsa a
úsáidtear níos mó ná mar is gá chun ceann de na cuspóirí atá leagtha amach
in Airteagal 2 (2) a chomhlíonadh;
5 Dá ngairtear ‘An Coinbhinsiún’ amach anseo.
6 ECtHR (2001) European Court of Human Rights (ECtHR) Judgments, 4 Bealtaine 2001:
Jordan v UK App no 24746/94; McKerr v UK App no 28883/95; Kelly and Others v UK App no
30054/96; Shanaghan v. UK App no 377715/97.
2020] Éagóir nó Ceartas
17
International human rights law has increasingly evolved, becoming
a necessary consideration for the obligations and the responsibility of the
State and the rights of citizens and victims with respect to the coronial
system. Of particular significance is the enactment of the European
Convention on Human Rights in Ireland in 2003.5
13
Paramount to this is an
articulation of the State’s obligations under Article 2 of the ECHR, arising
from four cases in Northern Ireland.6
14
Article 2 of the ECHR enshrines a
number of distinct, but interlinked, duties to secure the protection of life
as follows: (i) the duty on the State to put in place effective criminal law
provisions to deter the commission of offences against the person, backed
up by law enforcement machinery for the prevention, suppression, and
punishment of breaches of such provisions; (ii) the duty on the State not
to take life unless the force used is no more than is absolutely necessary
for one of the purposes outlined in Article 2(2);
5Hereinafter referred to as the ‘ECHR’.
6European Court of Human Rights (ECtHR) Judgments, dated 4 May 2001, including: Jordan
v UK App no 24746/94; McKerr v. UK, App no 28883/95; Kelly & Ors v UK App no 30054/96;
Shanaghan v UK, App no 377715/97.
Trinity College Law Review [Vol 23
18
(iii) an dualgas gníomhú chun saol an duine a chosaint in imthosca
áirithe;7
15
agus (iv) an dualgas chun básanna a imscrúdú go dóthanach.8
16
Níl an dualgas imscrúdaithe teoranta d’imthosca ina n-éagann duine faoi
lámh ghníomhairí an Stáit, faoina gcoimeád nó i gcúinsí ina raibh dualgas
ar an Stát an duine aonair a chosaint, ós rud é go mbaineann sé, freisin, le
cásanna ina gcinntear go bhfuil an duine aonair tar éis a bheith curtha i
mbaol a bháis mar gheall ar na gortuithe a d’fhulaing sé faoi chúinsí
amhrasacha.9
17
nach bhfuil aon chinneadh suntasach den
Choinbhinsiún ann le déanaí i gcásanna a bhaineann le hÉirinn, ní
bhaineann sé seo d’ábharthacht Airteagal 2 ar chaoi ar bith. Is amhlaidh a
tharlaíonn sé go mbaineann mórán de na príomhchúiseanna leis an Ríocht
Aontaithe agus baineann roinnt díobh seo arís le básanna coimhlinte i
dTuaisceart na hÉireann. Cuireann cosúlacht na gcóras um imscrúdú ar
bhás sa Ríocht Aontaithe agus in Éirinn le hábharthacht na mbreithiúnas
a bhaineann leis an Ríocht Aontaithe d’Éirinn.
Idir an dá linn, níor achtaíodh reachtaíocht go dtí 2017 chun
sainmhíniú dlíthiúil a sholáthar den chéad uair ar íospartaigh agus a gceart
dlíthiúil chun faisnéise, tacaíochta agus cosanta.10
18
Is sonrach go
gclúdaíonn an sainmhíniú seo ar an íospartach nó garghaolta atá tar éis
duine muinteartha a chailliúint mar thoradh díreach ar chion coiriúil.11
19
7 Osman v UK (1998) ECRR 101. Sa chás seo, rinne an chúirt an cinneadh a shárú i Hill v
West Yorkshire 4 [1998] 2 WLR 1049, nach bhféadfaí comhlachtaí poiblí a chur faoi
dhliteanas i bhfaillí i gcomhthéacs an cheanglais dhearfaigh a chinntiú go dtógtar bearta
coisctheacha chun saoránaigh a chosaint nuair a thugtar faoi choimeád iad faoi Airteagal 2.
Dhearbhaigh an ECtHR go dteipeann ar údarás coinneála a dhualgas chun saol a chosaint
má tá a fhios ag an údarás nó gur cheart go mbeadh sé ar eolas aige go bhfuil baol ann do
shaol an phríosúnaigh, ach níor ghlac siad céimeanna réasúnacha chun an riosca a
sheachaint
8 Feach air Jor dan v UK [2001] 37 EHRR 52; Menson v UK (2003) 37 EHRR CD 220.
9 Menson v UK (2003) 37 EHRR CD 220. Bhain an cás seo le dúnmharú fear dubh mar
thoradh ar a bheith curtha ar thine ag ionsaitheoirí le linn ionsaí ciníoch. Ba é seo an chéad
atriall den ECtHR a rá ‘the absence of any direct State responsibility for the death’ do
dhuine, ‘[did] not exclude the applicability of Article 2.’
10 An tAcht um Cheartas Coiriúil (Íospartaigh na Coireachta) 2017.
11 Is pointe tábhachtach é seo maidir le ceartas a chuardach. De réir mar a phléifear, níl an
córas corónach gan locht, go deimhin a nádúr dochrach, trí éifeacht, comhdhúile a bhfuil
grá acu do theaghlaigh a chaill grá do chúinsí mí-ámharacha agus nach gcuireann an mhoill
seo ach a gcuid brón le chéile.
2020] Éagóir nó Ceartas
19
(iii) the duty to take action to protect life in certain circumstances;7
20
and (iv) the duty to adequately investigate deaths.8
21
The duty to investigate is not limited to circumstances where an
individual dies at the hands of agents of the State, in their custody, or in
circumstances where the State was under a duty to protect the individual,
as it also applies to situations where an individual has sustained life-
threatening injuries in suspicious circumstances.9
22
While there are no
recent ECtHR decisions involving the Republic of Ireland, this does not
diminish, in any way, the relevance of Article 2. Indeed, much of the
leading case law concerns the UK, while several others concern conflict
related deaths in Northern Ireland. Due to the similarities between the two
jurisdictions’ coronial systems, therefore, UK judgments are particularly
relevant within Ireland.
Meanwhile, it was not until 2017 that legislation was enacted
providing a definition of victims and enumerating legal rights to
information, support and protection.10
23
Flowing from the legislation, the
definition extends to immediate family members who have lost loved ones
as a direct result of a criminal offence, as well as deaths that are an indirect
result of crime, as will be discussed.11
24
7Osman v UK [1998] ECRR 101. In this case, the court overruled the decision in Hill v West
Yorkshire 4 [1998] 2 WLR 1049, that public bodies could not be held liable in negligence in
the context of the positive requirement to ensure that preventative measures are taken to
protect citizens when they are taken to custody under Article 2. The ECtHR declared that a
detaining authority fails in its duty to protect life if the authority knows or ought to have
known of a risk to a prisoner’s life, but did not take reasonable steps to avert the risk.
8 See Jordan v UK [2001] 37 EHRR 52; see also Menson v UK (2003) 37 EHRR CD 220.
9Menson v UK [2003] 37 EHRR CD 220. This case concerned the murder of black male as a
result of being set on fire by assailants during a racist attack. This was the first iteration of
the ECtHR that ‘the absence of any direct State responsibility for the death’ of an individual
did ‘not exclude the applicability of Article 2.’
10 Criminal Justice (Victims of Crime) Act 2017.
11 This is an important point when it comes to the search for justice. As will be discussed,
numerous deficiencies lie with the coronial system, including its dilatory nature which, by
effect, compounds grieving families who have lost a loved one to unfortunate
circumstances and this delay only compounds their grief.
Trinity College Law Review [Vol 23
20
Ní hamháin go nglacann an córas corónach leis an mbás mar thoradh
díreach ar choir, áfach, mar a phléifear níos faide ar aghaidh. B’fhéidir gurb
ionann an difríocht institiúideach seo agus an baol féideartha go mbeadh
leithcheal ann i ndéileáil le híospartaigh taobh istigh den chóras corónach.
básanna suntasacha ar mhaithe le leas an phobail, mar shampla bás
Savita Halappanavar, tar éis tuilleadh ceisteanna agus contrárthachtaí
laistigh den chóras corónach in Éirinn a thabhairt chun
solais.12
25
Déanfaidh an plé seo iarracht na ceisteanna sin a iniúchadh ó
thaobh chearta agus eispéireas na n-íospartach, ní hamháin iad siúd a bhí
ina n-íospartaigh coireachta. Tabharfaidh Cuid a 2 achoimre ghairid ar
chuspóir agus ar scóip an chórais chorónaigh sa dlínse seo. Scrúdóidh Cuid
a 3 cuid de na réimsí is conspóidí ina bhfuil an córas gafa, lena n-áirítear
básanna máithreacha, básanna faoi choimeád, agus básanna a bhaineann
le fórsa marfach marú neamhdhleathach. Pléifidh Cuid a 4 Acht na
Cróinéirí (Leasú) 2019; cé go nglacann an t-údar seo gur athchóiriú ea é
atá fáilte roimhe, tabharfaidh sé faoi cheist má dhéanann an tAcht go leor
chun na saincheisteanna forleathana seo a shárú. Mar fhocal scoir, beidh
mar chonclúid i gCuid a 5 go bhfuil gá le hathchóiriú breise, chun a
chinntiú go bhfuil cearta na n-íospartach, lena n-áirítear teaghlaigh atá ag
fulaingt daoine a bhfuil bás acu, daingnithe go hiomlán.
I. Cad é an Córas Corónach agus Conas a
Fheidhmíonn Sé?
Tá an córas corónach ar cheann de na seirbhísí poiblí is sine atá ann, a
dtagraítear dó chomh fada siar leis an dara haois déag.13
26
12 Féach ar Feidhmeannacht na Seirbhíse Sláinte, Final Report: Investigation of Incident 50278
from time of patient’s self referral to hospital on the 21st of October 2012 to the patient's death
on the 28th of October, 2012 (Meitheamh 2013). Dá ngairtear ‘An Tuarascáil Deiridh’ amach
anseo. Freisin, féach ar Sinead O’Carroll, ‘Savita Inquest: the Coroner’s Nine
Recommendations Endorsed by the Jury’ The Journal (The Journal.ie, 19 Aibreán 2013)
inquest-the-coroners-9-recommendations-876864-
Apr2013/> faighte ar an 23 Samhain 2019.
13 Féach go ginearálta ar Annette Jocelyn Otway-Ruthven, A History Of Medieval Ireland
(Barnes & Noble 1980).
2020] Éagóir nó Ceartas
21
Perhaps this institutional deference itself signals the potential risk of
differential treatment of victims within the coronial system. Deaths of
significant public interest such as Savita Halappanavar have served to
reveal further questions and contradictions within the coronial system in
Ireland.12
27
This discussion will seek to explore these questions from the
standpoint of the rights and experiences of victims, not only those who
have been victims of crime. Part I will give a brief summary of the purpose
and scope of the coronial system in this jurisdiction. Part II will explore
some of the most contentious areas in which the system is engaged,
including maternal deaths, deaths in custody, and deaths involving the use
of lethal force or unlawful killing. Part III will discuss the Coroners
(Amendment) Act of 2019; whilst accepting it as a welcome reform, it will
question whether the Act does enough to overcome these prevalent issues.
Finally, Part 5 will conclude that further reform is required, in order to
ensure that the rights of victims, including bereaved families, are fully
vindicated.
I. The Coronial System: Purpose And Scope
The coronial system is one of the oldest existing public services, dating as
far back as the twelfth century.13
28
12 See Health Service Executive, Final Report: Investigation of Incident 50278 from time of
patient's self referral to hospital on the 21st of October 2012 to the patient's death on the 28th of
October, 2012 (June 2013). Hereinafter referred to as the ‘Final Report’. See also Sinead
O’Carroll, ‘Savita Inquest: the Coroner’s Nine Recommendations Endorsed by the Jury’ The
Journal (The Journal.ie, 19 April 2013) inquest-the-
coroners-9-recommendations-876864-Apr2013/> accessed 23 November 2019.
13 See generally, Annette Jocelyn Otway-Ruthven, A History of Medieval Ireland (Barnes &
Noble 1980).
Trinity College Law Review [Vol 23
22
Cé go bhfuil baint shonrach aige le básanna tobanna nó gan mhíniú,
tá castacht agus tábhacht chróinéir an lae inniu an-éagsúil leis an bpost a
bhí aici14
29
i bhfad siar.15
30
Go deimhin, tá lear mór dualgas ar chróinéir an
lae inniu, a chuimsíonn dualgais imscrúdaithe, riaracháin, breithiúnacha,
coisctheacha agus oideachais.16
31
Go bunúsach, is é ról an chróinéara
feidhmiú mar oifigeach breithiúnach neamhspleách a chinníonn ‘cé,
cathain, cén áit agus conas’ a maraíodh an t-íospartach i gcásanna nach
bhfuil míniú ar an mbás.17
32
Níl aon amhras ach go léiríonn an córas seo, a
dhéanann imscrúdú ar bhásanna gan mhíniú, bunéiteas de chuid
Bhunreacht na hÉireann agus an luach a chuireann sé ar shaol an
duine;18
33
ba cheart gach bás a imscrúdú ach amháin má tá míniú doshéanta
stuama ar an mbás sin. I dtéarmaí a chuid oibríochtaí, básanna a thagann
faoi chatagóir an bháis thobainn, an bháis fhoréignigh nó an bháis gan
mhíniú, ní mór iad a thuairisciú don chróinéir de bhun Acht na gCróinéirí
196219
34
agus sna Rialacha Cleachtais.20
35
Ar a thuairisciú dó, murar féidir
míniú a thabhairt ar an mbás, an t-údarás ag an gcróinéir uatóipse a
ordú chun cúis an bháis a chinneadh. Is faoi phaiteolaí an gnáthamh seo a
dhéanamh mar ghníomhaire neamhspleách de chuid an chróinéara
seachas de chuid na n-ospidéal maidir le scrúdú iarbháis. Má tá cúis an
bháis go fóill gan mhíniú tar éis uatóipse, féadann an cróinéir dul ar
aghaidh chuig fiosrúchán.21
36
Thairis sin, má chreideann an cróinéir gurbh
fhéidir gur tharla an bás ar bhealach foréigneach agus mínádúrtha, nó go
tobann agus ar chúiseanna anaithnide, nó in áit nó in imthosca a bhfuil sé
éigeantach faoi reachtaíocht eile nach mór coiste cróinéara a chur ar bun,
is amhlaidh go bhfuil ar an gcróinéir fiosrúchán a dhéanamh.22
14 Úsáidfear an pronounach baininscneach mar áis ar fud an aiste.
15 Tuarascáil an Ghrúpa Oibre (n 3).
16 ibid 2.
17 ibid.
18 Airtegeal 40.3.2°
19 An tAcht Cróinéirí 1962, a 8 (4); féach ar ‘Deaths which must be reported to the Coroner -
The Department of Justice and Equality’ (Coroners.ie, 2018)
0the%20coroner> faighte ar an 17 Samhain 2018. Dá ngairtear ‘Acht 1962’ amach anseo.
20 Brian Farrell, Coroners: Practice And Procedure (Round Hall Sweet & Maxwell 2000) 143.
21 Tuarascáil an Ghrúpa Oibre (n 3) 2.
2020] Éagóir nó Ceartas
23
While specifically connected with sudden or unexplained deaths, the
complexity and significance of the modern coroner is very different to that
of her14
37
ancient predecessor.15
38
Indeed, the modern coroner has a vast
array of obligations, extending across investigatory, administrative,
judicial, preventative, and educational duties.16
39
Essentially, the role of a
coroner is to act as an independent judicial official who determines the
‘who, when, where and how’ of unexplained deaths.17
40
Undeniably, this
system of investigating unexplained deaths reflects the essential ethos and
value placed by the Irish Constitution on human life;18
41
where every death
ought to be investigated, unless there exists an unequivocal and coherent
explanation for that death. In terms of its operations, deaths which fall
under the category of sudden, violent, or unexplained must be reported to
the coroner pursuant to the Coroners Act 196219
42
and in the Rules of
Practice.20
43
When reported, if the death is not capable of being explained,
the coroner has the authority to order a post-mortem to determine the
cause of death. This procedure is carried out by a pathologist who acts as
an independent agent of the coroner, as opposed to that of the hospital. If
the cause of death following a post-mortem is still inexplicable, the coroner
may proceed to an inquest.21
44
Moreover, if the coroner holds the belief
that the death may have occurred in a violent and unnatural manner,
suddenly, and from unknown causes, or in a place or circumstances which
under other legislation makes an inquest mandatory, then the coroner
must hold an inquest.22
45
14 The feminine pronoun shall be used for convenience throughout the essay.
15 The Report of the Working Group (n 3).
16 ibid 2.
17 ibid.
18 Article 40.3.2°.
19 Coroners Act 1962, s 8(4). See further, ‘Deaths which must be Reported to the Coroner -
The Department of Justice and Equality’ (Coroners.ie, 2018)
0the%20coroner> accessed 17 November 2018. Hereinafter referred to as the '1962 Act’.
20 Brian Farrell, Coroners: Practice and Procedure (Round Hall Sweet & Maxwell 2000) 143.
21 The Report of the Working Group (n 3) 2..
22 ibid 105.
Trinity College Law Review [Vol 23
24
Déanann Ailt 21 agus 23 d’Acht 1962 foráil le haghaidh imthosca eile ina
bhféadfadh sé bheith dodhéanta teacht ar chorp nó inar chosúil go bhfuil
dhá bhás nó níos mó tar éis tarlú san eachtra céanna.23
46
Is é an coiste cróinéara an phríomhghné bhreithiúnach de ról an
chróinéara, nach mbaineann ach le ‘cé, cathain, cén áit agus conas’ a tharla
an bás. Ós le fiosrúchán seachas leis an tsáraíocht a bhaineann an próiseas
seo, ní bhíonn fáil ar fhianaise go héasca roimh an gcoiste cróinéara, cé go
bhfuil rogha éigin ag an gcróinéir maidir leis seo.24
47
Trí scrúdú a
dhéanamh ar na forálacha reachtúla, áfach, is léir gur féidir le coiste
cróinéara bheith ina fhiosrúchán poiblí maidir leis na himthosca a
bhaineann le bás neamhghnách. Mar a leagtar síos san Acht 1962, is féidir
go mbeadh coiste cróinéara ina fhiosrúchán poibar na cúinsí a bhaineann
le bás neamhghnácha.25
48
Tríd sin a dhéanamh, is follas go bhféadfadh
páirtithe áirithe páirt a ghlacadh in imeachtaí ar bhealach a cheadaíonn
dóibh a leagan féin d’imeachtaí a chur i láthair, arbh fhéidir go bhfuil an
leagan sin ina mhalairt ghlan ar a bhfuil ann cheana.26
49
Dá bhrí sin, cé go
léiríonn an dgo bhfuil imeachtaí fós faoi smacht an chróinéara, an
fhoráil ann go gcuirfí nithe eile chun cinn i gcoiste cróinéara, fiú má
thagann siad salach ar leas an íospartaigh. Baineann tábhacht ar leith leis
seo maidir le taithí íospartaigh an chórais chorónaigh. Caithfidh an
cróinéir torthaí a thabhairt ar aithint an duine éagtha, an dáta agus an áit
inar tharla an bás chomh maith le cúis leighis an bháis.27
50
Ba cheart an
fíorasc maidir leis an gcaoi a tharla an bás a thabhairt ar ais agus tá sé
teoranta do bhás timpiste, -eachtra, féinmharú, fíorasc oscailte,
cúiseanna nádúrtha nó marú neamhdhleathach.28
51
Caithfidh an coiste
cróinéara a bheith dírithe ar ábhair a bhaineann le cúis an bháis agus gan
aon ní eile.
23 ibid.
24 ibid 3.
25 Féach go sonrach, Acht na Cróinéirí 1962, a 17.
26 Ramsayer v. Mahon [2005] IESC 82.
27 Farrell (n 20).
28 Shane Kilcommins, Eimear Spain agus Mic Léinn Fochéime ó Ollscoil Luimnigh, ‘Deaths
of Prisoners while in the Custody of the Irish Prison Service: Developing an Irish Database’
(Oifig Chigire na bPríosún; Ollscoil Luimnigh 2015)
>
faighte ar an 18 Samhain 2018.
2020] Éagóir nó Ceartas
25
Sections 21 and 23 of the 1962 Act make provision for other circumstances
whereby a body may be unrecoverable or two or more deaths appear to
have taken place due to the same occurrence.23
52
The inquest is the primary judicial aspect of the coroner’s role,
which pertains exclusively to the ‘who, when, where and how’ questions
surrounding the circumstances of the death. As an inquisitorial rather than
adversarial process, evidence is not readily made available before the
inquest, although the coroner does have a degree of discretion in this
area.24
53
As stipulated by the 1962 Act, an inquest may be a public inquiry
into the circumstances surrounding an abnormal death.25
54
In so doing, it
is clear that certain parties may participate in proceedings in a manner
that permits their own, perhaps alternative, version of
events.26
55
Therefore, while the law makes clear that proceedings remain
under the control of the Coroner, there is provision for alternative, perhaps
even adversarial interests to be advanced at an inquest. This has particular
relevance for victims’ experience of the coronial system. The coroner must
make findings on the identification of the deceased, the date and place in
which the death occurred as well as the medical cause of death.27
56
The
verdict as to the manner by which death occurred should be returned and
is limited to either an accidental death, a misadventure, a suicide, an open
verdict, natural causes, or an unlawful killing.28
57
The inquest must be
directed to matters which bear on the cause of death and to no other
matter.
23 ibid.
24 ibid 3.
25 See specifically, Coroners Act 1962, s 17.
26 Ramsayer v. Mahon [2005] IESC 82.
27 Farrell (n 20).
28 Shane Kilcommins, Eimear Spain and Mic Léinn Fochéime ó Ollscoil Luimnigh ‘Deaths of
Prisoners while in the Custody of the Irish Prison Service: Developing an Irish Database’
(Office of the Inspector of Prisons, University of Limerick 2015)
>
accessed 18 November 2019.
Trinity College Law Review [Vol 23
26
Sa chás Farrell v. Attorney General,29
58
chuir an Chúirt Uachtarach an
beartas poiblí in iúl d’aon fhiosrú, go sonrach, gur chóir é a choinneáil sna
himthosca a shainmhínítear san Acht 1962 mar seo a leanas:
(a) Chun cúis bháis leighis a chinneadh;
(b) Ráflaí nó amhras a mhaolú;
(c) Aire a tharraingt ar imthosca a bheith ann, más rud é go bhféadfadh
básanna breise a
bheith ann, más éagmais é;
(d) Chun eolas leighis a chur chun cinn;
(e) Chun leasanna dlíthiúla daoine éagtha a chaomhnú teaghlaigh,
oidhrí nó páirtithe
leasmhara eile.30
59
Ó am go chéile, bíonn an t-ionchas poiblí ar an bhfiosrach níos mó ná an
méid atá ceadaithe de réir dlí agus míthuiscintí i ndáil leis na himeacht
a bheith cúistiúnach, seachas go bhfuil an droch-nádúr coitianta i measc
an phobail.31
60
Cé go bhfuil sé de dhualgas ar an gcróinéir na fíricí uile a
bhaineann leis an bhfiosrúchán a imscrúdú agus cúinsí an bháis a
nochtadh go poiblí, aon bhreithniú nó imscrúdú a dhéanamh ar
dhliteanas sibhialta nó dliteanas coiriúil aon duine ag fiosrúchán a bhfuil
toirmeasc dian orthu.32
61
Agus an coiste cróinéara á sheoladh aige, ní mór
do chróinéir a bheith ar an eolas freisin ar chearta bunreachtúla
theaghlaigh bás an íospartaigh atá i gceist maidir le príobháideacht, nós
imeachta chothrom agus ceartas nádúrtha.
29 Brian Farrell v Attorney General [1998] 1 IR 203.
30 ibid. De réir Keane Brmh ag tagairt don Thuarascáil Broderick, Report of the Committee on
Death Certification and Coroners (Cmnd. 4810) (1971). Dá ngairtear ‘An Tuarascáil
Broderick’ amach anseo. Ina dtuarascáil i mí na Samhna i 1971, shainaithin an coiste na
critéir thuasluaite a aithníodh mar chuspóirí den choiste chróinéara. Le haghaidh tuilleadh
tagartha, féach freisin an tAcht Cróinéirí 1962 ag a. 24 (1). Soláthraíonn sé sin ‘[W]here the
Attorney General has reason to believe that a person has died in circumstances which in his
opinion make the holding of an inquest advisable he may direct any coroner (whether or
not he is the coroner who would ordinarily hold the inquest) to hold an inquest in relation
to the death of that person, and that coroner shall proceed to hold an inquest in accordance
with the provisions of this Act (and as if, not being the coroner who would ordinarily hold
the inquest, he were such coroner) whether or not he or any other coroner has viewed the
body, made any inquiry, held any inquest in relation to or done any other act in connection
with the death.’
31 Farrell (n 20).
32 An tAcht Cróinéirí 1962, a 30.
2020] Éagóir nó Ceartas
27
In Farrell v. Attorney General,29
62
the Supreme Court articulated the public
policy fundamental to any inquest, specifically that it should be held in the
circumstances defined in the 1962 Act as follows:
(a) To determine the medical cause of death;
(b) To allay rumours or suspicions;
(c) To draw attention to the existence of circumstances which, if
unremedied, might lead to further deaths;
(d) To advance medical knowledge;
(e) To preserve the legal interests of the deceased person’s family, heirs
or other interested parties.30
63
Occasionally, public expectation of the inquest exceeds what is
permissible by law and misconceptions in relation to the proceedings
being inquisitorial rather than adversarial in nature is common amongst
the public.31
64
While the coroner has an obligation to investigate all facts
pertinent to the inquest and to disclose the circumstances of the death to
public scrutiny, any consideration or investigation of civil or criminal
liability of any person at inquest is strictly prohibited.32
65
In conducting
the inquest, a coroner must also be cognizant of the constitutional rights
to privacy, fair procedure and natural justice of the bereaved family of
the victim in question.
29 Brian Farrell v Attorney General [1998] 1 IR 203.
30 ibid. Per Keane J referring to Broderick Report, Report of the Committee on Death
Certification and Coroners (Cmnd. 4810) (1971). Hereinafter referred to as the ‘Broderick
Report’. In its Report of November 1971, the Committee identified the above mentioned
criteria identified as the purposes of the coroner’s inquest. For further reference, see also
the Coroners Act 1962 at s 24(1). This provides that ‘[W]here the Attorney General has
reason to believe that a person has died in circumstances which in his opinion make the
holding of an inquest advisable he may direct any coroner (whether or not he is the coroner
who would ordinarily hold the inquest) to hold an inquest in relation to the death of that
person, and that coroner shall proceed to hold an inquest in accordance with the provisions
of this Act (and as if, not being the coroner who would ordinarily hold the inquest, he were
such coroner) whether or not he or any other coroner has viewed the body, made any
inquiry, held any inquest in relation to or done any other act in connection with the death.’
31 Farrell (n 20).
32 Coroners Act 1962, s 30.
Trinity College Law Review [Vol 23
28
D’ainneoin na gcearta bunúsacha sin, b’fhéidir níos tábhachtaí fós, go
gcuireann teaghlaigh íospartaigh bás agus an tsochaí ina n-iomláine
ionchas go ndéanfar an coiste cróinéara le leibhéal ard gairmiúlachta agus
go nochtfar na fíricí ábhartha go léir agus cuirfear iad ar an taifead
poiblí.33
66
Ina theannta sin, d’féadfadh dualgas reachtúil an chórais
corónach ‘ráflaí nó amhras a mhaolú’ a dhualgas ar an gcróinéir imeachtaí
fiosrúcháin a leathnú chun cúrsaí a scrúdú taobh amuigh d’ábhar
tuarascáil iarbháis nó ceisteanna a tugadh os comhair an chróinéara mar
ábhar fíorais. Arís, d’fhéadfadh go mbeadh an rogha a d’fheidhmigh an
cróinéir ar an ábhar seo go háirithe le taithí na n-íospartach, lena n-áirítear
teaghlaigh an mharbhanaigh, go háirithe nuair a tharla bás i gcúinsí a
bhfuil díospóidí nó plé poiblí acu.
II. Táithí Na n-Íospartach
I ndlí na hÉireann, faoin Acht Um Cheartas Coiriúil (Íospartaigh na
Coireachta) 2017,34
67
tá an t-íospartach sainmhínithe mar dhuine nádúrtha
a d’fhulaing díobháil, lena n-áirítear dochar fisiceach, meabhrach nó
mothúchánach nó caillteanas eacnamaíoch, a bhí mar chúis go díreach ag
cion.35
68
Mar a léiríodh roimhe seo, áfach, níl an t-iompar ó imscrúdú faoi
fhorálacha an t-Acht 1962 teoranta do na básanna sin a ndearnadh cion
coiriúil leo go díreach. Is é ceann de na limistéir sin a bhí mar fhoinse
díospóireachta suntasacha agus imní a spreagadh maidir le cearta agus
cóireáil íospartaigh ná básanna an mháthar nó básanna in ospidéil
mháithreachais,36
69
básanna faoi choimeád, agus básanna a bhaineann le
fórsa marfach nó marú neamhdhleathach. Pléifidh an roinn seo gach
ceann ar a seal.
33 Farrell (n 20).
34 Dá ngairtear ‘Acht 2017’ amach anseo.
35 Acht um Cheartas Coiriúil (Íospartaigh na Coireachta) 2017, a 2(1)(f).
36 Ar mhaithe le soiléiriú, tagraíonn bás máithreachais d’fháil bháis le linn di a bheith ag
iompar clainne, beag beann ar fhad agus ar shuíomh an toirchis, ó aon chúis a bhaineann
leis an toircheas nó a bhain leis an mbainistíocht, ach ní gá do bheith bainteach le cúiseanna
de thaisme nó teagmhasacha. Ciallaíonn sé seo go bhféadfadh an bás féin tarlú sa bhaile nó
in aon suíomh eile, ní gá go mbeadh sé laistigh de bhallaí ospidéil. Le haghaidh tagartha
iomlán féach ar ‘Definition and Classification of Maternal Death’ (Fiosrú Báis Mháthar -
Éire) https://www.ucc.ie/en/mde/definitionandclassificationofmaternaldeath/> faighte ar
10 Feabhra 2020. Baineann an tagairt dheireanach, áfach, is é sin le rá, básanna in ospidéil
mháithreachais, le bás na mban le linn toirchis a bhíonn ar siúl i dtimpeallacht an ospidéil.
2020] Éagóir nó Ceartas
29
Notwithstanding the rights of the bereaved families, society as a whole
shares an expectation that inquests will be conducted with a high degree
of professionalism and relevant facts will be disclosed and placed on the
public record.33
70
Moreover, the statutory duty of the coronial system ‘to
allay rumours or suspicions’ may oblige the coroner to widen inquest
proceedings to examine matters beyond the scope of a post-mortem report,
or issues brought before the coroner as a matter of fact. Again, the
discretion exercised by the coroner on this matter may be especially
pertinent to the experience of victims, including bereaved families,
particularly where a death has occurred in circumstances which are
disputed or publicly debated.
II. The Experience of the Victims
In Irish law, under the Criminal Justice (Victims of Crime) Act 2017,34
71
a
victim has been defined as ‘a natural person who has suffered harm,
including physical, mental or emotional harm or economic loss, which was
directly caused by an offence.’35
72
However, as previously indicated, the
conduct of an inquest under the provisions of the 1962 Act is not limited
to those deaths which have been directly caused by a criminal offence.
Some of the most contentious areas which have been the source of
significant debate and have prompted concern for the rights and treatment
of victims are maternal deaths,36 deaths in custody, and deaths involving
lethal force or unlawful killing.
73
This section shall discuss each in turn.
33 Farrell (n 20).
34 Hereinafter referred to as the ‘2017 Act’.
35 Criminal Justice (Victims of Crime) Act 2017, s 2(1)(f).
36 For clarification, a maternal death refers to the death of a woman while pregnant,
irrespective of the duration and the site of the pregnancy, from any cause related to or
aggravated by the pregnancy or its management, but not from accidental or incidental
causes. This means that the death itself could take place in the home or any other site, not
necessarily within the walls of a hospital. For full reference see ‘Definition and
Classification of Maternal Death’ (Maternal Death Enqu iry - Ireland)
> accessed 10
February 2020. The latter reference, however, namely deaths in maternity hospitals, relates
to the deaths of women during pregnancy taking place within the hospital environment.
Trinity College Law Review [Vol 23
30
A. Básanna Máthat in Ospiil
Áitíodh go láidir go bhfuil ‘gach bás an mháithreach’ mar thrágóid
uafásach le hiarmhairtí fadtéarmacha do na teaghlaigh atá i gceist.37
74
na bacainní ar choiste cróinéara a dhaingniú go bhfuil an-bhréagnú ar
mhéala; moilleanna fada ag fanacht le himeachtaí tosú agus deacracht
maidir le nochtadh a fháil ón bhFeidhmeannacht Sláinte agus
Sábháilteachta (FSS). Idir 2008 agus 2014, bhí ocht mbás máthar i gcás ina
ndearnadh cinntí -eachtra leighis a sheachadadh ag fiosrúchán
poiblí.38
75
Ach amháin leis na moltaí chun Seirbhís na gCeannairí a
athchóiriú a cuireadh ar taispeáint os comhair na Dála, tá an t-ionchas ann
go bhféadfadh cúnamh dlíthiúil a bheith ar fáil do theaghlaigh a cailleadh
mar thoradh ar bhásanna do mháithreacha a bheith ionadaithe in aon
imeachtaí teagmhais a thionólfar. Tá imní buan ann, mar gheall ar na
prionsabail dhlíthiúla a bhaineann le ‘comhionannas airm’, ach tá sé mar
gheall ar fhíorú na gceart ar nósanna imeachta cóir a thugtar aitheantas
bunreachtúil mar cheart neamhréirithe39
76
faoi bhun Bunreacht na
hÉireann.40
77
Ina theannta sin, is foinse imní eile d’íospartaigh an
fhéidearthacht a bhaineann le foghlaim faoi chúram leighis fheabhsaithe.
Tar éis bás Tania McCabe i 2007, thug an FSS faoi deara sainmhíniú a
glacadh go náisiúnta le seipsis máthar a sholáthar. Más amhlaidh gur
tugadh onóir dó seo agus do gnóthais eile, áitíodh go bhféadfaí bás Savita
Halappanavar in 2012, a choisc.41
78
37 Jo Murphy-Lawless, ‘Inquests are Essential to Understanding Maternal Deaths’ (Nuacht
agus Imeachtaí na Tríonóide, 26 Samhain 2015)
are-essential-to-understanding-
maternal-deaths/> faighte ar an 23 Samhain 2019.
38 ibid.
39 Daingníodh an chéad léiriú den cheart seo i ndlí na hÉireann i Re Haughey [1971] IR 217.
De réir Ó Dálaigh Brmh, ‘[T]o deny such [fair procedure rights] is, in an ancestral adage, a
classic case of clocha ceangailte agus madraí scaoilte. Article 40, s 3, of the Constitution is a
guarantee to the citizen of basic fairness of procedures. The Constitution guarantees such
fairness, and it is the duty of the Court to underline that the words of Article 40, s 3, are not
political shibboleths but provide a positive protection for the citizen and his good name’ ag
264.
40 Airteagal 40.3.
41 Murphy-Lawless (n 37).
2020] Éagóir nó Ceartas
31
A. Maternal Deaths in Hospitals
It has been compellingly argued that ‘every maternal death...is a dreadful
tragedy with life-long consequences for the families involved.’37
79
The
anguish of bereavement has been compounded by obstacles to securing
an inquest; prolonged delays in waiting for proceedings to commence;
and difficulty in securing disclosure from the Health and Safety
Executive. Between 2008 and 2014, there were eight maternal deaths in
which verdicts of medical misadventure were delivered at a public
inquest.38
80
Yet only now, with the proposals to reform the Coroners
Service that have been tabled before the Dáil, is there a prospect that
legal aid may be available for families bereaved as a result of maternal
deaths, to allow them to be represented at any inquest proceedings
convened. This has been, and remains, an enduring concern, not least
because of the legal principles of ‘equality of arms’, but also due to the
vindication of the right to fair procedures which has been afforded
constitutional recognition as an unenumerated right39
81
under Bunreacht
na hÉireann.40
82
Furthermore, the potential for learning to be derived for
improved medical care is another source of concern for victims. After the
death of Tania McCabe in 2007, the HSE had undertaken to provide a
nationally accepted definition of maternal sepsis. If this and other
undertakings had been honoured, it has been argued that the death of
Savita Halappanavar in 2012 may have been prevented.41
83
37 Jo Murphy-Lawless, ‘Inquests are Essential to Understanding Maternal Deaths’ (Trinity
News and Events, 26 November 2015)
are-essential-to-understanding-maternal-deaths/> accessed 23 November 2019.
38 ibid.
39 The first articulation of this right in Irish law was affirmed in Re Haughey [1971] IR 217.
Per Ó Dálaigh J, ‘[T]o deny such [fair procedure rights] is, in an ancestral adage, a classic
case of clocha ceangailte agus madraí scaoilte. Article 40, s 3, of the Constitution is a
guarantee to the citizen of basic fairness of procedures. The Constitution guarantees such
fairness, and it is the duty of the Court to underline that the words of Article 40, s 3, are not
political shibboleths but provide a positive protection for the citizen and his good name’ at
264.
40 Article 40.3.1.°
41 Murphy-Lawless (n 37).
Trinity College Law Review [Vol 23
32
Go deimhin, fuair tuarascáil ina dhiaidh sin ag an Údarás um Fhaisnéis
agus Cáilíocht Sláinte42
84
in 2013 amach go raibh ‘disturbing resemblance’
ann idir na himthosca a bhaineann le bás máthartha Tania McCabe agus
bás Savita Halappanavar.43
85
Sula ndearnadh an choiste cróinéara ar bhás Savita Halappanavar,
chuir aturnae a teaghlaigh in iúl go láidir leis an bpróiseas ar na forais nach
gcomhlíonann an ras cróinigh in Éirinn le hAirteagal 2 den
Choinbhinsiún. D’aontaigh Comhairle na hÉireann um Shaoirsí Sibhialta
le measúnú theaghlach Halappanavar.44
86
Rinneadh trí thuairisc ar leith
sna himthosca a chúisigh bás tragóideach Savita Halappanavar: tuarascáil
FSS a rinneadh faoi chathaoirleach Sir Sabaratnam Arulkumaran;
tuarascáil UFCS; agus an tuarascáil ar imscrúdú uatóipse an Dr Ciarán
MacLoughlin, go léir a rinneadh i 2013. Léirigh na trí thuarascálacha go
raibh easpa iomarcacha sna heilimintí bunúsacha de chúram Bean
Halappanavar agus d’admhaigh siad go raibh an t-easpa idirghabhála mar
imní tromchúiseach. D’aimsigh an tuarascáil FSS go raibh ‘an-bhéim ar an
ngá aird chuí a dhíriú ar mhonatóireacht agus riosca ionfhabhtaithe agus
sepsis sa mháthair a bhainistiú.’45
87
Chinn an tuarascáil HIQA go raibh:
Easpa soláthair ginearálta cúraim bhunúsach, bunúsach, mar
shampla, gan leanúint ar aghaidh le tástálacha fola; gan teip a aithint
go raibh i mbaol meathlú cliniciúil ag Bean Uí Halappanavar agus
nach ndearna sé nó sí imní le cliniceoir cáilithe a bheith ag gníomhú
nó a ardú nuair a bhí comharthaí meath cliniciúil ag Bean Uí
Halappanavar.46
88
42 Dá ngairtear ‘UFCS’ air amach anseo, ach ‘HIQA’ atá air as Béarla mar eolas.
43 ‘HIQA Report Finds “Disturbing Resemblance” Between Death of Garda Tania Mccabe
and Savita Halappanavar’ (Augustus Cullen Law Solicitors.ie, 11 Deireadh Fómhair 2018)
events/current-news/hiqa-report-finds-
disturbing-resemblance-between-death-of-garda-tania-mccabe-and-savita-halappanavar/>
faighte ar an 23 Samhain 2019.
44 Sinead O’Carroll, ‘Savita Halappanavar: Her Tragic Death and how she became part of
Ireland’s Abortion Debate’ (The Journal.ie, 29 Aibreán 2018)
amendment-4-3977441-Apr2018> faighte ar an 16
Samhain 2019.
45 Feidhmeannacht na Seirbhíse Sláinte, ‘An Tuarascáil Deiridh’ (n 12).
46 Údarás um Fhaisnéis agus Cáilíocht Sláinte (UFCS), ‘Investigation into the Safety, Quality
and Standards of Services Provided by the Health Service Executive to Patients, including
Pregnant Women, at Risk of Clinical Deterioration, including those provided in University.
2020] Éagóir nó Ceartas
33
Indeed, a subsequent report by the Health Information and Quality
Authority42
89
in 2013 found a ‘disturbing resemblance’ between the
circumstances surrounding the maternal death of Tania McCabe and the
death of Savita Halappanavar.43
90
Before the inquest into the death of Savita Halappanavar was
convened, her family’s solicitor expressed strong objections to the process
on the grounds that the coronial system in Ireland is not compliant with
Article 2 of the ECHR. The Irish Council for Civil Liberties concurred with
the Halapannavar family’s assessment.44
91
Three separate reports were
carried out into the circumstances that lead to the tragic death of Savita
Halappanavar: the HSE Report carried out under the chair of Sir
Sabaratnam Arulkumaran; the HIQA report; and the postmortem inquest
report of Dr. Ciarán MacLoughlin, all of which were conducted in 2013.
All three reports signalled gross inadequacies in the basic elements of Ms
Halappanavar’s care and acknowledged that the lack of intervention was
of serious concern. The HSE report found there was ‘an under-emphasis
on the need to focus appropriate attention on monitoring and managing
the risk of infection and sepsis in the mother.’45
92
The HIQA report
concluded that there was:
[A] general lack of provision of basic, fundamental care, for
example, not following up on blood tests; a failure to recognise that
Ms Halappanavar was at risk of clinical deterioration and a failure
to act or escalate concerns to an appropriately qualified clinician
when Ms Halappanavar was showing the signs of clinical
deterioration.46
93
42 Hereinafter referred to as ‘the HIQA’.
43 HIQA Report Finds ‘Disturbing Resemblance’ Between Death of Garda Tania McCabe and
Savita Halappanavar’ (Augustus Cullen Law Solicitors.ie, 11 October 2018)
events/current-news/hiqa-report-finds-disturbing-
resemblance-between-death-of-garda-tania-mccabe-and-savita-halappanavar/> accessed 23
November 2019.
44 Sinead O’Carroll, ‘Savita Halappanavar: Her Tragic Death and how she became part of
Ireland’s Abortion Debate’ (The Journal.ie, 29 April 2018)
amendment-4-3977441-Apr2018> accessed 16 November 2019.
45 Health Service Executive, ‘Final Report’ (n 12).
46 Údarás um Fhaisnéis agus Cáilíocht Sláinte (UFCS), ‘Investigation into the Safety, Quality
and Standards of Services Provided by the Health Service Executive to Patients, including
Pregnant Women, at Risk of Clinical Deterioration, including those provided in University.
Trinity College Law Review [Vol 23
34
Go sonrach, d’aimsigh torthaí an uatóipse gurbh é turraing seachtrach ba
chúis le bás Halappanavar agus gur éirigh leis an bhfiosrúchán ina dhiaidh
sin go bhfuair sí bás mar thoradh ar ‘míthapa leighis.’47
94
Ach, in ainneoin
seo agus an raic poiblí a d’fhógair bás Savita Halappanavar, ní ach anois
go bhfuil sé éigeantach go ndéanfaí fiosrúchán a thionól go huathoibríoch
i ngach bás máthar. Ní bhíonn teaghlaigh an mhairbh óna bhfuil cúnamh
dlí ag teastáil, i dteideal air go huathoibríoch, cé go bhféadfadh moltaí le
haghaidh athchóirithe a bhfuil os comhair na Dála faoi láthair, cabhrú le
leigheas na n-easnamh. Cé go n-áitítear gurb é ‘an próiseas ionchúisimh
an ionstraim iontaofa amháin ag teaghlaigh le croílár na nithe a tharla a
fhiosrú,’48
95
coinníonn an teaghlach Halappanavar le haon fhírinniú nár
comhlíonaigh an Stát a oibleagáid chun fiosrúchán comhlíontach Airteagal
2 a sholáthar. De réir dealraimh, is cosúil go bhfuil an tairseach d’Airteagal
2 ard, ach fós nílsoiléir cé acu an raibh cásanna ina bhfuil cúram sláinte
tar éis báis a bhaint amach fiú, go háirithe i gcás Bean Uí Halappanavar.
Sa chás Fernandes v. Portugal,49
96
fuair Cúirt na hEorpa um Chearta an
Duine sa Mhór-Sheomra Cumarsáide, i ndáil le gníomhartha agus
easnaimh ghairmithe cúram sláinte, ní sháraítear Airteagal 2 ach amháin
in ‘imthosca an-eisceachtúla’ ina bhfuil na ceithre chomhpháirt seo a
leanas i láthair:
(i) Ní mór go gcaithfeadh gníomhartha nó easnaimh ghairmithe
cúram sláinte dul níos faide earráid nó faillí míochaine
amháin agus go gcaithfí cóireáil éigeandála othair a dhiúltú in
ainneoin an fheasa go bhfuil saol an othair i mbaol mura
dtugtar cóireáil;
47 Sinead O’Carroll, ‘Savita Inquest: The Coroner's Nine Recommendations Endorsed by the
Jury’ (TheJournal.ie, 19 Aibreán 2013) inquest-the-
coroners-9-recommendations-876864-Apr2013/> faighte ar an 23 Samhain 2018.
48 Murphy-Lawless (n 37).
49 Lopes de Sousa Fernandes v Portugal (Application No. 56080/13) [2017] ECHR 1174.
2020] Éagóir nó Ceartas
35
Specifically, the results of the post-mortem found that Ms Halappanavar’s
death was caused by septic shock, and the inquest subsequently concluded
that she had died as a result of ‘medical misadventure.’47
97
Yet, despite this
and the public furore evoked by the death of Savita Halappanavar, it is not
yet mandatory for an inquest to be automatically convened in every
maternal death. While it is argued that ‘the inquest process is the one
reliable instrument families have to get to the core of what
happened,’48
98
the Halappannavar family maintain with justification that
the State did not fulfill its obligation to provide an Article 2 compliant
inquest. Granted, it would appear that the threshold for an Article 2 is high,
and yet it is unclear whether cases where healthcare has contributed to a
death even reach it, particularly in Ms Halappanavar’s case. In Fernandes
v. Portugal,49
99
the Grand Chamber of the European Court of Human Rights
found that, in relation to acts and omissions of healthcare professionals,
Article 2 will only be breached in ‘very exceptional circumstances’ where
the following four components are all present:
(i) Acts or omissions by healthcare professionals must go beyond
mere error or medical negligence and would need to involve denying
a patient emergency treatment despite knowing that the patient's life
is at risk if treatment is not given;
47 Sinead O’Carroll, ‘Savita Inquest: the Coroner’s Nine Recommendations Endorsed by the
Jury’ (The Journal.ie, 19 April 2013) inquest-the-
coroners-9-recommendations-876864-Apr2013/> accessed 23 November 2019.
48 Murphy-Lawless (n 37).
49 Lopes de Sousa Fernandes v Portugal (Application No. 56080/13) [2017] ECHR 1174.
Trinity College Law Review [Vol 23
36
(ii) Caithfidh an mhífheidhmiú atá i gceist a bheith inmharthana go
hoibiachtúil nó i ndáiríre mar chórasach / struchtúr ionas go mbeidh
sé inchurtha i leith an Stáit, ní hamháin cásanna indibhidiúla de rud
éigin ‘mícheart’ nó ‘droch-fheidhmiú’ mar shampla;
(iii) Ní mór nasc a bheith ann idir an mhífheidhm agus an dochar;
(iv) Ní mór go n-eascraíonn an mhífheidhm ó chliseadh an Stáit
freastal ar a oibleagáid
creat rialála feidhmiúil éifeachtach a sholáthar.50
100
Leagann sé seo tairseach sách ard dóibh siúd atá ag iarraidh argóint a
dhéanamh le haghaidh fiosrúchán Airteagal 2, ceann a tugadh dúshlán
neamhthorthúil i gcúirteanna Sasanach sa chás R (Parkinson) v. HM
Senior Coroner for Kent and others.51
101
Bhain an cás le dúshlán
athbhreithnithe breithiúnach ar chinneadh an chróinéara gan imscrúdú
Airteagal 2 a dhéanamh ar bhás bean 91 bliain d’aois a tugadh chuig an
ospidéal ina raibh an t-othar a bhí ag fulaingt ina stát atá ag fáil bháis
cheana féin ach gur chreid a mac go bhféadfadh níos mó déanta chun í a
shábháil. Ag aithint an ard-thairsigh atá leagtha síos ag Fernandes i
gcásanna den chineál seo, rinne abhcóide thar ceann an teaghlaigh iarracht
a mhaíomh nach raibh prionsabail Fernandes i bhfeidhm. Dhiúltaigh an
Ard-Chúirt an líne argóinte seo, áfach, agus ghlac Fernandes leis mar ‘the
latest, very recent and authoritative summary of the applicable
principles.’52
102
Dá bharr sin, b’fhéidir nach mbeadh sé éasca idirdhealú a
dhéanamh idir eachtra faillí agus teip córasach a d’fhéadfaí Airteagal 2 a
shárú.53
103
50 ibid.
51 [2018] EWHC 1501.
52 ibid [64].
53 Cé nach bhfuil baint dhíreach aige leis an bplé seo a bhaineann le básanna máithreacha,
pointe breise le tabhairt faoi deara ná gur dhiúltaigh an chúirt don chonspóid freisin gur
cheart an cás a mheas mar an gcéanna leis na cásanna coinneála sláinte meabhrach de facto
toisc nach raibh cumas meabhrach ag an othar mar gheall ar a néaltrú, rud a chuirfeadh
dualgas Airteagal 2 ina dhiaidh sin. Dhearbhaigh siad nach raibh an cás seo cosúil leis na
cásanna coinneála meabhracha ar an bhfíric seo agus go minic go mbeidh saincheisteanna
cumais mheabhraigh ag othair A&E ach go mbeidh feidhm ag na gnáthphrionsabail maidir
le cásanna leighis. Féach [94] (Tiarna Dlí agus Cirt Singh)..
2020] Éagóir nó Ceartas
37
(ii) The dysfunction in question must be objectively or genuinely
identifiable as systemic/structural in order to be attributable to the
State, not just individual instances of something 'going wrong’ or
‘functioning badly’ for example;
(iii) There must be a link between the dysfunction and the harm;
(iv) The dysfunction must have resulted from a failure of the State
to meet its obligation to provide an effectively functioning
regulatory framework.50
104
This sets a rather high threshold for those trying to argue for an Article 2
inquest, one which was unsuccessfully challenged in the English courts in
R (Parkinson) v. HM Senior Coroner for Kent and others.51
105
The case
concerned a judicial review challenge to the coroner’s decision not to
conduct an Article 2 inquest into the death of a 91 year old woman who
was brought to hospital in what the attending doctor determined to be a
fatal condition. Her son believed, however, that more could have been
done to save her. Recognising the high threshold set by Fernandes in cases
of this kind, counsel on behalf of the family tried to argue that the
Fernandes principles did not have to be applied. However, the High Court
rejected this line of argument and embraced Fernandes as being ‘the latest,
very recent and authoritative summary of the applicable
principles.’52
106
Consequently, it may not be easy to distinguish between an
incident of negligence and a systemic failure which potentially breaches
Article 2.53
107
50 ibid.
51 [2018] EWHC 1501.
52 ibid [64].
53 While not directly linked to this discussion pertaining to maternal deaths, an additional
point to note is that the court also rejected the contention that the case should be regarded
as analogous to the de facto mental health detention cases as the patient lacked mental
capacity due to her dementia, which would consequently trigger Article 2 obligations. They
asserted that, on the facts, this case was nothing like the mental detention cases and that,
whilst A&E patients will often have mental capacity issues, the normal principles for
medical cases will apply nonetheless. See [94] ( Lord Justice Singh).
Trinity College Law Review [Vol 23
38
Ach tugtar an méid atá ar eolas anois tar éis fhoilsiú tuarascála an HIQA
maidir leis an ‘disturbing resemblance’ idir bhás Tania McCabe agus bás
Savita Halappanavar, is cosúil go bhfuil an argóint go gcuireann teip
córasach le Bean Uí Halappanavar an-inchreidte. Cé go bhfuil sé thar
theorainneacha an phlé seo chun críche cinntitheach a tharraingt, bíonn
ceisteanna breise mar thoradh ar na saincheisteanna a bhfuil béim orthu
maidir le comhoiriúnacht chearta an choráis atá ann cheana féin.
B. Básanna I gCothabháil
Mar a tharlaíonn le básanna máthar, níl aon cheanglas éigeantach ann go
ndéanfaí fiosrúcháin a thionól i mbásanna a bhíonn i gcoimeád agus nach
bhfuil aon mholtaí ann reachtaíocht a athchóiriú ina leith sin. Ina áit sin,
féadfaidh an tAire Dlí agus Cirt Coimisiún Imscrúdaithe a bhunú faoin
Acht Um Choimisiúin Imscrúdaithe 200454
108
a dhéanamh go
príobháideach, ach amháin i gcúinsí an-eisceachtúla. Faoin reachtaíocht
reatha, níl cumhacht bunúsach ag an gCoimisiún a thuarascáil féin a
fhoilsiú. Is leis an tAire Dlí agus Cirt atá an cinneadh chun an tuarascáil a
dhéanamh ná go n-éilítear an tuarascáil a fhoilsiú, ach féadfaidh sé iarratas
a dhéanamh chun na hArd-Chúirte le haghaidh treoracha mheasann
go bhféadfadh dochar d’aon imeachtcoiriúla de bhun Alt 38
d’Acht 2004. B’fhéidir go bhfuil sé níos tábhachtaí fós, go bhféadfadh
cúinsí as a n-eascraíonn imní tromchúiseacha, mar shampla bás
phríosúnach, nach n-áiritheofaí go leor iniúchadh poiblí orthu chun
Airteagal 2 den Choinbhinsiún a chomhlíonadh.55
109
54 Dá ngairtear ‘Acht 2004’ amach anseo.
55 Agnieszka Martynowicz, ‘Oversight of Prison Conditions and Investigations of Deaths in
Custody: International Human Rights Standards and the Practice in Ireland’ (2010) 91 The
Prison Journal.
2020] Éagóir nó Ceartas
39
Yet given what is now known following the publication of the HIQA report
about the ‘disturbing resemblance’ between the death of Tania McCabe
and the death of Savita Halappanavar, the argument that a systemic failure
contributed to Ms Halappanavar seems highly plausible. While it is beyond
the purview of this discussion to draw a definitive conclusion, the issues
highlighted give rise to further questions about the human rights
compatibility of the existing coronial system.
B. Deaths in Custody
As with maternal deaths, there is no mandatory requirement for inquests
to be convened into deaths which occur in custody and there are no
proposals to reform legislation in this respect. Instead, the Minister for
Justice may establish a Commission of Investigation under the
Commissions of Investigation Act 200454
110
to take place in private, save
for very exceptional circumstances. Under current legislation, the
Commission does not have inherent power to publish its own report. The
decision to make the report public rests with the Minister for Justice who
is required to publish the report, but may apply to the High Court for
directions if she or he considers that publication might prejudice any
criminal proceedings pursuant to Section 38 of the 2004 Act. Perhaps more
importantly, situations that give rise to the gravest concern, such as the
death of a prisoner, may not in themselves ensure sufficient public
scrutiny to comply with Article 2 of the ECHR.55
111
54 Hereinafter referred to as ‘the 2004 Act’.
55 Agnieszka Martynowicz, ‘Oversight of Prison Conditions and Investigations of Deaths in
Custody: International Human Rights Standards and the Practice in Ireland’ (2010) 91 The
Prison Journal.
Trinity College Law Review [Vol 23
40
Tá srianta tromchúiseacha ann freisin ar an áis don neasghaol chun cur le
himeachtaí den chineál seo, agus níl aon fhoráil le haghaidh cúnamh
dlíthiúil chun comhaltaí de theaghlach caillte nó a n-ionadaithe dlí a chur
ar chumas páirt a ghlacadh in imeachtaí. D’fhéadfadh imní breise a bheith
ann go bhfuil Éire fós ag daingniú an Phrótacail Roghnach don
Choinbhinsiún i gcoinne Céastóireachta.56
112
D’fhéadfadh sé seo a bheith comhdhúile do thaithí an íospartaigh nó á
n-athghaoil agus leis na forálacha atá i bhfeidhm faoi láthair chun scrúdú
a dhéanamh ar bhásanna faoi choimeád is dócha nach gcomhlíonann siad
caighdeán na gcosaintí cearta daonna atá cumhdaithe in Airteagal 2 den
Choinbhinsiún.
C. Básanna a Bhaineann le Húsáid Fórsa nó Ma
Neamhdhleathach
Bíonn deacrachtaí ar leith ag tabhairt aghaidh ar theaghlaigh a chaill duine
i gcás gurb é atá i gceist le bás coibhneasta úsáid a bhaint as feidhm
mharfach ag an Stát nó mar thoradh neamhdhleathach ag páirtí eile.
Déanta na fírinne, is annamh a bhíonn na cásanna seo a bhaineann le
cásanna báis lena n-úsáidtear fórsa marfach ag an Stát.57
113
Agus é sin ráite,
i gcás ina bhfuil gníomhairí an Stáit, mar shampla comhaltaí d’Aonad
Freagartha Éigeandála an Gharda Síochána, curtha i bhfeidhm go
gníomhach le húdarás chun fórsa marfach a úsáid, d’fhéadfadh ceisteanna
a bheith ann do theaghlach an duine éagtha cén fhaisnéis a d’fhéadfaí a
nochtadh os comhair an cróinéarar nó laistigh d’imeachtaí poiblí an
choiste cróinéara.
56 Comhthionól Ginearálta na Náisiún Aontaithe, Optional Protocol to the Convention
Against Torture and other Cruel, Inhuman and Degrading Treatment or Punishment, 9 Eanáir
2003, A/RES/57/199, ar fáil ag: faighte ar
an 23 Feabhra 2020. Do thuilleadh eolais, féach ar Deirdre Malone, ‘Ireland has not Ratified
a Protocol to Prevent Torture in Places of Detention’ The Irish Times (Dublin, 8 Lúnasa
2018) https://www.irishtimes.com/opinion/ireland-has-not-ratified-a-protocol-to-prevent-
torture-in-places-of-detention-1.3588981> faighte ar an 23 Samhain 2019.
57 Comhchoiste Oireachtais um Maoirseacht agus Achainíocha Seirbhíse Poiblí, Deb 10
Meitheamh 2015, 10.
2020] Éagóir nó Ceartas
41
There are also severe constraints on the facility for the next-of-kin to
contribute to proceedings of this kind, and no provision for legal aid to
enable members of a bereaved family or their legal representatives to
participate in the same. Of further concern may be the fact that Ireland has
yet to ratify the Optional Protocol to the Convention against Torture.56
114
This apathy, arguably, contributes to the grief already felt by victims or
their next-of-kin, as the provisions currently in place for examining deaths
in custody are unlikely to meet the standard of human rights safeguards
enshrined in Article 2 of the ECHR.
C. Deaths Involving Use of Force & Unlawful Killing
Particular difficulties confront bereaved families where the death of a
relative involves use of lethal force by the State or unlawful killing by
another party. Admittedly, these cases involving instances of death
involving use of lethal force by the State are rare.57
115
However, where
agents of the State, such as members of An Garda Síochána’s Emergency
Response Unit, have been operationally deployed with authority to use
lethal force, questions may arise for the deceased’s family as to what
information may be disclosed before the coroner or within the public
proceedings of the inquest.
56 UN General Assembly, Optional Protocol to the Convention Against Torture and other
Cruel, Inhuman and Degrading Treatment or Punishment, 9 January 2003, A/RES/57/199,
available at: accessed 23 February 2020.
See further Deirdre Malone, ‘Ireland has not Ratified a Protocol to Prevent Torture in Places
of Detention’ The Irish Times (Dublin, 8 August 2018)
has-not-ratified-a-protocol-to-prevent-
torture-in-places-of-detention-1.3588981> accessed 23 November 2019.
57Joint Oireachtas Committee on Public Service Oversight and Petitions, Deb 10 June 2015,
10.
Trinity College Law Review [Vol 23
42
Is amhlaidh a bhí sé sa chás go ndearna duine a bhí i mbun robála armtha
i mBaile Átha Luain bás i 2009, a rinne na Gardaí idirdhealú air; bhain
Coimisinéir an Gharda Síochána agus Coimisiún Ombudsman an Gharda
Síochána páirt i bpróiseas fada de dhoiciméadú a nochtadh don
chróinéir.58
116
Ina theannta sin, chuir Gardaí isteach nach raibh doiciméadú
eile ann agus ní bheadh sceidealaithe le nochtadh in aon fhoirm chuig
an bhfiosrach, mar a bhain siad seo le pleanáil oibríochtúil ag Gardaí.
D’éirigh le moilleanna maidir le faisnéis a sholáthar don chróinéir agus
díospóid maidir le faisnéis a nochtadh gan údaráis Stáit aighneachtaí ó
dhlíodóirí go raibh iompar na n-imeachtaí ag cur le muinín an teaghlaigh
dífhostaithe.59
117
Thairis sin, ardaíonn seo saincheisteanna faoi
thrédhearcacht nochtadh an Stáit ar imeachtaí fiosrúcháin chomh maith
leis an gcaoi a ndéanfar cinneadh maidir le hábharthacht faisnéise
d’imeachtaí fiosrúcháin.
Anuraidh, rinneadh coiste cróinéara ar bhás Garda Tony Golden. Chinn sé
seo go maraíodh Garda Golden go neamhdhleathach le h-arm tine nuair a
d’fhreastail sé ar an mbaile a bhí ag íospartaigh ar drochíde baile in Ó
Meith, Contae an Lú.60
118
Tá an coiste cróinéara faoin duine a mharaigh é,
Adrian Crevan Mackin, fós ar siúl.61
119
58 Féach ar ‘Garda Commissioner ‘Withholding Documents’ on Raider’s Death’ (The Irish
Times, 27 Eanáir 2015) https://www.irishtimes.com/news/crime-and-law/courts/coroner-s-
court/garda-commissioner-withholding-documents-on-raider-s-death-1.2081429> faighte ar
an 20 Samhain 2018.
59 ibid.
60 Conor Lally, ‘Garda Tony Golden was shot in the back as he helped assault victim,
Inquest told’ The Irish Times (Dublin, 23 Aibreán 2018)
and-law/garda-tony-golden-was-shot-in-the-
back-as-he-helped-assault-victim-inquest-told-1.3470901?mode=sample&auth-failed=1&pw-
origin=https%3A%2F%2Fwww.irishtimes.com%2Fnews%2Fcrime-and-law%2Fgarda-tony-
golden-was-shot-in-the-back-as-he-helped-assault-victim-inquest-told-1.3470901> faighte
are an 22 Samhain 2019.
61 Tá conspóid ann maidir le scaoileadh an duine a mharaigh é, Adrian Crevan Martin, agus
ráflaí nó líomhaintí go raibh an duine seo ina fhoghlaimeoir, nó ina fhoinse rúnda um
fhaisnéis dhaonna don Stát. Féach do thuilleadh, Cliodhna Russell, ‘Prime Time Questions if
Killer of Garda Tony Golden was Garda Informer’ (The Journal.ie, 20 Aibreán 2017)
rda-tony-golden-prime-time-investigates-rte-3350264-
Apr2017/> faighte ar an 23 Samhain 2019.
2020] Éagóir nó Ceartas
43
This was the case in the inquest of a man involved with an armed robbery
in Lucan in 2009, which Gardaí intercepted; the Garda Commissioner and
an Garda Síochána Ombudsman Commission both engaged in a lengthy
process of redacting documentation disclosed to the
coroner.58
120
Moreover, Gardaí submitted that other documentation had
not and would not be scheduled for disclosure in any form to the inquest,
as these documents related to operational planning by Gardaí. Delays in
provision of information to the coroner and dispute about the non-
disclosure of information by State authorities prompted submissions from
legal counsel that the conduct of the proceedings risked eroding the
confidence of the bereaved family.59
121
Moreover, this raises issues about
the transparency of disclosure by the State in the context of inquest
proceedings as well as how and by whom the relevance of information to
inquest proceedings is to be decided.
In 2018, the inquest into the death of Garda Tony Golden took place. This
found that Garda Golden was unlawfully killed with a firearm when
attending the home of Siobhán Phillips, a victim of domestic abuse in
Omeath, County Louth.60
122
The inquest into the person who killed him,
Adrian Crevan Mackin, has yet to be held.61
123
58 ‘Garda Commissioner ‘Withholding Documents' on Raider’s Death’ The Irish Times
(Dublin, 27 January 2015) https://www.irishtimes.com/news/crime-and-
law/courts/coroner-s-court/garda-commissioner-withholding-documents-on-raider-s-
death-1.2081429> accessed 20 November 2019.
59 ibid.
60 Conor Lally, ‘Garda Tony Golden was shot in the back as he helped assault victim,
Inquest told’ The Irish Times(Dublin, 23 April 2018)
and-law/garda-tony-golden-was-shot-in-the-
back-as-he-helped-assault-victim-inquest-told-1.3470901?mode=sample&auth-failed=1&pw-
origin=https%3A%2F%2Fwww.irishtimes.com%2Fnews%2Fcrime-and-law%2Fgarda-tony-
golden-was-shot-in-the-back-as-he-helped-assault-victim-inquest-told-1.3470901> accessed
22 November 2019.
61 Surrounding the death of Garda Golden is a controversy about the release on bail of the
person who killed him Adrian Crevan Martin, and rumours or allegations that this
individual was an informer, or a covert human intelligence source for the State. See further,
Cliodhna Russell, ‘Prime Time Questions if Killer of Garda Tony Golden was Garda
Informer’ (The Journal.ie, 20 April 2017) tony-golden-
prime-time-investigates-rte-3350264-Apr2017/> accessed 23 November 2019.
Trinity College Law Review [Vol 23
44
Tá athair an íospartaigh drochíde baile teaghlaigh a ghortaíodh go mór i
rith lámhach Garda Golden ag iarraidh cead páirt a ghlacadh sna
himeachtaí sin, áfach.62
124
Cé nach gceadóidh an t-Acht 1962 go sainráite é, d’aimsigh na
cúirteanna in Éirinn go bhfuil sé de cheart ag an gcéad dulghabhálach páirt
a ghlacadh i gcoiste cróinéara agus éisteacht le linn na n-imeachtaí ar
bhonn ceartais nádúrtha agus bunreachtúla.63
125
Ní léir go bhfuil an ceart
seo le tuismitheoir duine atá gortaithe go dona. Is dócha gurb é seo an
tábhacht a bhaineann le cás-dlí ar cheisteanna comhlíontacha Airteagal 2
a chothaíonn tábhacht níos mó.
Cás amháin a chabhraíonn le fiosrúcháin a bhaineann le
saincheisteanna ná na cúinsí a bhaineann le bás Denis Donaldson an 4ú
Aibreán 2006 i nDún na nGall. Tar éis a rá go poiblí gur earcaíodh é mar
fhaisnéisoir ag Constáblacht Ríoga Ulaidh agus Seirbhísí Slándála na
Breataine (MI5), theith an tUasal Donaldson lena bhean chéile i nDún na
nGall sula bhfuarthas amach go raibh a chorp ceithre mhí ina dhiaidh sin
le créachta gunna. Cé gur imscrúdaigh an Garda Síochána a dhúnmharú ó
shin i leith, cuireadh a fhiosrú ar atráth ar níos mó ná fiche uair.64
126
Chuir
a chlann a n-agóid in iúl go poiblí leis na h-atráthuithe seo agus a n-
éagothroime agus a n-éagmais ag seoladh fiosrúcháin.65
127
Léiríonn
imeachtaí imscrúdaithe ar bhás an tUasal Donaldson go dtugann an
cróinéir iarratais ar atráthú ar ndiaidh na n-iarratas chuig an nGarda
Síochána faoi Alt 25 d’Acht 1962 ar chostas aighneachtaí dlíthiúla thar
ceann teaghlaigh caillte.
62 Breda Heffernan, ‘Dad of Woman Shot by IRA Garda Killer seeks Inquest Participation’
The Belfast Telegraph(Belfast, 25 Aibreán 2018)
ireland/dad-of-woman-shot-by-ira-
garda-killer-seeks-inquest-participation-36841781.html> faighte ar an 22 Samhain 2019.
63 The State (McKeown) v. Scully [1986] 1 IR 524.
64 Féach ar ‘Inquest Delay ‘Dismays’ Donaldson Family’ (BBC News, 27 Meán Fómahir 2018)
northern-ireland-45661161> faighte ar an 20 Samhain
2018.
65 ibid.
2020] Éagóir nó Ceartas
45
However, Sean Phillips, father of Ms Phillips who was also seriously
injured during the shooting of Garda Golden, is seeking permission to
participate in those proceedings.62
128
Although the 1962 Act does not expressly permit it, the courts in
Ireland have found that the next-of-kin has the right to participate in an
inquest and to be heard during the proceedings on the basis of natural and
constitutional justice.63
129
Whether this right extends to the parent of a
person seriously injured is not clear. Arguably, this is where the
importance of case law on Article 2 compliant inquests assumes greater
significance.
One case which helps to spotlight cognate issues is the
circumstances surrounding the death of Denis Donaldson on 4 April 2006
in Donegal. Having stated publicly that he had been recruited as an
informer by the Royal Ulster Constabulary and British Security Services
(MI5), Mr Donaldson had fled with his wife to Donegal before his body
was found four months later with gunshot wounds. While An Garda
Síochána have been investigating his murder since, his inquest has been
adjourned on more than twenty occasions.64
130
His bereaved family have
publicly articulated their objection to these adjournments and their dismay
and distress at the conduct of the inquest.65
131
Inquest proceedings into the
death of Mr Donaldson also reveal that applications for successive
adjournments by An Garda Síochána under Section 25 of the 1962 Act are
given primacy by the coroner at the expense of legal submissions on behalf
of a bereaved family.
62 Breda Heffernan, ‘Dad of Woman Shot by IRA Garda Killer seeks Inquest Participation’
(Belfast Telegraph.co.uk, 25 April 2018)
ireland/dad-of-woman-shot-by-ira-
garda-killer-seeks-inquest-participation-36841781.html> accessed 22 November 2019.
63 State (McKeown) v. Scully [1986] 1 IR 524.
64 ‘Inquest Delay ‘Dismays’ Donaldson Family’ (BBC News, 27 September 2018)
northern-ireland-45661161> accessed 20 November 2019.
65 ibid.
Trinity College Law Review [Vol 23
46
Tá siad tar éis aighneachtaí dlíthiúla a dhéanamh go gcaithfidh ról
Stát na Breataine i mbás an tUasal Donaldson a bheith ina ábhar d’fhiosrú
comhlíontach Airteagal 2, agus go bhfuil imní orthu maidir le
neamhspleáchas agus éifeachtacht an imscrúdaithe coiriúla ag An Garda
Síochána atá ag brath ar fhaisnéis agus comhoibriú ó na gníomhaireachtaí
Stáit céanna a earcaigh an tUasal Donaldson mar eolaí.66
132
Thug
Comhchoiste Choimisiún um Chearta an Duine Thuaisceart Éireann agus
Coimisiún na hÉireann um Chearta an Duine tacaíocht phoiblí do na
hábhair imní atá ag teaghlach an Uasail Donaldson.67
133
Ar bhonn
teagmhasach, mar gheall ar chás-dlí agus imeachtaí fiosrúcháin i
dTuaisceart Éireann, léiríonn seo neamhshiméadracht idir an gcóras
corónach i ndlínsí ar leith ar oileán na hÉireann d’ainneoin an achtaithe
sa dá áit, Thuaidh agus Theas, den Choinbhinsiún. Ardaíonn sé féin
ceisteanna breise maidir le taithí dhifreálach íospartaigh i ndlínsí éagsúla
ar oileán na hÉireann; rud atá ag teacht leis an Treoir um Íospartaigh na
hEorpa68
134
agus le hintinn na cúirte i leith Airteagal 2 Choinbhinsiún, is
infheidhme i ngach ballstát.
66 Simon Carswell, ‘Arrests in Denis Donaldson Murder Investigation’ The Irish Times
(Dublin, 7 Eanáir 2018) https://www.irishtimes.com/news/ireland/irish-news/arrests-in-
denis-donaldson-murder-investigation-1.3347854?mode=sample&auth-failed=1&pw-
origin=https%3A%2F%2Fwww.irishtimes.com%2Fnews%2Fireland%2Firish-news%2Farrests-
in-denis-donaldson-murder-investigation-1.3347854> faighte ar an 20 Samhain 2019.
67 Coimisiún um chearta an duine i dTuaisceart Éireann, ‘Northern Ireland and Irish Human
Rights Commissions Comment on Denis Donaldson Inquest’ (2011): ‘We are also concerned
that five years after Mr Donaldson’s murder this inquest has still not taken place.
Additionally we have heard from the family their concerns about the lack of disclosure and
information from the Coroner and the Gardaí. Human rights law requires that the family in
these types of cases must be involved in the investigative proceedings to safeguard their
legitimate interests.’ https://thedetail-
website.s3.amazonaws.com/files/225/original/5%20May%202011%20%20Northern%20Ireland
%20and%20Irish%20Human%20Rights%20Commissions%20comment%20on%20Denis%20Don
aldson%20Inquest.pdf?1359543865> faighte ar an 20 Samhain 2019.
68 Directive 2012/29/EU of the European Parliament and the Council of 25 October 2012
establishing minimum standards on the rights, support and protection of victims of crime,
and replacing Council Framework Decision 2001/220/JHA.
2020] Éagóir nó Ceartas
47
They have made legal submissions that the role of the British State
in Mr Donaldson’s death must be the subject of the Article 2 compliant
inquest, and have highlighted concerns for the independence and
effectiveness of the criminal investigation by An Garda Síochána which is
reliant upon information and cooperation from the same State agencies
which recruited Mr Donaldson as an informer.66
135
A Joint Committee of
the Northern Ireland Human Rights Commission and the Irish Human
Rights Commission have publicly supported the stated concerns of Mr
Donaldson’s family.67
136
Incidentally, given the case law and conduct of
inquest proceedings in Northern Ireland, this highlights an asymmetry
between the coronial system in separate jurisdictions on the island of
Ireland notwithstanding the enactment in both places, North and South, of
the ECHR. That in itself raises further questions for differential
experiences of victims in different jurisdictions on the island of Ireland;
something which is at variance with the European Victims
Directive68
137
and the intent of the court in respect of Article 2 ECHR,
applicable in all member states.
66 Simon Carswell, ‘Arrests in Denis Donaldson Murder Investigation’ The Irish Times
(Dublin, 7 January 2018) https://www.irishtimes.com/news/ireland/irish-news/arrests-in-
denis-donaldson-murder-investigation-1.3347854?mode=sample&auth-failed=1&pw-
origin=https%3A%2F%2Fwww.irishtimes.com%2Fnews%2Fireland%2Firish-news%2Farrests-
in-denis-donaldson-murder-investigation-1.3347854> accessed 20 November 2019.
67 Northern Ireland Human Rights Commission, ‘Northern Ireland and Irish Human Rights
Commissions Comment on Denis Donaldson Inquest’ (2011): ‘We are also concerned that
five years after Mr Donaldson’s murder this inquest has still not taken place. Additionally
we have heard from the family their concerns about the lack of disclosure and information
from the Coroner and the Gardaí. Human rights law requires that the family in these types
of cases must be involved in the investigative proceedings to safeguard their legitimate
interests.’ https://thedetail-
website.s3.amazonaws.com/files/225/original/5%20May%202011%20%20Northern%20Ireland
%20and%20Irish%20Human%20Rights%20Commissions%20comment%20on%20Denis%20Don
aldson%20Inquest.pdf?1359543865> accessed 20 November 2019.
68 Directive 2012/29/EU of the European Parliament and the Council of 25 October 2012
establishing minimum standards on the rights, support and protection of victims of crime,
and replacing Council Framework Decision 2001/220/JHA.
Trinity College Law Review [Vol 23
48
I. An t-Acht Nua
Maidir leis an ábhar athchóirithe, tugadh dúinn anuraidh an tAcht
Cróinéirí (Leasú) 2019 a rabhthas ag tnúth leis le fada, a aithníodh go
forleathan é mar ‘landmark bill to significantly clarify, strengthen and
modernise the powers available to coroners in the reporting, investigation
and inquest of deaths.’69
138
Ag cuir fáilte roimh an mBille, dúirt Charlie
Flanagan, an t-Aire Dlí agus Cirt, ‘this is a very important Bill which has
been a priority for me personally and for the Government.’70
139
Is é ceann
de na rudaí is tábhachtaí san Acht ná an riachtanas tuairisciú éigeantach
ar bhásanna máithreacha, go háirithe go gcuirfí bás an duine mar bhás
máithreachais mar bhás máthair déanach laistigh den dualgas
ginearálta chun ionchoisne a thionól agus a aithint.71
140
Baineann seo
freisin le dualgas na gcróinéirí scrúdú iarbháis a stiúradh faoi Alt 33A.
D’fhorbair an sainmhíniú ar bhás máthar déanach a bhfuil cur síos air san
Acht mar:
‘the death of a woman occurring more than 42 days and less than
365 days after the end of pregnancy from any cause related to or
aggravated by the pregnancy or its management, but not from
accidental or incidental causes and, without prejudice to the
generality of the foregoing, includes a direct maternal death or an
indirect maternal death occurring during that period.’72
141
Mar a scrúdaíodh, tá cásanna na mbásanna máithreacha ar cheann de
na saincheisteanna is conspóidí in Éirinn ó bhásaigh Savita
Halappanavar.73
142
69 ‘Bill to Clarify, Strengthen and Modernise Powers of Coroners passed by Oireachtas’
(Irish Legal News, 11 Iúil 2019) to-clarify-
strengthen-and-modernise-powers-of-coroners-passed-by-oireachtas> faighte ar an 12
Eanái r 2020 .
70 ibid.
71 Acht na Cróinéirí (Leasú) 2019, a. 10 (c). Deir an Acht nua, mar leasú ar an Acht 1962: ‘the
insertion of the following subsection after subsection (1): “(2) Without prejudice to the
generality of subsection (1), it shall be the duty of a coroner to hold an inquest in relation to
the death of a person in the following cases: (a) the deceased person was, at the time of his
or her death or immediately before his or her death, in State custody or detention; (b) the
death of the person is a maternal death or a late maternal death.”’
72 ibid a 2 (Leasú ar alt 2 d’Acht 1962).
73 I measc na mbásanna eile tá Sally Rowlette agus Malak Thawley sa chomhthéacs seo. Do
thuilleadh eolais, féach ar Kitty Holland, ‘Families of Woman who Died in Childbirth left in
the Dark, says Midwife’ The Irish Times (Dublin, 30 Eanáir 2019).
2020] Éagóir nó Ceartas
49
III. The New Act
On the topic of reform, last year brought the long-awaited Coroners
(Amendment) Act 2019, dubbed as the ‘landmark bill to significantly
clarify, strengthen and modernise the powers available to coroners in the
reporting, investigation and inquest of deaths.’69
143
Minister for Justice Mr
Charlie Flanagan, in welcoming the passing of the Bill, said that ‘this is a
very important Bill which has been a priority for me personally and for
the Government.’70
144
One of the biggest takeaways from the Act is the
requirement for mandatory reporting of maternal deaths, particularly the
insertion and recognition of the death of the person as a maternal death or
a late maternal death within the general duty to hold an inquest.71
145
This
also applies in the coroners’ duty to direct a post-mortem examination
under Section 33A. The advancement has also developed the definition of
a late maternal death which has been described in the Act as
‘the death of a woman occurring more than 42 days and less than
365 days after the end of pregnancy from any cause related to or
aggravated by the pregnancy or its management, but not from
accidental or incidental causes and, without prejudice to the
generality of the foregoing, includes a direct maternal death or an
indirect maternal death occurring during that period.’72
146
As examined, the cases of maternal deaths has been one of the most
contentious issues in Ireland since the death of Savita Halappanavar.73
147
69 ‘Bill to Clarify, Strengthen and Modernise Powers of Coroners passed by Oireachtas’
(Irish Legal News, 11 July 2019) https://www.irishlegal.com/article/bill-to-clarify-
strengthen-and-modernise-powers-of-coroners-passed-by-oireachtas> accessed 12 January
2020.
70 ibid.
71 Coroners (Amendment) Act 2019, s 10(c). In amending the 1962 Act, this specifies: ‘the
insertion of the following subsection after subsection (1): “(2) Without prejudice to the
generality of subsection (1), it shall be the duty of a coroner to hold an inquest in relation to
the death of a person in the following cases: (a) the deceased person was, at the time of his
or her death or immediately before his or her death, in State custody or detention; (b) the
death of the person is a maternal death or a late maternal death.”’
72 ibid s 2 (Amendment of section 2 of 1962 Act).
73 Other deaths include Sally Rowlette and Malak Thawley in this context. For further
information, see Kitty Holland, ‘Families of Woman who Died in Childbirth left in the Dark,
says Midwife’ The Irish Times (Dublin, 30 January 2 019).
Trinity College Law Review [Vol 23
50
Go deimhin, bunaithe ar staitisticí náisiúnta, tarlaíonn thart ar ocht
go deich mbás máithreachais in Éirinn gach bliain.74
148
Is cinnte go
gcabhróidh an ceanglas éigeantach a n-eascraíonn as an leasú seo ar Acht
1962 le seirbhísí cúraim mháithreachais agus sláinte atáirgthe a fhorbairt.
Cabhraíonn sé seo freisin le neartú chumhachtaí an chróinéara chun
finnéithe a thoghairm chuig coiste cróinéara,75
149
táirgeadh cáipéisí
ábhartha a dhíriú nó dul isteach in áitreabh agus taifid ábhartha a
ghlacadh.76
150
Go bunúsach, cinnteoidh sé go mbeidh deis leordhóthanach
ann le foghlaim ó bhotúin tragóideacha agus -eachtraí agus faillí leighis
sa todhchaí a chosc agus seasamh leis an gceart chun beatha.
Ina theannta sin, agus na saincheisteanna éagsúla á mbreithna
luadh níos luaithe sa phlé seo, tá ionchoisní éigeantacha tugtha isteach ag
an Acht freisin nuair a fhaigheann daoine aonair bás faoi choinneáil nó
faoi choimeád an Stáit.77
151
Mar a luadh, is iad na sanna seo a thagann
saincheisteanna suntasacha chun cinn maidir leis an dualgas cúraim atá
dlite ag an Stát;
nuair a fhaigheann duine faoi choimeád an Stáit bás, fíorthábhachtach
ceisteanna a chur faoi fhreagracht an Stáit agus a chumhachtaí á riaradh
aige. De réir Conway, is oibleagáid bhunúsach chearta daonna i stáit
dhaonlathacha í an chóireáil dhíniteach orthu siúd atá faoi chúram an
Stáit.78
152
74 Féach ar ‘Maternal Death Enquiry Ireland Data Brief No. 4’ (2015-2017) le fáil ag:
fNo4December2019.pdf> faighte ar an 20 Feabhra 2020.
75 Acht na Cróinéirí (Leasú) 2019, a 13, 18B a chur isteach, agus a 23, go háirithe (2A) a chur
isteach in Acht 1962.
76 ibid a 24. Baineann an chuid seo go ginearálta le cumhacht leasaithe an chróinéara maidir
le fianaise a ghlacadh ag an choiste cróinéara..
77 ibid a 10(c).
78 Vicky Conway, ‘Coroners’ Court a Cold Place for Families of Bereaved’The Irish Times
(Dublin, 17 Bealtaine 2019) https://www.irishtimes.com/opinion/coroner-s-court-a-cold-
place-for-families-of-bereaved-1.3894921> faighte ar an 10 Eanáir 2020.
2020] Éagóir nó Ceartas
51
Indeed, based on national statistics, approximately eight to ten
maternal deaths occur in Ireland every year.74
153
The mandatory
requirement brought about by this amendment to the 1962 Act will
undoubtedly assist in the development of sound maternity care and
reproductive health services. This is also aided by the strengthening of the
coroner’s powers to summon witnesses to an inquest,75
154
to direct
production of relevant documents or to enter premises and take possession
of relevant records.76
155
Crucially, it will ensure that there is the adequate
opportunity to learn from tragic mistakes and to prevent future medical
misadventures and negligence in upholding the right to life.
Furthermore, in the consideration of the various issues highlighted
earlier in this discussion, the Act has also introduced mandatory inquests
when individuals die in detention or custody of the State.77
156
As espoused,
it is these cases that raise significant issues in relation to the duty of care
owed by the State; when a person in State custody dies, it is of paramount
importance to ask questions about State responsibility in its administration
of powers. Per Conway, the dignified treatment of those in the care of the
State is a fundamental human rights obligation in democratic states.78
157
74 See further Maternal Death Enquiry Ireland Data Brief No. 4 (2015-2017) to be found at:
fNo4December2019.pdf> accessed 20 February 2020.
75 Coroners (Amendment) Act 2019, s 13, insertion of 18B, and s 23, specifically the
insertion of (2A) to the 1962 Act.
76 ibid s 24. This section generally deals with the amended power of the coroner with
respect to taking evidence at the inquest.
77 ibid s 10(c).
78 Vicky Conway, ‘Coroners’ Court a Cold Place for Families of Bereaved’ The Irish Times
(Dublin, 17 May 2019) https://www.irishtimes.com/opinion/coroner-s-court-a-cold-place-
for-families-of-bereaved-1.3894921> accessed 10 January 2020.
Trinity College Law Review [Vol 23
52
Go deimhin, léirigh an measúnú ar chomhaid 66% de phríosúnaigh
leochaileacha a fuair bás in Éirinn le seacht mbliana anuas go raibh na
taifid míthreorach nó míchruinn.79
158
Dá bhrí sin, is forbairt shuntasach í
go bhfuil Éire ag déanamh éigeantach i gcásanna dá leithéid. I gcoinne na
bhforbairtí maithe seo, áfach, is ábhar imní fós é go bhfuil go leor
cleachtais oibríochtúla eile laistigh den chóras ársa agus neamhleor; ní gá
do chróinéirí tuarascálacha a fhoilsiú agus fágtar go bhfuil sé dodhéanta
patrúin a aithint sna fadhbanna a aibhsítear trí ionchoisní, mar a ndírítear
thuas.80
159
Mar thoradh ar sin, cothrom tuairimíocht a thabhairt go
bhféadfadh an tAcht nua níos mó teaghlaigh a thabhairt isteach i gcóras
níos neamhfhabhraí agus níos míshásta a chuireann a n-achan brón ar
dhaoine a chaill iad. Cé gur cinnte gur dul chun cinn suntasach atá ann, ar
an drochuair, ní dhéanann sé ach tús le plé níos forbartha ar imscrúdú ar
bhásanna neamh-mhínithe agus amhrasacha in Éirinn.81
160
Conclúid
Dúirt William Gladstone , ‘[S]how me the manner in which a community
cares for the dead and I will measure, with exactness, the tender
sympathies of its people, their respect for the laws of their land and their
loyalty to high ideals.’82
161
Laistigh de theorainneacha an phlé seo, is féidir
a thabhairt i gcrích go bhfuil taithí íospartaigh an chórais corónach in
Éirinn as ceim le cosaint agus cur chun cinn chearta an duine.
79 Oifig an Chigire Príosún ‘Annual Report 2018’
of-prisons-annual-report-2018.pdf/Files/inspector-of-prisons-annual-report-2018.pdf>
faighte ar an 15 Eanáir 2020.
80 Conway (n 78).
81 Mar phointe faisnéise, faoi láthair tá Comhairle na hÉireann um Shaoirsí Sibhialta, le
tacaíocht ó Choimisiún na hÉireann um Chearta an Duine agus Comhionannas, ag
déanamh taighde ar an ábhar seo le cabhair ón Dr Vicky Conway agus ón Ollamh Phil
Scraton chun imscrúdú a dhéanamh ar an gcaoi a seasann cearta daonna le próiseas
ionchoisne. Tá dáta críochnaithe don tionscadal seo daingnithe fós.
82 Cuireadh é seo i leith i ‘Successful Cemetery Advertising’ i The American Cemetery
(Márta 1938) lth. 13; tuairiscíodh nach bhfuil sé deimhnithe i Respectfully Quoted: A
Dictionary of Quotations (1989).
2020] Éagóir nó Ceartas
53
Indeed, the assessment of the files of 66% of vulnerable prisoners
who have died in Ireland during the last seven years revealed that the
records were either misleading or inaccurate.79
162
Therefore, it is a
significant development that Ireland is making inquests in such cases
mandatory. Against these laudable developments, however, a concern
remains that many other operational practices within the system are
archaic and inadequate; coroners are not required to publish reports which
makes it impossible to discern patterns in the problems highlighted by
inquests, as addressed.80
163
As a consequence, it is fair to speculate that the
new Act may bring more families into an even more neglected and unjust
system that compounds their grief for lost loved ones. While it is
undoubtedly a significant advancement, unfortunately, it only marks the
beginning of a more fully developed discussion on the investigation of
unexplained and suspicious deaths in Ireland.81
164
Conclusion
William Gladstone once said, ‘[S]how me the manner in which a
community cares for the dead and I will measure, with exactness, the
tender sympathies of its people, their respect for the laws of their land and
their loyalty to high ideals.’82
165
Within the ambit of this discussion, it is
possible to conclude that the experience of victims of the coronial system
in Ireland is out of step with the protection and promotion of human
rights.
79 Office of the Inspector of Prisons ‘Annual Report 2018’
of-prisons-annual-report-
2018.pdf/Files/inspector-of-prisons-annual-report-2018.pdf> accessed 15 January 2020.
80 Conway (n 78).
81 As a point of information, the Irish Council for Civil Liberties, supported by the Irish
Human Rights and Equality Commission, is currently conducting research into this area
with the assistance of Dr Vicky Conway and Professor Phil Scraton to investigate how
human rights are upheld in the inquest process. A completion date for this project remains
unconfirmed.
82 Attributed in ‘Successful Cemetery Advertising’ in The American Cemetery (March 1938)
13; reported as unverified in Respectfully Quoted: A Dictionary of Quotations (1989).
Trinity College Law Review [Vol 23
54
Thairis sin, tá imní ann maidir le neamhoiriúnacht an chórais Chorónaigh
reatha leis an Choinbhinsiún, lena n-áirítear Airteagal 2.83
166
Glactha, tá
aird mhionsonraithe ar na heasnaimh seo glactha ag an
Oireachtas.84
167
Ach, is cosúil go bhfuil luas agus méid an athchóirithe ar
an gcóras corónach socair, agus ina dhiaidh sin, tá sé díobhálach do chearta
agus teidlíochtaí íospartaigh. Má ghlactar leis gurb é bás bhaill teaghlaigh
mar chúis in aon imthosca go dtiocfaidh anacair mhothúchánach don
neasghaol, ansin, oibleagáid ar an Stát gníomhú ar bhealach a
chabhraíonn leis an anacair a bhí ag íospartaigh cheana féin a mhaolú.
Agus é sin ráite, áfach, mar a léirigh roinnt de na cásanna a measadh, tá
an Stát tar éis dul i gcomórtas i gcónaí i gcoinne teaghlaigh na marbh
laistigh den chóras corónach. I gcásanna den chineál sin, is cosúil nach
bhfuil an córas corónach ann faoi láthair neamhspleách, údaraithe nó
cumhachtach leordhóthanach a éileamh go gcoinneoidh an Stát a chuid
oibleagáidí maidir le cearta an duine go bhfuil dúshlán láidir aige maidir
le neamhchomhlíonadh. Dúirt Brian Farrell, Cróinéir Chathair Bhaile Átha
Cliath, ‘it is necessary to continue to press for developments in practice
and procedure so that the coroner’s inquest may better serve the needs of
a changing society.’85
168
Rinneadh an ráiteas seo i 1994. 2020 atá ann anois
agus tá an dearcadh céanna fós i réim in ainneoin na reachtaíochta nua.
Tá sé seo do-ghlactha, amach is amach. Dá bhrí sin, tá leasú práinneach de
dhíth ar mhaithe le taithí na n-íospartach a fheabhsú agus, freisin, ar
mhaithe le Bunreacht na hÉireann a chosaint.
83 Cé nach bhfuil sé faoi réim na díospóireachta seo, tá imní ann freisin maidir lena
chomhoiriúnacht le hAirteagal 13 a bhaineann leis an gceart chun leigheas éifeachtach a
thagann as an coiste cróinéara féin.
84 Díospóireacht Comhchoiste Oireachtais (n 57).
85 Brian Farrell, ‘Development Of Procedures At Coroners’ Inquests Needed’ Irish Medical
Times (1994).
2020] Éagóir nó Ceartas
55
Moreover, there are concerns as to the incompatibility of the present
coronial system with the ECHR, particularly Article 2 as explored.83
169
Granted, the Oireachtas has given detailed attention to these
deficiencies.84
170
Yet, the pace and extent of reform of the coronial system
seems to be dilatory, and in turn deleterious to the rights and entitlements
of victims. If it is accepted that the death of a family member in any
circumstances occasions emotional distress to next-of-kin, then there is an
obligation on the State to act in a way which helps to alleviate the distress
already experienced by victims. However, as several of the cases
considered have indicated, the State has at times entered into contest
against bereaved families within the coronial system. In such instances, it
would seem that the present coronial system is not sufficiently
independent, authoritative, or empowered to insist that the State upholds
its human rights obligations or to be robustly challenged for non-
compliance. Brian Farrell, Dublin City Coroner has said that ‘it is
necessary to continue to press for developments in practice and procedure
so that the coroner’s inquest may better serve the needs of a changing
society.’85
171
This statement was made in 1994; it is now 2020 and the same
sentiment prevails despite new legislation. This is unequivocally
unacceptable. Consequently, urgent reform is not only required in the
interests of improving the experience of victims, but also in the interests
of protecting Bunreacht na hÉireann.
83 While not within the purview of this discussion, concerns also exist in relation to its
compatibility with Article 13 which engages the right to an effective remedy flowing form
the inquest itself.
84 Joint Oireachtas Committee Debate (n 57).This is also evidenced through the enactment
of the Coroners (Amendment) Act 2019 as examined in Section 4 of this discussion.
85 Brian Farrell, ‘Development of Procedures at Coroners’ Inquests Needed’ Irish Medical
Times (1994).

To continue reading

Request your trial