In Ireland, in cases of sudden, unexplained, or unnatural death (for example suicides, drug overdoses, poisonings, road traffic collisions), occurring either in the community, or in a hospital, the death is reported to the local coroner. In these cases, the coroner may direct an autopsy. An inquest may also be held.

Among the recommendations made by the Committee are:

1. The Committee recommends that rules should be established to inform the threshold necessary to reach a verdict in an inquest, in order to ensure consistency of approach by coroners across different jurisdictions.
2. The Committee recommends that the existence of a website and adequate information on the Coroner’s Service and its processes be promoted to the public and that adequate information on coronial processes be provided to the families involved.
3. The Committee recommends that consideration be given to link the registration of deaths with the Electoral Register and other public databases.
4. The Committee recommends that the Coroner’s Service should be restructured to establish an office of the Chief Coroner and an office of the Deputy Coroner, to steer leadership of the Service.
5. The Committee recommends that a ‘Central Coroner Service’ be established as a new statutory agency, to uphold the fundamental principles of the Coroner’s Service and assist with administrative and organisational duties. An Inspectorate should also be appointed to monitor consistency in practice.
6. The Committee recommends that a structured and formalised process for implementing jury and coroner recommendations following an inquest should be introduced, similar to English and Welsh ‘Prevention of Future Death Reports’ (PFDs).
7. The Committee recommends that a central database be established for all recommendations made by coroners.
8. The Committee recommends that a formal jury selection process be established for juries presiding at inquests.
9. The Committee recommends that the resourcing of the Coroner’s Service be re-evaluated to ensure that it receives adequate funding, for example, in terms of staffing levels.
10. The Committee recommends that consideration be given to the introduction of an accessible process to appeal the verdict of a coroner’s inquest