Caitríona Lucas inquest returns verdict of death by misadventure

Safety recommendations made to Irish Coast Guard as family say mother of two was ‘let down so terribly’

The jury at the inquest into the death of Irish Coast Guard volunteer Caitríona Lucas has returned a verdict of misadventure.

The jury also made seven recommendations on safety management which they said should be adopted by the Irish Coast Guard. These included a call for a review of the suitability of all safety gear, including helmets.

Michael Kingston, solicitor for woman’s family, had urged a verdict of unlawful killing but this was outside the scope for the jury to consider, coroner John McNamara said.

A verdict of accidental death or death by misadventure – the latter of which related to an unintentional outcome – would be appropriate, the coroner said before sending the jury to deliberate.


Ms Lucas (41) had died on September 12th, 2016, at University Hospital Limerick. The cause of death was drowning and a head injury was a contributory factor.

The jury, the coroner, the family solicitor, counsel for the coastguard, gardaí and the health and safety authority all expressed their sympathy to the family of Ms Lucas.

The married mother of two and librarian from Ballyvaughan in Co Clare had been a dedicated, meticulous and highly respected volunteer member of the Doolin Coast Guard Unit, the inquest heard.

On the day of her death she had been called in to assist the undermanned Kilkee Coast Guard unit which was conducting an ongoing search that weekend.

A wave had struck the Delta Rigid Inflatable Boat (RIB) she and two other volunteers, both members of the Kilkee unit, were on and thrown all three into the water at Lookout Bay where they had been taking part in the search.

Ms Lucas had been winched by helicopter but was pronounced dead in hospital. She had been conscious for 17 minutes in the water, the inquest revealed.

The inquest was told of “interpersonal” relationship issues in the Kilkee Coast Guard and how numbers had “dwindled” from 30 in 2010 when it was amalgamated with the Irish Coast Guard to just 12 in 2013 and how four senior members had left the week before the tragedy.

It also heard that when the mayday signalling from the capsizing of the Delta RIB was received a second rescue boat could have been launched.

A UK safety consultant raised concerns about the helmets worn by Irish Coast Guard members on the day as the helmets had come off all three people thrown into the sea.

In final submissions, Mr Kingston said crucial time had been lost in getting to Ms Lucas and there was also key evidence that the volunteers had not been trained to work in surf zones.

Ms Lucas lost her life in an unsafe workplace “therefore unlawful killing should be considered”, Mr Kingston said.

However, Simon Mills, SC, for the Irish Coast Guard, said the verdict of unlawful killing was not open to this jury.*

All three in the Delta boat had done advanced training and the boat was safe and they had carried out body checks, Mr Mills said.

In his address to the jury, the coroner said the role of an inquest was not to exonerate or attach blame.

Mr McNamara referred to “the window of 17 minutes” before Ms Lucas lost consciousness and to the evidence from deputy officer in charge Orla Hassett that the second rescue boat, the D-Class, might have been launched and might have got to the scene at Lookout Bay in 10 minutes and effected a good rescue.

He also referred to the commandeering of a civilian boat by Ms Hassett.

“Orla Hassett had the presence of mind to get a civilian boat back into the water, and managed to save the life of Jenny Carway,” the coroner said.

The third volunteer thrown from the boat, James Lucey had subsequently been rescued from the cave where he had found refuge.

The coroner also referred to the fact two of the helmets including Ms Lucas’ had come off on the capsizing.

“If Ms Lucas’ helmet had remained on, it may have avoided the head injury she had sustained,” Mr McNamara said.

The other recommendations made by the jury were:

* Each Coast Guard station should take appropriate steps to ensure volunteers were aware of relevant exclusions for vessels and where possible display same clearly at the base station;

* An immediate and ongoing review of training of Coast Guard volunteers/staff to provide up-to-date training for capsize incidents;

* An “urgent” implementation/education of all lessons learned and recommendations of all reviews into Coast Guard incidents;

* Measures should be taken to ensure that all Coast Guard vessels are fitted with voyage data recorders;

* Establishment of an appropriate centralised safety management/portal for identified risk issues on a confidential basis, and;

* The Irish Coast Guard should consider ongoing training for the officer-in-charge (OIC) and deputy OIC “as appropriate” at units.

Ms Lucas’ father Tom Deely, brother Padraig and sister Bríd along with her husband Bernard, son Ben (28) and daughter Emma (25) were in Kilmallock for the verdict.

After the inquest, in a statement read by Ben, the family said it was “extremely unsatisfactory” the inquest had not taken place until now, seven years since his mother had died. The recommendations by the jury should have been made seven years ago, he said.

The Irish Coast Guard and the Department of Transport had been instructed in a 2012 report on senior safety systems to better protect volunteers and those they went to help, he said.

“That never happened and my mother went to help others but was let down so terribly.”

*This article was amended on Wednesday, December 6th, 2023 to correct an erroneous reference to Simon Mills SC having stated that a verdict of unlawful killing was not one open to a jury in a coroner’s court. In fact, he said it was not a verdict open to the jury at this particular inquest.