HC 163/04
THE HIGH COURT

JUDICIAL REVIEW

RECORD NO. 2003/43JR

BETWEEN/

NUALA RAMSAYER

APPLICANT

AND

BRIAN MAHON
ACTING CORONER FOR THE COUNTY OF OFFALY

RESPONDENT

Judgment of Mr. Justice Roderick Murphy dated the 23rd day of April, 2004.

1.	Outline of Case
	Nuala Ramsayer, the applicant herein, is the sister of James Goonan, (the deceased) who died on the 11th March, 2002.  In respect of that death Brian Mahon, the Acting Coroner, proposed to hold an inquest.
	The applicant requested draft depositions from the coroner which were refused.  In respect of this refusal the applicant sought a declaration that the coroner erred in law when he held that he could only release draft depositions when they had been sworn by the deponents at the inquest.

2.	The relevant dates of events and correspondence between the applicant’s solicitor and the respondent are set out hereunder.
	11th March, 2002 – death of deceased.
	21st May, 2002  -  request for date of post mortem.
	23rd May, 2002  -  reply: no decision had been made.
28th May, 2002  -  request for information of developments.
5th July, 2002  -  request for post mortem report.
8th July, 2002  -  respondent indicated that he had directed an inquest.
11th July, 2002 -  request for all information.
15th July, 2002  - reply: the Gardaí report death not from natural causes.
17th July, 2002  - request for Garda report and post mortem report.
18th July, 2002  -  reply:  material to be retained until inquest – request for statement from applicant.
30th July, 2002  -  applicant statement declined.
8th October, 2002 -  request: garda investigation? 
10th October, 2002  -  reply: no role in garda investigation. 
14th October, 2002  -  inquest fixed for the 21st October, 2002.
16th October, 2002  -  request for witnesses and evidence.
16th October, 2002  -  reply: report of the State Pathologist. 
18th October, 2002  -  request for witnesses’ statements.
21st October, 2002  -  pathologist unavailable, inquest postponed.
31st October, 2002  -  request for draft depositions. 
25th November, 2002  -  further request.
28th November, 2002  -  reply: draft depositions unavailable until sworn. Inquest likely in January or February, 2003.
16th January, 2003  -  inquest set for 27th January, 2003.
6th February, 2003  -  McKechnie J. granted leave for judicial review and a stay on the holding of the inquest.
8th April, 2003     -  Opposition statement filed.

3.	Statement of Grounds
	The applicant was granted leave for the following relief:
3.1	A declaration that the respondent erred in law when he held that he could only release draft depositions when they had been sworn by their deponents at the inquest.
3.2	A declaration that the respondent’s ongoing refusal to disclose to the applicant draft depositions and other relevant information in his possession in advance of the inquest into the death of James Goonan was arbitrary and irrational.
3.3	A declaration that the respondent’s ongoing refusal to disclose to the applicant draft depositions and other relevant information in his possession in advance of the inquest into the death amounted to a breach of the applicant’s constitutional rights to fair procedure and natural justice, and to a breach of the right to life of James Goonan contrary to Article 40.3.2 of the Constitution insofar as the duty on the State to investigate a death that occurs in suspicious circumstances is adjectival to the right to life and was contrary to Article 2 of the European Convention for the Protection of Human Rights and Fundamental Freedoms in relation to the same duty.  Was also a breach of the right to an effective remedy of the applicant and James Goonan, contrary to Article 13 of the same Convention insofar as the failure to disclose the information may have a basis in domestic law.  Was also in breach of the applicant’s right to equality, contrary to Article 40.1 of the Constitution.  Was a breach of the applicant’s constitutional right to effective legal assistance.  Amounted to a breach of the applicant’s legitimate expectations.
3.4	An order of mandamus directing the respondent to furnish to the applicant draft depositions and other relevant information in his possession in advance of the inquest into the death of James Goonan.
3.5	An order pursuant to the provisions of Order 84, rule 20 (7)(b) of the Rules of the Superior Courts, granting interim and/or interlocutory injunctions preventing the holding of the inquest until these proceedings were determined.
3.6 	An order providing for all necessary and/or incidental directions in relation to the hearing of the application and further or other reliefs.
	
4.	Statement of Opposition
	The respondent filed opposition papers on the 8th April, 2003.  The grounds were as follows:
4.1	It was denied that the refusal of the acting coroner to furnish the draft depositions in advance of the inquest was either arbitrary or irrational or in breach of any right of the applicant to equality or in breach of the applicant’s legitimate expectations.
4.2	The coroner did not operate a blanket policy of not supplying information to interested parties in advance of an inquest.  In each case the respondent exercised his discretion as to what information is appropriate to furnish to any interested parties and is entitled to exercise such discretion.  He did not err in law.  
4.3	The release of the post mortem report to the applicant was not in breach of any stated policy and was neither arbitrary nor irrational.  
4.4	The opportunity to effectively participate in the inquest was not denied and the applicant would be afforded representation at the inquest and the right to cross-examine witnesses and to be in a position to effectively participate therein.
4.5	There was no failure in the coroner’s duty to conduct the inquest in the manner alleged.  He had set out his functions and discharged his duties in a manner in accordance with the Coroner’s Act. 
4.6	There was no constitutional right to receive the requested information in advance of the inquest.
4.7	If there were such right, it has been unaffected by the refusal to furnish the draft depositions or other information in advance of the inquest.
4.8	The refusal to furnish draft depositions and other relevant information did not amount to a breach of Article 2 or Article 13 of the Convention.
4.9	Procedures at an inquest were inquisitorial not adversarial and were not to determine civil or criminal liability.  The coroner was entitled to adopt procedures which have regard to the nature and function of the inquest.

5.	Affidavit of Coroner
	The respondent averred that, under s. 30 of the Coroner’s Act, 1962, he was precluded in the conduct of any inquest from considering or investigating any question of civil or criminal liability.  He was obliged to confine the inquiry to the ascertainment of the identity of the deceased person and how, when and where the death occurred.  
	It was not part of his function to inquire, nor would the parties appearing at the inquest be permitted to investigate such form or matters.
	He exercised his discretion with regard to the furnishing of a copy of the post mortem report.  With regard to the draft depositions taken from proposed witnesses, as these depositions remained unsigned and unsworn at the time of the inquest, they had no standing and he said he exercised his discretion by not releasing them.  Section 29 of the Act required the release of those documents only after the inquest.
	He was unaware of the practice of releasing draft depositions and referred to Farrell on Coroners at 372 as follows:
“16-10 . . . There is a general rule of practice that inquest papers (draft depositions) are not available to interested parties prior to inquest.  The coroner retains the discretion in the matter.  Constitutional justice requires the coroner to exercise his limited discretion in a fair and reasonable manner.  For example, where reports of a technical nature form part of the evidence at inquest, it might be reasonable for a coroner to provide sight of such reports to interested persons or their legal representatives prior to the hearing (if requested).  Where death occurs in prison or garda custody, legal representatives of the authority concerned will have access to statements of witnesses (by virtue of representing the authority) and it may sometimes be necessary for the coroner to furnish copies to the next of kin before or during the inquest.  Slavish adherence to an unwritten rule of practice may sometimes fall short of the requirements of constitutional justice.  Each case must be considered on its merits.”
	The coroner believed that the prior release of documents in the manner sought was calculated to make the proceedings adversarial in nature and for this reason he did not generally release such documents in advance of inquests.  In relation to ‘relevant information’ he said that it was undesirable in general that the most sensitive material (including suicide notes etc. in other cases) should be released before the inquest.
	He further averred that the applicant had not demonstrated her ability to participate in the inquest would be affected adversely by his decision.  He had no objection to releasing draft depositions from her family to the persons who made them.

6.	The Coroner’s Act, 1962
	The Act imposes a general duty to hold an inquest in relation to the death of a person if the coroner is of opinion that the death may have occurred in a violent or unnatural manner, or suddenly, or from unknown causes, or in a place or in circumstances which require that an inquest should be held.  (s. 17)
	A post mortem examination in lieu of an inquest can suffice if, in the opinion of the coroner, the report of the examination shows that an inquest in relation to the death is unnecessary.
	A coroner has an obligation to preserve every deposition or note, of the name and address of the witnesses taken at the inquest, every report of a post mortem examination and every record of the verdict returned at the inquest.  When he ceases to hold office the County Registrar shall preserve the documents.  (s. 29 (1) and (2)).
	Section 29 (3) provides that a coroner shall furnish a copy of any document preserved by him under this section to every applicant therefor and, except where the application is made on behalf of a Minister of State or the Garda Síochána, may charge for a copy such fee as may be prescribed.  
	The coroner is prohibited from considering civil and criminal liability pursuant to s. 30.  Such liability should not be considered or investigated at the inquest.  Every inquest should be confined to ascertaining the identity of the person in relation to whose death the inquest is being held and how, when and where the death occurred.  Moreover, neither the verdict nor the rider to the verdict at inquest should contain a censure or exoneration of any person but recommendations of a general character required to prevent further fatalities may be appended to the verdict at any inquest.

7.	Submissions of the Applicant
7.1	The applicant relied on Farrell v. The Attorney General [1998] 1 I.R. 203.  The Supreme Court (per Keane J.) in Farrell had indicated five grounds of public interest served by a purely fact-finding exercise of inquest as follows:
-	to determine the medical cause of death,
-	to allay rumours or suspicions,
-	to draw attention to the existence of circumstances which, if unremedied, might lead to further deaths,
-	to advance medical knowledge,
-	to preserve the legal interests of the deceased person’s family, heirs or other interested parties.
7.2	The jurisdiction to review judicially the proceedings in a coroner’s court extends to circumstances identified by the House of Lords in Anisminic Ltd. v. Foreign Compensation Commission [1968] 2 Q.B. 862 and by the Supreme Court in The State (Holland) v. Kennedy [1977] I.R. 193.  
Even where there was no error as to jurisdiction, no fraud on the part of the coroner and no error on the face of the record, where there was some frailty in the course of the proceedings, such as an error in law or a want of natural justice and fair procedures, the High Court was entitled to set aside the verdict in whole or in part.  
In Holland, the High Court (Smyth J.) had directed that the decision to hold a second inquest following complaints of the deceased’s wife after the first inquest, be quashed and declared that the inquest conducted by the applicant to be in accordance with law.  The Supreme Court (Hamilton C.J., Barrington and Keane J.J.) dismissed the appeal, as inter alia, there was no material before the coroner which justified him in reversing his earlier decision not to direct the holding of a fresh inquest.  His decision to direct a fresh inquest was unreasonable and ultra vires his powers of the 1962 Act.  That case dealt with a verdict as distinct from a decision relating to procedure.  It is, however, of relevance in relation to the question of breach of fair procedures.  The respondent in this case had fully communicated to the applicant and given reason for his refusal.  
7.3	The European Convention on Human Rights (Article 2 – everyone’s right to life shall be protected by law) and Article 40.2 of the Constitution encompass an adjectival obligation to investigate a death which occurs as a result of the use of force (Kaya v. Turkey [1999] 28 E.H.R.R. 1 and Yasa v. Turkey [1999] 28 E.H.R.R. 121; or where agents of the State have been involved (Edwards v. United Kingdom [2002] 35 E.H.R.R. 19; Jordan v. United Kingdom [2003] 37 E.H.R.R. 2 and R. v. Secretary of State for the Home Department, ex parte Amin [2003] U.K.H.L. 51.    
These cases indicate the desirability of the police disclosing witness statements in advance as had become the practice in England since 2003 at the time of the decision in Jordan where the European Court on Human Rights stated:
“Prior to the recent development of disclosure of documents, the court is not persuaded that the applicant’s interests as next of kin are fairly or adequately protected in this respect.” (at 134)
7.4	It was further submitted that the respondent’s decision was unreasonable in that he had made the draft deposition of the State Pathologist available without giving any reason as to why this should be disclosed, while other documents were not.
If the family of the accused were entitled to attend and participate in the inquest and for that purpose were entitled to be represented, it was submitted that their legal representative must be provided with sufficient information in advance to make such representation meaningful and effective.  In Nolan v. Irish Land Commission [1981] I.R. 23, Costello J. had held, at 33, that:
“The plaintiff should know prior to the hearing what case he has to meet so as to enable him to cross-examine the defendant’s witnesses and to adduce evidence himself, if he should be so advised.  It follows from this conclusion that, as the plaintiff will not have had an adequate opportunity to know the case he is to meet, the proposed hearing would infringe the principles of natural justice because it would be held contrary to the principle audi alteram partem and because the absence of the procedures sought would impair the fair hearing of the issues to be determined.”
	The Supreme Court (O’Higgins C.J. at 39) came to the conclusion that the trial judge was right in the view he formed.  In the absence of discovery, an inspection of the appropriate documents which were considered by the lay commissioners prior to certification was proper and a requirement of natural justice.  Griffin J. (at 43) held that basic fairness and the essential interests of justice dictated that the plaintiff was entitled to discovery, limited to the documents mentioned.  

8.	Submissions on behalf of the Respondent
8.1	The essential issue is whether the respondent was entitled to refuse to furnish the applicant with draft depositions or other relevant information in his possession in advance of the inquest.  The applicant’s solicitor sought, in addition to the post mortem report furnished on the 16th October, 2002, the garda investigation file, medical reports and all information and material.

8.2	It was submitted that the Coroner’s Act, 1962 governed the functions of the coroner in Ireland.  Section 30 of the Act provides as follows:-
“Questions of civil or criminal liability shall not be considered or investigated at an inquest and accordingly every inquest shall be confined to ascertaining the identity of the person in relation to whose death the inquest is being held and how, when and where the death occurred.”
Section 31(1) of the Act emphasises that:
“Neither the verdict nor any rider to the verdict at an inquest shall contain a censure or exoneration of any person.”
In Farrell v. the Attorney General [1998] 1 I.R. 203 Keane J. had stated at p. 233:
“In its modern form there are two features of the Coroner’s inquest which are of particular relevance to this case.  First, it is a purely inquisitorial procedure.  As Lane, L.C.J. put it in R. v. South London Coroner ex parte Thompson (1982) 126 S.J. 625:
‘. . . it should not be forgotten that an inquest is a fact finding exercise and not a method of apportioning guilt.  The procedure and rules of evidence which are suitable for one are unsuitable for the other.  In an inquest it should never be forgotten that there are no parties, there is no indictment, there is no prosecution, there is no defence, there is no trial, simply an attempt to establish facts.  It is an inquisitorial process, a process of investigation quite unlike a criminal trial where the prosecutor accuses and the accused defends, the judge holding the balance or the ring, whichever metaphor one chooses to use.’
Secondly, the verdict resulting from an inquest cannot impose civil or criminal liability of any sort on any person.”
	In a subsequent decision of the Supreme Court in the case of Eastern Health Board v. Brian Farrell [2001] 4 I.R. 627 at p. 63, Keane C.J. stated as regards s. 30:
“While this provision undoubtedly lays stress on the limited nature of the inquiry to be conducted at an inquest, the prohibition on any adjudication as to criminal or civil liability should not be construed in a manner which would unduly inhibit the inquiry.  That would not be in accord with the public policy considerations relevant to the holding of an inquest to which I have referred.  It is clear that the inquest may properly investigate and consider the surrounding circumstances of the death, whether or not the facts explored may, in another forum, ultimately be relevant to issues of civil or criminal liability.”

8.3	In the case of Northern Area Health Board v. Geraghty [2001] 3 I.R. 321, an inquest was held into the death of a patient in hospital managed and controlled by the applicant.  An autopsy was carried out by a pathologist who concluded that the death was due to acute bronchopneumonia.  The deceased’s daughter had concerns in that case in relation to the circumstances in which her mother had died and contacted the coroner who decided to conduct an inquest for the purposes of allaying rumours and suspicions.  During the course of the hearing, two statements which had been prepared by the deceased’s daughter were read to the court.  The applicant complained that it had not been afforded the opportunity of seeing these statements prior to the inquest.  The inquest was adjourned in order that the evidence of a nurse employed by the hospital would be heard.  In the interim period the applicant issued judicial review proceedings seeking, inter alia, a declaration that the inquest, as conducted by the respondent, was ultra vires the provisions of the Coroner’s Act, 1962, a declaration that the respondent had acted in an unreasonable and unfair manner and a declaration that the respondent be confined to conducting an inquest into the proximate medical cause of death only and was not permitted to examine other issues relating to the standard of care afforded to the deceased.
	In making the case that the coroner had acted in a manner which was unfair and unreasonable the applicant complained that the coroner failed to disclose the nature and contents of the statements to be given at the inquest, despite request.  
In his judgment, Kelly J. stated as follows at p. 335:
“In essence the applicant contends that the rules of natural justice require that the statements of witnesses to be given at a coroner’s inquest ought to be furnished in advance of the hearing to the interested parties.  There was no case cited in support of this contention.  Rather reference was made to general principles dealing with the rules of natural justice.  But it is well settled that these rules do not apply in a vacuum.  The necessity to disclose material prior to a hearing and the extent of such disclosure will very much depend on the nature of such a hearing . . . I would be slow to hold that an inquisitorial procedure whose verdict cannot impose civil or criminal liability of any sort on any person requires the full panoply of natural justice requirements of disclosure in advance of the hearing to be applied to it as would be the case, for example, in a criminal trial.  However, it is not necessary for me to decide this question.  The grant of a declaratory order, such as is sought here, is a discretionary one.  Even if the applicant convinced me that the behaviour of the respondent and indeed the general practice of the coroner’s court was in breach of the requirements of natural justice, I would nonetheless refuse a declaration in this case.  I do so because I am quite satisfied on the evidence that the applicant was neither prejudiced nor damnified by such alleged shortcomings.”

8.4	It is submitted that in Geraghty the applicant was claiming that it was in danger of an adverse finding relating to the regime of care in its hospital.  In the present case, there was no question of any adverse findings against the applicant.  The applicant’s only interest is that she is the sister of the deceased.  She has already indicated in correspondence that she has no evidence to offer which might be of assistance to the respondent.
	The applicant in the present case had not demonstrated any prejudice by reason of the decision of the respondent.  There was no evidence that her ability to participate at the inquest would be adversely affected by the decision of the coroner.
	It was further submitted that the complaints of the applicant stem from a misconceived understanding of the function of the inquest.  This misconceived understanding was evidenced by the following averments in the applicant’s affidavit:
(i)	At paragraph 3 the applicant mentioned that she had suspicions about the actions of a couple of persons in or about the time of her brother’s death.  She mentioned, inter alia, that a life assurance policy was taken out about six to eight weeks before he died;
(ii)	At para. 4 of her affidavit she stated that she is concerned that the circumstances surrounding the death of her brother are not being properly investigated by the Gardaí;
(iii)	At para. 6 of her affidavit she stated that the inquest is the only official forum in which she will discover more about the circumstances in which her brother died and that she has serious concerns regarding the circumstances surrounding his death and wishes to participate fully in the inquest;
(iv)	At para. 8 of her affidavit she referred to the fact that statements from witnesses ‘may well show that there is another side to the story that might support the non-accidental death theory’.
It would appear from the tenor of the applicant’s affidavit that she understands the inquest as an adversarial type hearing rather than an inquisitorial type hearing.  It would also appear that she sees it as an opportunity for a wide ranging inquiry in which it will be possible to ventilate her suspicions about other persons.  
In Eastern Health Board v. Brian Farrell [2001] 4 I.R. 627, the proceedings arose out of an inquest into a death from aspiration pneumonia.  The family of the deceased claimed that the aspiration pneumonia arose because of the deceased’s mental handicap which, in turn, was caused by an encephalopathic reaction to the ‘3-in-1 vaccination when he was an infant’.  The coroner had arranged for the attendance of several expert witnesses to deal with the possible link between the vaccination and the death of the deceased.  The applicant health board sought, inter alia, declarations that the coroner was acting ultra vires, his powers under the 1962 Act.  The High Court granted the relief sought and held that the duty of the coroner at an inquest was to investigate what was the real and actual cause of death, which, in turn, meant the proximate medical cause of death.  The Supreme Court dismissed the appeal.  The Chief Justice stated at p. 644:
“If a coroner’s inquest were to extend its inquiries beyond the circumstances, including the proximate medical cause of death, in which the death occurred, it would become, in my view, an inquiry of a radically different nature and one which was not envisaged by the Oireachtas in enacting the Act of 1962.”
	The decision demonstrates that an inquest must not stray too widely from an inquiry into the proximate cause of death.  It is submitted that implicit in the applicant’s affidavit is a desire that the inquiry into the death of her brother should be a very wide-ranging inquiry.
	The State (McKeown) v. Scully [1984] I.L.R.M. 133 does not, however, go as far as to suggest that the next of kin or any person must be entitled to receive draft depositions or other material in advance of the hearing.
	
8.5	The Convention on Human Rights
	The applicant seeks to rely on the jurisprudence of the Court of Human Rights in support of an alleged entitlement to receive the draft statements in this case.  It is submitted that the jurisprudence referred to by the applicant does not support that proposition (see the decision of the European Court in Jordan v. U.K. (2001) 11 B.H.R.C. 1.
	That case, and the related cases considered by the court with it, related to deaths of individuals who had been shot and killed by police in Northern Ireland.  It is in this context that Article 2 was relevant.
	It was submitted that the Jordan v. U.K. decision and related decisions have no relevance to the present case where there is no allegation that the State or State agents were involved in the death of the applicant’s brother.
	R (on the Application of Amin) v. Secretary of State for the Home Department [2003] 4 All E.R. 1264 likewise was not relevant to the present case.  It concerned a prisoner who was killed by a cellmate whilst serving a prison sentence in a young offenders’ institution, an institution of the State.
	It was submitted that the European Convention on Human Rights does not provide any support for the applicant’s case.

8.6	It is further contended on behalf of the applicant that the failure to furnish her with the draft depositions and other material was arbitrary and irrational and in breach of certain constitutional rights.
The respondent submitted that it is clear from the respondent’s affidavit that, far from being irrational or arbitrary, the decision made was reasonable and in the interests of the proper conduct of the inquest.  Fair procedures did not require that the applicant received the draft depositions in advance and no prejudice has been demonstrated.
There was no basis or authority for the proposition that Article 40.3.2 requires the State to put in place a mechanism to investigate the death of each citizen or that such investigation must as a minimum standard have in place procedures allowing each member of the deceased’s family the right to see all of the evidence in advance of any inquisitorial hearing.
The evidence did not support the proposition that the applicant is being treated less favourably than all other persons at an inquest.  There is no breach of any right to equality or of any legitimate expectation.  The practice of other coroners is evident from para. 16-10, p. 372 of Coroners: Practice and Procedure (Brian Farrell) where it states:
“There is a general rule of practice that inquest papers (draft depositions) are not available to interested parties prior to inquest.  The coroner retains a discretion in the matter.”
	The applicant had not established how, as an interested person, she is being prejudiced by the failure to see draft depositions in advance of the inquest.  She is entitled to be represented at the inquest.  That representation was not hindered by the refusal of the respondent to furnish the draft depositions.

9.	Decision of the Court 
	The applicant in this case seeks to expand the role of the coroner’s inquest from the statutory requirement of s. 30 of the 1962 Act which confines it to “ascertaining the identity of the person in relation to his death the inquest is being held and how, when and where the death occurred.”  The prohibition of censure and exoneration in s. 31 further delimits the scope of the verdict of the inquest.  
	The cases referred to by the applicant in the context of Article 2 of the Convention on Human Rights arise from an investigation of death that resulted from the use of force, death in which agents of the State had been involved and death in prison at the hand of other inmates.  The common thread in these cases is the State or emanations thereof and documents held or generated by or on their behalf.  There were compelling reasons in those cases why the next of kin should have discovery and inspection of these documents.  This practice emanated from English practice and from a recommendation of the European Court of Human Rights in that context where there was an allegation of State involvement in the death the subject of the inquest.   
	The applicant relies, in this jurisdiction, on Nolan v. The Irish Land Commission [1981] I.R. 23, which arises in a contentious matter between a landowner and the Land Commission seeking to compulsorily acquire it for the relief of congestees.  Clearly the applicant has a right, as determined by Costello J. and upheld by O’Higgins C.J. and Griffin J. to protect his right to property being acquired by the defendant.
	There is no litigation involved in the present application.  There is no lis inter partes, no pleadings, no case to meet.  
	Of significance also is the absence of any statement from the applicant when requested to do so and her averment that she would not attend the inquest until the documentation required was given to her.
	The coroner has given her the pathologist’s report which would appear to be in a different category, being an expert report, to the category of statements of fact.
	In his affidavit the coroner says that the applicant had not demonstrated that her ability to participate in the inquest would be affected adversely by the decision (see para. 12 of his affidavit).  He had previously referred, at para. 8, to his discretion as to whether draft depositions taken from proposed witnesses should be provided.  As these had remained unsigned and unsworn up to the time of the inquest they had no standing until that time.  He exercised his discretion by not releasing them.  He was entitled to make a distinction between the expert report of the pathologist and the statements of fact.  It appears that the decision of Kelly J. at 335 in Northern Area Health Board v. Geraghty is apposite.
	The applicant is, of course, entitled to be present at and to be represented at the inquest.  She has had the opportunity of making a statement.  It seems to me that she is insisting on being furnished with all information, without distinction but is unwilling, as is her right, to give information to the coroner.  Of course, she is entitled to give any information at the inquest itself and, indeed, to question any witness with regard to their statement.
	It would seem to me to be highly inappropriate to demand all information, including the garda investigation.  It seems to me that the coroner, in the exercise of his discretion, has distinguished between the expert report which he gave to the applicant and the depositions of fact which would be given to those who made them if so requested.
	The procedures under the Coroners Act are not adversarial but inquisitorial.  Accordingly Nolan has no application.  The matter before the coroner does not involve the State or anyone under its care which gave rise to the practice under the Convention for Human Rights.  It seems to me that the prior release of documents, particularly the depositions of non-expert witnesses, may make the coroner’s fact finding exercise into adversarial litigation.  I agree that an inquisitorial procedure whose verdict cannot impose civil or criminal liability of any sort on any person does not require what Kelly J. terms the “full panoply of natural justice requirements” of disclosure in advance of the hearing.
	Moreover, there is no evidence whatever that the applicant is prejudiced by the absence of such disclosure. 
	For these reasons I refuse the application.