Minister Flanagan publishes the Coroners Amendment Bill 2018
The Minister for Justice and Equality, Charlie Flanagan, has today published the Coroners (Amendment) Bill 2018, which will significantly clarify, strengthen and modernise the law on the reporting of deaths to coroners, and their powers to investigate and inquest such deaths.
The Minister said: “This is a very important Bill, which has been a priority for me personally and for the Government. It will amend the existing legislation, the Coroners Act 1962, to significantly strengthen and modernise the powers available to coroners in the reporting, investigation and inquest of deaths.
In particular, the Bill will allow a wider scope for inquiry where necessary at inquests, clarifying that they are not limited to establishing the medical cause of death, and seek to establish the circumstances in which the death occurred. The public importance of effective, transparent, and independent investigation in such cases is obvious. This, and other changes made by the Bill, will also enhance our compliance with our obligations under the European Convention on Human Rights.
More particularly, the Bill addresses a key problem in a number of high-profile cases which have caused great public unease – that some maternal deaths and perinatal deaths occurring in hospitals, which should have been reported to coroners because they raised issues of medical error and were ‘unnatural deaths’ under the Coroners Act 1962 – were not so reported. Bereaved families, and in some instances even coroners, experienced considerable difficulty in obtaining basic information which should have been provided to them.”
The Bill will require mandatory reporting to a coroner and inquest in all cases of maternal death. It will also require mandatory reporting to a coroner of all stillbirths, intrapartum deaths and perinatal deaths. Such reporting is already established as good practice.
The Minister added: “These changes to the law will ensure clarity for responsible persons, including hospital authorities, and will support the development of transparent and accountable oversight for checking and investigating certain types of death. Most importantly, they will support timely and transparent provision of information by health and other authorities to bereaved families.”
The Minister added that Government has also agreed to priority drafting of a number of specified further amendments, which he intends to bring forward at Committee Stage. These will include, subject to the advice of the Attorney General, amendments:
- to provide a statutory basis for a coroner to inquire into a stillbirth where there is cause for concern, for example, arising from matters raised by the bereaved parents,
- to allow a coroner to seek directions from the High Court on a point of law in relation to the performance of their functions,
- providing for the Minister to make regulations on the proper storage and disposal of any material removed for the purposes of a post mortem examination, including return to a family member for disposal where requested and appropriate, and
- providing a power for the coroner to direct a hospital or other health institution to make medical records of the deceased person available, for the purposes of a post mortem examination.
“I want to acknowledge the contribution of Deputy Clare Daly, through her earlier Private Members Bill on the issue of maternal deaths. My Bill incorporates all the amendments sought by Deputy Daly on this issue, and also addresses the issue of perinatal deaths and other important reforms to coronial law.”
The Minister concluded “It is my firm intention to move the Bill as early as possible in the new parliamentary session, so that, with the co-operation of all sides, we can facilitate its swift passage through the Houses of the Oireachtas.”
Note to Editors:
The Bill is available here: https://www.oireachtas.ie/en/bills/bill/2018/94/
The Coroners (Amendment) Bill 2018 contains a number of key provisions, many of them long intended and included in the Coroners Bill 2007. These will strengthen the effectiveness of the coroner’s inquest, and improve compliance with our obligations under the European Convention on Human Rights. They include:
· Clarifying that the purpose of the inquest goes beyond establishing the medical cause of death, to establishing the circumstances in which death took place (though it will remain the position that an inquest does not make any finding of civil or criminal liability),
· Strengthening the coroner's powers to summon witnesses to an inquest, and to direct a witness to produce documents and evidence, or answer questions,
· New powers for the coroner, acting under a warrant from the District Court, to enter and inspect premises, and to take copies or take possession of any documents or material relevant to the inquest,
· Appropriate penalties for a witness not co-operating with the inquest,
- Express requirements for mandatory reporting, post-mortem examination and inquest of a death occurring in a range of specified situations which constitute State custody or detention. (Legal aid is already available to a family member of the deceased at inquest in such cases, under an amendment to the Coroners Act 1962 made by the Civil Law (Miscellaneous Provisions) Act 2013),
- Greater clarity and transparency in the mandatory reporting of certain types of deaths, including a detailed list of specific examples of mandatory reportable deaths,
- It will be an offence for a responsible person, not to report a mandatory reportable death to the coroner,
- Updating and modernising of the provisions regarding post-mortem examinations, to take account of forensic developments and current practice,
- Specific provisions on notice of an inquest to be provided to family members of the deceased person , and regarding information and access to any report of a post-mortem examination.
More specifically, in relation to maternal deaths, the Bill:
- Applies to both maternal deaths and late maternal deaths, whether direct or indirect, defined in accordance with the internationally-recognised World Health Organisation definitions (WHO-ICD): see below for details,
- Introduces mandatory reporting, post-mortem examination and inquest, in all cases of maternal death or late maternal death,
- Provides for a special exception to mandatory inquest, at the discretion of the coroner after consultation with the bereaved family, if the coroner is satisfied, taking account of specified matters including the views of the family and whether sufficient information has been provided to the coroner regarding the death, that the death was a natural one and there are no matters of concern requiring inquest, and
- Extends the scheme of legal aid for a family member of the deceased at inquest, introduced in 2013 for certain categories of deaths, to cases of maternal death or late maternal death.
A ‘maternal death’ is defined under the Bill as the death of a woman while pregnant or within 42 days after the end of the pregnancy (whether by delivery, miscarriage or by intervention, for instance in the case of ectopic pregnancy), from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes, and including direct and indirect maternal deaths.
A ‘late maternal death’ is similarly defined under the Bill, but occurs more than 42 days and less than 365 days after the end of the pregnancy.
Such deaths are, medically, rare events, but due to their seriousness should be carefully monitored. (The latest Report on Ireland of the Confidential Maternal Death Enquiry (CMDE), published by University College Cork in December 2017, identified a total of 53 maternal deaths or late maternal deaths in Ireland over the period 2009 – 2015, an average of just under 8 such deaths per year. The Report is available at: https://www.ucc.ie/en/mde/ . )
Perinatal deaths and stillbirths
The Bill provides for mandatory reporting to a coroner of stillbirths, intrapartum deaths and infant deaths.
- A stillbirth is defined as a foetus of 24 weeks’ gestation or more, or of birth weight of 500 grammes or more, delivered without signs of life.
- An intrapartum death is one where the baby dies during delivery.
- An infant death is defined as the death of a live born child, occurring immediately after birth or within 365 days of birth.
- There is no proposal for mandatory post-mortem examination or inquest in these cases.
- Post-mortem examination or inquest in a perinatal or infant death may, as currently, be directed by the coroner if concerns are raised, usually by the bereaved parents.
Reporting of deaths
Under the Coroners Act 1962, certain deaths are to be immediately reported to a coroner by a doctor or other responsible person, including:
- any death where there is reason to believe that it was due to a cause other than natural illness or disease for which the deceased was treated by a doctor within a month prior to the death, and
- any death ‘in such circumstances as may require investigation’.
The Bill provides for a new Part IIA in the Coroners Act 1962, specifying more clearly which types of deaths are required to be reported to a coroner, and which persons are responsible for reporting them.
It also includes a new Second Schedule containing a list of specific types of mandatory reportable deaths, which expressly includes any maternal death or late maternal death, and any death of a stillborn child, death intra partum or infant death.
Reporting a death to a coroner does not mean that it would automatically be subject to a post-mortem examination or an inquest or that the report would have to be made by a bereaved family. Normally the report is made by one of the responsible persons listed in section 16B. A doctor reporting the death to the coroner must indicate whether he or she is satisfied in the circumstances to certify that the death was due to natural causes. Where no cause for concern arises, such a certificate is sufficient under the Coroners Act.
Of 11,856 deaths reported to coroners in Ireland in 2017, 3,338 went for post-mortem examination, and 2,143 went to inquest.
Coroners Bill 2007
The Coroners Bill 2007 was a Government Bill, which passed Second Stage in the Seanad on 4 October 2007. It proposed a comprehensive reform of coronial law, which would both strengthen and modernise the legal powers available to coroners, and include a major administrative restructuring of the coroner system. In the light of the major challenges then confronting public finances, the 2007 Bill was not progressed following Second Stage. The Bill was not restored to the Order Paper of the Houses of the Oireachtas in 2016, as it by then also required significant updating. Elements of the Coroners Bill 2007 have contributed to the approach adopted in the current Bill, which primarily seeks to strengthen and modernise the powers available to coroners in the reporting, investigation and inquest of deaths.