An Oireachtas committee has heard that families trying to establish how their loved ones died felt they were sometimes "gagged" by powerful medical institutions.
Barrister Doireann O'Mahony told the Justice Committee that families of victims sometimes "felt like furniture" when attending inquests.
They had to fight to ensure that "their loved one does not get forgotten", sometimes in the face of hospitals or consultants who try to have their statements "ruled out or redacted".
This "makes the families feel as if they're being gagged", Ms O'Mahony said.
But she said that those grieving families have little recourse, as any legal action is "terribly expensive", and so they are "frightened off".
"They are exhausted. They are broken down. And they are grieving," she said, adding that a court case is far more than they can manage.
To tackle this, Ms O'Mahony urged that the Coroner Service be standardised, serious inconsistencies rooted out, and a review board put in place.
The current set-up results in "families whose grief has been compounded, and whose questions remain unanswered," she said.
After a medical tragedy, when people go to lawyers, "it's not to seek compensation - it's to get answers", Roger Murray SC, Head of Clinical Negligence at Callan Tansey Solicitors, told the committee.
He said that a well-resourced service would avoid unnecessary litigation, save money, and also have a "massive knock-on effect" in addressing the suspicion that grows if facts remain hidden.
And he added that Coroners' Courts "should not take place in dance halls, ball rooms", or "most farcically of all, the stage of the town hall theatre".
Doireann Ansbro, Head of Legal and Policy at the Irish Council for Civil Liberties, said that the many systemic failings were identified in a report over two decades ago.
"Little has changed 22 years later," she said, with families feeling "marginalised" and "experiencing retraumatisation".
Ms Ansbro expressed serious concern over threats to "the right to a jury", which is a "fundamental burning issue" in light of the Stardust inquest, due to start in the autumn.
Sinn Féin Senator Lynn Boylan has introduced a private members bill which, she says, aims to ensure that the inquest is "held before a jury, and that the jury will be selected in a transparent manner".
"We are facing a deadline of September," the Senator told the committee.
We owe to those who go through the "extremely agonising and tortuous process" of an inquest "the one glimmer of hope it can offer", namely that learning will result in fewer deaths, she said.
Patrick Costello, Green Party TD, asked how recommendations from the Coroners' Courts can be made "more binding".
Roger Murray advised following the UK model, where Prevention of Future Death Reports are "designed to have a practical effect".
In Ireland, however, he noted that while recommendations have "moral authority and have saved lives", "there is no follow-up and there's no penalty if somebody doesn't respond".
Last year, more than 80% of all deaths were reported to the Coroner Service, according to Professor Denis Cusack, Senior Coroner for the District of Kildare. But he noted that only 12% proceeded to inquest.
In 2021, there were 25,421 coroner cases, of which 18,746 were "report only", and 2,101 went to inquest.
"The structure, organisation and financing are not fit for purpose in this modern era," he said.
"We have been pushing the door for reforms," he insisted, adding that, "much of the legislative reform has actually been passed".
