Gross understaffing leading to delays in holding of inquests, says coroner

One of the country’s busiest coroners has said that understaffing in his office is leading to delays in the holding of inquests and dealing with the concerns of bereaved families anxious to conclude inquiries into the deaths of their loved ones.

Cork city coroner Philip Comyn said that he was seriously understaffed, with just one person available to him to deal with correspondence from bereaved relatives and schedule and organise inquests for all deaths within the Cork City Council area, which has a population of more than 220,000.

“Through no fault of my office and primarily due to gross understaffing, delays are occurring beyond our control, delays which are avoidable,” said Mr Comyn during a pre-inquest submission hearing in relation to the death of Cameroonian woman Geraldine Yankeu (31) at Cork University Hospital (CUH).

Mr Comyn asked all parties to the inquest to facilitate his office by “avoiding scattergun correspondence” of letters and emails “every second day” but he stressed that by making such a request, he was not seeking to restrict any legal practitioners from representing their clients.

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“That I have to make such a request of you is due to the fact that my office is extremely understaffed – I have one person, namely Ms O’Leary in front of you to deal with inquests,” said Mr Comyn as he indicated towards registrar Deborah O’Leary.

Mr Comyn made his comments in the course of a detail pre-inquest hearing in which he outlined whom he intended to call as witnesses in the case of Ms Yankeu, who died on August 2nd, 2021, at CUH some days after the stillbirth of her daughter Mary at Cork University Maternity Hospital.

Mr Comyn had proposed calling five witnesses to the inquest, including the late Ms Yankeu’s partner Patrick Mbeng and her sister Ornella Nana, as well as her GP and obstetrician.

Medical witnesses

Barrister for Ms Yankeu’s family, Doireann O’Mahony, said she believed additional witnesses should be called. She said that at least eight other medical witnesses should be called, including a midwife and various doctors at CUMH who saw Ms Yankeu at various stages in her pregnancy, which was characterised by hypertension and resulted in her being admitted to the emergency department of CUH.

She also suggested that Mr Comyn should also call external experts in that area of obstetrics, and she suggested he could call either Prof Lucy Chappell or Prof David Williams, who are both based in London.

Ms O’Mahony also pointed out that under legislation, every maternal death triggered mandatory reporting to the HSE’s National Incident Management Systems within 24 hours and an investigation conducted into the death within four months.

She asked Mr Comyn if he was aware of any investigations into the care of Ms Yankeu and her stillborn daughter, and Mr Comyn said there had been both an internal hospital review and an external review, both of which he was happy to supply to Ms O’Mahony for the family.

Ms O’Mahony also requested that any correspondence between Ms Yankeu’s GP and CUMH relating to her pregnancy be made available and any statements or memos sent between CUMH and CUH, where she was admitted due to suffering from hypertension.

Counsel Dr John O’Mahony SC, for Ms Yankeu’s family, said given the lapse of time since Ms Yankeu’s tragic death just days after the stillbirth of her daughter, such memos and statements could assume a great importance given that people may be prone to memory loss.

Meanwhile, Ms O’Mahony also raised concerns on behalf of Ms Yankeu’s family, who were deeply traumatised to learn that an inquest was to be held into Ms Yankeu’s death, not from correspondence from the coroner’s office but from an online report on the Irish Examiner.

“It is unacceptable that in 2022, a bereaved family had to find out that there was to be an inquest into the death of a loved one from an online publication – it is grossly unfair on the family,” said Ms O’Mahony, who also raised concerns about a lack of communication with Ms Yankeu’s brother.

Apologised

Ms O’Mahony said that Ms Yankeu’s brother, Romuald Chainey, had sent two emails to the coroner’s office on September 11th, 2022, seeking information about the inquest but had not received any response and this was also completely unacceptable.

Mr Comyn apologised for any upset caused by his office’s failure to respond to Mr Chainey’s emails, but he stressed that his office was seriously understaffed and struggling to cope with the volume of correspondence it was receiving in relation to inquests.

Dr O’Mahony SC, also for the family, said that it was perhaps, a reflection of the fact that Ms Yankeu’s family were based in Cameroon which was 7,000km from “ground zero” and he invited Mr Comyn to issue an apology to the family over the failure to inform them.

Mr Comyn said he had no difficulty reiterating his apology to Ms Yankeu’s family, but he said that his office “deals with everybody equally and distance does not concern us – we deal with every family equally and have dealt with families as far away as Australia, America, Africa and the Middle East”.

Mr Comyn suggested that Ms O’Mahony and solicitor for the HSE, Eamon Harrington, should work with him to agree a comprehensive list of statements and documents that he could then assess and use to assist him in drawing up a final list of witnesses.

But Mr Comyn told Ms O’Mahony he was unable to assist her at this stage in confirming either a date or a venue for the hearing in that he needed to assess what all the additional witnesses that she was seeking might have to say in relation to the case and how long their testimonies might take.

Ms O’Mahony said that it was important the case proceed as quickly as possible, not just for the family, but also in terms of its national importance as it may raise issues regarding the care of pregnant women with hypertension that went beyond the particulars of this double-death tragedy.

Mr Comyn said he was anxious to facilitate Ms Yankeu’s family as much as possible, but the reality was that he was dealing with a huge backlog of inquests, and it would be 2023 before he was able to find a vacant date to hold a hearing with potentially many witnesses that could run for several days.

He pointed out he already was trying to hold inquests into two deaths at Cork Prison that would involve calling more than 20 witnesses and take some time, while there were also inquests into other perinatal deaths cases that predated Ms Yankeu’s death that he also had to hold.

Ms Yankeu was born in Douala, Cameroon, but had been living in Cork for a number of years. She had attended the Munster Technological University and Cork College of Commerce before obtaining work as a customer services adviser in Cork.