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

• Author: Blánaid Ní Chearnaigh
• Position: Iarrthóir Sophister Sinsearach LL.B, Coláiste
• Pages: 14-55

2020] Éagóir nó Ceartas

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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.

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(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

Cé 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

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(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.

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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.

Tá 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 nó 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

sé 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

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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).

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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 ná

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, tá 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

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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.

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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 poiblí ar 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 dlí go bhfuil imeachtaí fós faoi smacht an chróinéara, tá 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, mí-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

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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 himeachtaí

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 Ospidéil

Áitíodh go láidir go bhfuil ‘gach bás an mháithreach’ mar thrágóid

uafásach le hiarmhairtí fadtéarmacha do na teaghlaigh atá i gceist.37

74

Tá

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 mí-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 40.3.1°

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 córas 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 Uí

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 níl sé soiléir 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 ná 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 dó 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 má mheasann

sé nó sí go bhféadfadh dochar d’aon imeachtaí coiriúla 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 Marú

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 sé 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 sé 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 1962Act 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 sé 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

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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 nó mar bhás máthair déanach laistigh den dualgas

ginearálta chun ionchoisne a thionól agus a aithint.71

140

Baineann sé 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

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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 mí-eachtraí agus faillí leighis

sa todhchaí a chosc agus seasamh leis an gceart chun beatha.

Ina theannta sin, agus na saincheisteanna éagsúla á mbreithniú a

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 cásanna 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, tá sé 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

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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, tá sé 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, tá 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 nó 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 Bunreachtna 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).