Five months ago, a coroner outlined how the husband of the King's second cousin had killed himself.
Coroner Katy Skerrett set out in stark detail how 45-year-old Thomas Kingston had ended his own life and said there were no suspicious circumstances.
No family would welcome this public examination of such a horrific situation, yet even the Royal Family was amenable to a system set up to protect the wider public interest.
But had this happened in Northern Ireland, there might never have been an inquest.
An examination of inquest data by the Belfast Telegraph shows an alarming collapse in the number of inquests being held in Northern Ireland.
Figures released under the Freedom of Information Act show that since 1992 there has been an almost 90% drop in the number of inquests.
Whereas there were 492 inquests in 1992; more than three decades that had fallen to just 52 last year.
This decline is not accounted for by the end of the Troubles; there has been an 82% decline in inquests since 1998. As recently as a decade ago, there were more than double the number of inquests being conducted.
The decline is despite the fact that there are far more people living in Northern Ireland, and, with an aging population, more people are dying.
It's also dramatically different to what's happening elsewhere in the UK. In England and Wales, the number of inquests has risen from 25,784 in 1950 to 36,855 last year.
In 1950, almost a third of deaths reported to the coroner resulted in an inquest. By 1996, that had dropped to just 10% – but has since climbed again to 19%.
Inquests held in Northern Ireland
All of this means that something very odd is happening in Northern Ireland.
Most of us will never be involved in an inquest and so this might seem an esoteric issue.
Yet this centuries-old system exists to protect all of us: If we die suddenly in circumstances which are suspicious or unexplained, an inquest should establish the facts of what happened.
It doesn't apportion blame and so will not, for instance, say that someone is a murderer. But it can find that someone died violently, with a court then separately examining whether that involved a crime.
It can find patterns of deaths which warn the rest of us about a particularly dangerous drug, or location, or hazardous activity.
Where there has been a mistake, an accident or negligence, the inquest is very often the place where that is highlighted – and that should help reduce the likelihood of another person dying in those circumstances.
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It is also a process which helps allay suspicion and prevent inaccurate rumour, an aspect more important than ever in today's world of social media half-truth, innuendo and outright lies.
It can be harrowing for the family to hear how their loved one died or that that their death might have been prevented.
Yet an inquest can also provide comfort. Fears they had about the death can be dispelled, or those present at the time of an accident can hear experts say that there really was nothing they could have done to prevent the tragedy.
Despite all these reasons to hold an inquest, increasingly this process is a rarity.
As a newspaper, we have noticed the decline in inquests because we are among the few people beyond the family who will often be there, reporting on what is said so it can be read by the wider public.
Last December, we planned to cover the inquest of John Steele, the Larne man who died after falling from a bonfire two years ago.
The case had been listed for a pre-inquest hearing at Banbridge Courthouse. But it was then decided that there would be no inquest at all.
There has been no public explanation of why that was the case.
That decision is troubling. Bonfires are becoming increasingly tall and increasingly dangerous. In this instance, Mid and East Antrim Borough Council had been specifically warned of the danger of the bonfire in question – which was on its land – just days before Mr Steele's death, yet apparently did nothing.
Should it have acted differently? If so, that would apply to other councils across Northern Ireland so this stretched beyond this one tragedy.
Was there anything particularly hazardous about that bonfire or is there anything which bonfire builders can do to reduce the risk of death? Again, that would be relevant to many hundreds of people across Northern Ireland.
Without a public process, those questions went unasked and unanswered where the public could benefit from hearing them.
When asked about the absence of an inquest, and whether the coroner could say anything publicly about the death, all that Lady Chief Justice Dame Siobhan Keegan's office would say was: "The holding of an inquest is a matter for the Coroner, where the purpose of same is to establish who the person was, how, when and where they died. The Coroner carefully considered this case and spoke to the family before determining that the death should be registered without the need for an inquest."
The Lady Chief Justice's office has defended the dramatic fall in inquests, stating that even where there is no public hearing every death reported to a coroner is investigated.
In a statement, it said: "The fact that an inquest is not held does not mean that a death is not fully and scrupulously investigated. Every death reported to the Coroners Service NI (CSNI) is investigated by a coroner to the point where the coroner is satisfied that the death can be certified.
"Coronial decision-making is informed, where appropriate, by medical advice from doctors employed by CSNI and by postmortem reports from the State Pathologist’s Department."
However, without impugning the integrity or ability of coroners investigating cases behind closed doors, there is irreplaceable value in a public process, something which has long been recognised.
It would be much simpler, quicker and cheaper to not hold any inquests at all and allow coroners to come to decisions in private.
Yet a thousand years of experience demonstrate the value of publicly addressing sudden or unexplained deaths. A public process recognises that such deaths are often not just a tragedy for the family and friends of the deceased, but a matter of wider public interest.
There is also practical value to an inquest. The late John Lecky is Northern Ireland's most distinguished coroner. With Desmond Greer KC he wrote the comprehensive textbook Coroners’ Law and Practice in Northern Ireland.
In it, they warned that "where the death is 'unnatural', a coroner has to be cautious before dispensing with an inquest. Whilst he has in all such cases access to statements received from the police and others and to the post-mortem report, he will lack the advantage of hearing and seeing the witnesses and may as a result make some incorrect assumptions."
In recent years there have been numerous unexplained high profile deaths, some of which involved prominent public figures, which have not been examined by an inquest.
In some instances, there are widespread rumours as to how they died – and no conclusive public process to state what happened.
In none of these cases am I aware of any suspicion of foul play, yet without a public process to set out the facts it is far easier for those of a suspicious disposition to fear that something dark is being hidden.
There has been no explanation for the dramatic fall in inquests, and it is unlikely that just one factor is involved.
However, concerns have been expressed to me by several sources that in cases where suicide is suspected, an inquest can often now be avoided at the request of the family if the police agree that it seemed to be a suicide.
While it is understandable that few families would welcome the scrutiny of an inquest, that involves the risk that a murder made to look like a suicide will be missed without the level of scrutiny which an inquest involves.
The police are massively over-stretched. The murder of Katie Simpson shows how even what seemed to have been an obviously alarming death was missed by detectives.
In attempting to be kind to one group of people, a decision to keep out of the public eye that someone has died by suicide runs contrary to the wider efforts of the medical profession and mental health advocates to remove the stigma around suicide by dealing with it more openly.
When asked about those concerns, the Lady Chief Justice's office said: "While the coroner will take account of the views of the next-of-kin as part of their decision-making process, the final decision about whether an inquest is required rests with the coroner.
"In reaching this decision, the coroner will work closely with a range of public bodies, including health care professionals and police in this regard. A key change in the coronial process was the establishment in 2006 of a centralised Coroners Service for Northern Ireland and the appointment of full time, independent coroners, who are members of the judiciary. Prior to this, inquests were carried out by legal professionals at a regional level.”
A former police officer said that inquests are "of immense importance". He said: "I had always believed that they were to be considered by the coroner independently so as not to be swayed by personal factors of family emotions or institutions.".
One veteran lawyer said he believed there was a "fixation in relation to Troubles inquests" – a major political dispute over recent years – and that meant resources had been prioritised for those high profile cases.
Having worked on some of those long-delayed cases, he wasn't belittling their importance, but drawing attention to the inevitable consequences for other deaths if so much expenditure being devoted to a small number of deaths.
With significant legal aid funding for those Troubles cases, he said he now would "rarely go to non-legacy inquest".
Looking back through Assembly questions over the last decade confirms the dominance of Troubles inquests in the thinking of politicians.
Almost every written question to the Justice Minister on inquests in the last ten years related either to Troubles cases or the high profile case of the death of schoolboy Noah Donohoe.
The collapse in the number of inquests here is made possible by a fundamental difference between English and Northern Irish law.
In England, the law states that the coroner "must" hold an inquest into deaths in certain defined circumstances.
By contrast, the Northern Ireland legislation states the coroner "may" hold an inquest – unless directed by the Attorney General to do so.
Coroners deal with the most harrowing situations and require some discretion as to how their job should be done.
But this seems to give them too much power.
Writing in 1998, Lecky and Greer quoted a comment on the then situation in England and Wales in which a legal commentator had said: "As the number of suspicious deaths continues to rise, coroners remain very much a law unto themselves and very few lawyers, let alone laymen, know precisely what such officers can and cannot do."
Lecky and Greer said that "much the same criticism may validly be made of the law in this part of the UK". They said the law here was "flawed" and fundamental reform was "long overdue".
The law in England and Wales has since been updated in 2009, yet Northern Ireland is still operating under legislation from 1959.
Stormont has the power to inquire into this issue and to change the law. This ought to be an opportunity for common ground: We're all equal in death, and the consequences of failing to publicly examine sudden or unexplained deaths indirectly impacts us all.
Instead, MLAs have thus far spent almost all of their energy in this area on the small number of inquests which divide them.
by BelfastTelegraph
1 comment
Main concern with this is that two years ago it was decided a lot of undetermined deaths were instead marked as accidents rather than suicides, thereby lowering NI’s suicide rate so we weren’t the number one place for people killing themselves.
The less oversight into deaths, the more undetermined cases are thrown into the accidental pile so public figures can stay away from the narrative that we are in a massive mental health crisis.