Learning of the death of a loved one is a harrowing experience for families. As a matter of Law an Inquest must be held where a death is or may be due to unnatural causes. The primary purpose of an Inquest is to identify the deceased and establish how, when and where death occurred. It is an inquisitorial process.

It does not include a finding of liability either civilly or criminally on the part of any person.
An inquest is not confined to merely establishing a medical cause of death. An inquest can take into account the circumstances of a death.

In Farrell v Ag it was ruled that an Inquest should be held in following instances:

  • To determine the medical cause of death.
  • To allay rumours or suspicions
  • To draw attention to the existence of circumstances this, if un-remedied, might lead to further deaths.
  • To advance medical knowledge

Therefore an inquest is far more than a recording of the specific cause of death.
The Courts have also determined that parties to an Inquest are entitled to legal representation and fair procedures.
A very common inquest is deaths arising in the course of medical treatment.
A families’ legal representative can now investigate the medical records, cross-examine the witnesses and even offer independent witnesses to assist the inquisitorial process.
Inquests are developing into very forensic investigations regarding the cause of death.
In that regard the following practical pointers with regard to Inquests are important.

Has a post mortem been carried out?

In determining the cause of death a very important signpost is the underlying pathology. Therefore, any family with a concern re cause of death should immediately request a post-mortem so as to begin the inquisitorial process.

Has the Coroner been notified?

A family with any concerns regarding the death of a loved one should ask that the Coroner be notified. There is also a duty on doctors and the Gardai but experience has shown that it is the families that have a very acute sense of any questionable circumstances surrounding the death of a loved one.

What are the facts?

In inquests with regard to medical treatment it is essential to uplift the chart and forensically examine same. Independent experts may be required to extrapolate the voluminous medical considerations and determine the possible circumstances given rise to death. Lawyers can represent very skilled fact finders in this regard.

Have the appropriate witnesses been called?

It is important that the material treating doctors, nurses and pathologists give evidence at a medical inquest. It is vital that depositions are assimilated in advance of the inquest to adequately exhaust the inquisitorial process. A problem that can occur is traceability of doctors. By the time of an inquest doctors can be scattered round the globe. Coroners often proceed with inquests despite the unavailability of essential doctors. With the advent of technology no doctor should be uncontactable. Tools such as medical registers, video link should ensure mandatory attendance.
It is often only by pressure exerted by Lawyers that a satisfactory list of essential witnesses becomes forthcoming.

What about the inquest itself?

There are no winners or losers in an inquest. The common objective should be establishing all the pertinent facts as to how death occurred. Unfortunately, in recent times Inquests have become quite adversarial. Every witness now appears to have a legal team. The common goal of establishing the facts can be lost in the mire of risk management. Civil and/or criminal proceedings represent an entirely separate forum.

All parties need to be cognisant of the essential need for candour in any legitimate inquisitorial process.
The Coroner and legal representatives have one common goal; establishing how a death occurred having examined the facts and spoken to the witnesses involved in the proximate events.

There are generally four verdicts common in medical inquests: misadventure, medical accident, natural causes and a narrative verdict.

There are no set definitions underpinning same and if one adds in the multiplicity of Coroner’s and jury interpretations one could find four different verdicts regarding an identical death depending on the district of the death.

This only serves to emphasise that the true purpose of medical inquests is to comprehensively provide factual answers to families regarding how death occurred.

This should extend beyond medical immediacy to the legitimate realm of what chain of events gave rise to the death.
Only then can the true spirit of the Coroners Act 1962 be vindicated!!

If you have any concerns regarding the death of a loved one arising from medical treatment you should contact our medical negligence team at Callan Tansey Solicitors.

By David O Malley, 11 April 2016

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