The Living and the Dead: ‘Families are very much isolated from the process unless they are proactive’

Inside Ireland’s Coroners’ Courts: Three people share their experiences

Lisa Duffy: ‘There should be a statutory system to ensure recommendations by coroners are implemented’

“I felt confident after Luke’s inquest that more babies would be saved because of the coroner’s recommendations for the training of medical staff,” says Lisa Duffy.

“I felt what happened to Luke was terrible but some good might come out of it if the recommendations were acted on. But the coroner has since told us he only recently got an acknowledgement of his recommendations and there is no gatekeeping to ensure recommendations are followed through. That is baffling.”

Ms Duffy’s baby son Luke died at the Midlands Regional Hospital in Portlaoise on October 29th, 2018, a bank holiday Monday.

In January 2022, at the close of the inquest into the infant’s death, Laois coroner Eugene O’Connor found Luke died after suffering acute hypoxia and returned a verdict of medical misadventure.


He recommended that women giving birth in maternity units, and staff should have access at all times to the expertise provided by consultant paediatricians.

Other recommendations included regular training for obstetric staff on how back pain alone can indicate the start of labour.

For three days before Luke’s death, Duffy says she had begged staff to induce his birth but they did not because, she says, they failed to recognise her extreme back pain as a sign labour had commenced.

The inquest heard the maternity unit was very busy around the time and Duffy was not examined by a consultant for six days before her baby died. All available slots for inducing babies were booked until October 29th, the day Luke died.

Now Duffy is campaigning with other bereaved mothers for change. “I feel it is very unfair that the same mistakes are made. There should be a statutory system to ensure recommendations by coroners are implemented.”

She is very concerned that the bereaved have all relevant material, including the names of relevant witnesses, well in advance of the hearing of inquests.

She favours an open disclosure policy and describes as “absolutely ridiculous” that she and the coroner were told, by the HSE, the name of a key witness only about three days before the inquest opened,

The coroner and his secretary were “very helpful and compassionate” to her in contrast to her experience dealing with the hospital, she says. Hospitals need “to improve communications” with bereaved families.

Claire Cullen: No one tells you anything unless you go looking for information’

“I’m working with other mothers and we are planning to go to the Minister for Justice to inform him of the current state of inquests into the deaths of babies and to seek open disclosure. We will be asking that recommendations made by the coroners’ courts are implemented.”

Claire Cullen’s infant son Aaron died of a lung condition on May 9th, 2016, five days after he was born at the Midlands Regional Hospital in Portlaoise.

A March 2019 inquest found the baby died of pulmonary hypertension and renal vein thrombosis contributed to by acute and chronic hypoxia and mitochondrial myopathy.

Dublin senior coroner Dr Myra Cullinane supported recommendations in various reports concerning hospital systems improvements, including for continued training of medical staff.

Cullen, who with her husband, Keith, settled a High Court action in 2020 against the HSE for mental distress arising from Aaron’s death, is involved with Duffy and other bereaved parents in lobbying for change in the investigation of infant deaths, improved hospital communications and general reform of the coroner system.

“Families are very much isolated from the process unless they are proactive. I felt I wanted to give my own account of what happened, I wanted to reach out to the coroner herself and I did that early on.”

Most families are not represented by lawyers and some may not be computer literate and able to access information on coroners’ websites, she says.

“No one tells you anything unless you go looking for information. I think many people don’t think they can write to coroners or ask questions. I have seen families who feel they don’t have a voice, they feel they have to sit back and be quiet and just wait for the outcome.”

She considers herself lucky because her legal team engaged with her throughout on important issues, including about what witnesses to call.

She accepts delays in holding inquests are often linked to delays in investigations and obtaining reports and postmortems.

A priority for Cullen is achieving open disclosure of material for inquests and she believes some families may be unaware there may be issues indicating negligence and important material may exist but has not been disclosed.

While describing the inquest into her son’s death as adversarial, Cullen has no complaint about how it was conducted by Dr Cullinane. “I felt she was fair and compassionate across the board and to me when I was giving evidence.”

Some causal information concerning her son’s death became available only after the inquest had concluded and she is now considering seeking to have it reopened.

She was informed that recommendations following a systems review in the hospital concerning her son’s death had been implemented but wants a formal procedure to ensure inquest recommendations are followed up and acted upon.

Evan Gearns:My family’s experience of the system to date has been diabolical, I have no faith in the system’

“It’s the last thing I think about at night and the first thing in the morning.”

Evan Gearns is talking about the death by suicide of his older brother Andrew in Cork Prison in October 2020.

The inquest into Andrew’s death opened this week, having been deferred last September by Cork city coroner Philip Comyn, at the request of the family’s lawyers, to allow them examine CCTV evidence.

The coroner and the family were told only at the September hearing that all 72 hours of CCTV footage around the time of Andrew’s death was in fact available for viewing.

His family had to seek the adjournment because the dates set by the coroner for putting in evidence were not adhered to, says Evan.

Andrew was a talented soccer player who had a partner, two children and a good job but, for the last three years of his life “just went down the wrong kind of road”. He suffered back problems following a car crash and was prescribed benzodiapenes. “He got addicted to them, took to drink.”

He ended up in prison because a bench warrant was issued for him after he failed to turn up in court to answer drink and disorderly charges, says Evan.

“It was stupid stuff, he wanted help, we could see he really, really wanted help. He was crying when he was being taken away by the guards. My mam was crying too. ”

Andrew was hallucinating on the Friday before his death, had attempted suicide but did not tell the family that, Evan says. “I suppose he was coming down off the drugs, the Monday he did it, he rang my mam at 12.03pm, he wasn’t making sense and after he hung up she was worried and she rang the prison back and told them she was very concerned.”

Later that day, at 4.42pm, Andrew was found in the cell with a ligature around his neck.

The family have been in regular contact with the coroner’s office and were unhappy about the delays – some attributable to Covid-19 and lack of courtrooms – in having the inquest heard.

Evan was also hurt to receive letters from the coroner’s office mistakenly referring to Andrew as Evan. “It took three letters to get it right.

“We were waiting more than two years, it’s probably not down to his [coroner’s] fault, it’s just the way the whole system is structured, all nooks and crannies.

“Everything is blamed on Covid but the coroner’s office was short staffed well before Covid.”

He strongly supports reform of the coronial system.

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“It’s time for action, not for doing another report. There were calls for reform back in 2000, a Bill was introduced in 2007, no one seems to know what happened to that. My view is get on with it, sort it out.”

The Department of Justice has said it is up to Cork City Council to deal with the coroners’ service there as the council funds it. But it is the Government which allocates funds to the council, he says. “It should be taken out of the council and put into the court system. My family’s experience of the system to date has been diabolical, I have no faith in the system.”

The Cork city coroner has just two staff while the Dublin service has 24, he notes. “There is no clear structure. There is no proper communication, I would like to see all of that improved and families kept informed. You have to fight for everything in this country.”

Mary Carolan

Mary Carolan

Mary Carolan is the Legal Affairs Correspondent of the Irish Times