Shame of the Suicide Inquest

More than one person dies by suicide every day in this country. This means that every day some family faces the indescribable pain and anguish that such a death imposes on parents, siblings and friends, as well as the community at large. After the funeral is over, life moves on for some. For those most closely involved, the silence falls and the family are left to pick up the pieces. Many families are surprised when after six weeks or more a member of the Garda Síochána calls to the family home to inform them of the date of the inquest on their beloved family member. This inquest usually takes place in the local Courthouse or sometimes in a hotel room, neither of which are conducive to comfort and privacy. This is the start of yet another painful and intrusive journey into their grief and pain. Does it need to be this way? I do not think so. I think this approach adds a touch of criminality and stigma to a terrible tragedy and it important now to look at how it could be changed.


An inquest is a public inquiry into death. It is held to establish the identity of the deceased and the date, place and circumstances surrounding their death, including a medical cause of death. It is overseen by a Coroner (who acts as a judge) with the assistance of a jury of 10-12 people. The inquest will not tell you why a person died by suicide, but is a requirement of law to establish the facts. Similar to what happens in many courtrooms, there are a large number of people involved – uniformed Gardaí, the State pathologist, newspaper or other media reporters, witnesses who are called to give evidence under oath, other people who may have given a statement, not to mention the next of kin (if they decide to attend), friends and the general public. Evidence is given and generally, at the discretion of the Coroner, any suicide notes or relevant letters are read. In the presence of such a diverse group, an inquest can be a distressing and humiliating situation, adding to the terrible burden of anxiety, trauma and pain already being experienced by the family involved.


Suicide was rightly decriminalised in July 1993, some 20 years ago now. Families of those who die by suicide do not have lobby groups to highlight their plight into their very public pain while attending an inquest. They have already been thrust into an unknown situation when a sudden death arrives at their door. Families feel isolated and the shock and horror of being in a court of law escalates their excruciating pain and gives the impression of a criminal act. They should be able to expect some compassion as to how such a painful and public appearance is looked at by the authorities. I believe this could be all so different and so easily changed if the will to do so was there. There are no legal barriers to change, only the lack of human compassion and understanding.


There is a general lack of knowledge about the Coroner’s Service in the public domain. This is one of the oldest public services in existence. It has evolved over time to a position of importance in today’s society. It covers all sudden and questionable deaths and under law must be carried out before a death certificate is issued. The Act under which the Coroner’s Service currently functions was passed in 1962. It operates as an independent judicial office to establish the ‘who, when, where and how’ of unexplained deaths. It is not permitted to consider civil or criminal liability – it is there just to establish the facts. The system has not changed for 50 years, even though suicide was decriminalised in 1993. Yet the upward trend in suicide rates continues annually. For those who have already endured unimaginable grief and loss, it may be their first time to encounter such a system. For them, it is a system where empathy, compassion and love is forgotten and public intrusion into private grief is unaccounted for.


Things could be different. A working group on the Review of the Coroner’s Service published its report in 2000, making more than 100 recommendations to improve the system. The review stated that ‘rules should be established by statutory regulation and be capable of being amended’. It also stated that ‘changes in the work and practice of the Coroner are inevitable as the complexity and demands of modern society increase’. These statements give a mandate to those in charge to change the system. There is no need for the present inquest system to remain as it is and I believe it is imperative that it is changed to take cognisance of the deep suffering of those using its services.


One Coroner has shown how change can be made. John Lacey, Coroner for Navan, Co. Meath, has, with the help of concerned people, changed the structure of how he addresses inquests for the bereaved families of those whose loved ones have died by suicide. He holds the inquest in an annexe of Navan Hospital, in a place that is unlikely to be ever visited again by relatives and out of public view. It is humanised by the presence of a group of trained bereavement personnel, who provide refreshments and comfort for those attending. They explain in a gentle way the process and how it operates, to lessen the impact when the inquest begins and to make people aware of services that may help in their grief. Together with the Coroner, they encourage the family to ask questions if they so desire. The Gardaí sit with the family also and offer words of comfort and carry out their duty as gently as possible. There is no need for Gardaí to be in uniform and by eliminating these visual and upsetting modes of dress, a more humane and understanding environment exists. Sometimes statements by witnesses are being read and heard by the family perhaps for the first time. Their sensitivity to such painful statements should be respected. In this setting, the public are discouraged from attending the inquest.


Surely the dignity and the feelings of those involved could be better cared for in such sad circumstances and the Navan model should at least be taken on board by County Councils, who pay for this service, across the country. This would be a positive step to ensure the changes necessary for dignity and consolation to be afforded to those affected. There are premises in every area that could be used to give families the privacy where they can grieve with those close to them at such a challenging and frightening time. All we need is for the people in charge to have the courage to make the change.


While penning this article, I spoke with the father of two children, one daughter and her teenage brother, who died by suicide in the recent past and asked him about how the inquest system felt for him. The inquests were held in a hotel, which he felt was very public, ‘with people laughing and drinking which was upsetting and not suitable’, but he felt it ‘was better than in the Courthouse, with the people who would be circulating there’. I asked him where might be a good place, as he lives in a rural parish, and he felt that the Parochial House or someplace where public access was limited would give more privacy and support. He said he was scared on both occasions going into the inquest, walking into the unknown, and did not know what questions he would be asked or the outcome. The tragedies, even though a few years apart, were reported on the front page of the local newspaper, which of course added to his pain and grief. He felt angry at such a huge and unnecessary intrusion on the rest of his family and felt it was tempting fate at a time when everyone was vulnerable and finding life hard to cope with. It was all horrendous, with feelings of shame, guilt, disbelief and nightmare for his other children and his wife. Only his faith has kept him going.


This man’s story highlights the need for change, when so little could make such a huge difference. The stigma and myths around suicide can never really be changed until society begins to shift and alter its perception at a social level. We must never accept that a death by suicide has any criminality reflected in our attitudes and practices.