High Court of Ireland Decisions

1. Rosaleen O'Reilly (the deceased) died on the 25th February, 2000. Her death occurred at St Ita's Hospital, Portrane, Co Dublin which was managed and controlled by the applicant. The deceased had been admitted to that hospital as a patient on the 18th January, 2000. She had a previous history of psychiatric illness for a period in excess of 10 years. At the time of her death she had just turned sixty seven years of age.

2. An autopsy was carried out by a consultant pathologist following her death. His conclusion was that her death was due to acute bronchopneumonia.

3. Initially it was not the intention of the respondent to conduct an inquest into the death of the deceased. He was however, contacted by the deceased's daughter Carmel Kitching-O'Reilly who drew specific matters to his attention. He requested Ms Kitching-O'Reilly to convey her concerns to him in writing. She did so and as a result he decided that it would be appropriate to hold an inquest for the purposes of allaying rumours and suspicions having regard to these concerns of the deceased's daughter.

4. The applicant was served with a notice of intention to open an inquest at Tallaght Courthouse on the 17th October, 2000 at 10.00 am. The notice requested copies of medical reports from the applicant.

5. On the 26th September, 2000 the applicant, through its solicitors, wrote to the respondent seeking confirmation of the personnel required to attend the inquest and copies of the statements of evidence intended to be adduced thereat together with a copy of a toxicology report prepared by the State laboratory. No response was received to that letter.

6. The inquest commenced on the 17th October, 2000 and it is as a result of what transpired there that this judicial review application comes about.

7. The conduct of the inquest was of course governed by the provisions of the Coroners Act, 1962. Accordingly, it had to be confined to determining the identity of the deceased and how, when and where her death occurred. (see section 30 of the Coroners Act, 1962). In addition questions of civil or criminal liability were expressly prohibited from being considered or investigated at the inquest. The inquest is entitled to make recommendations of a general character designed to prevent further fatalities and such recommendations can be appended to the verdict. (see section 31 of the Coroners Act, 1962).

8. The first witness called at the inquest was a police officer who testified that at 4.30 am on the 25th February, 2000 she was called to St Ita's Hospital as a result of a sudden death. On arrival she met with the daughter of the deceased and the deceased's husband (the Notice Party). There were no visible marks on the body of the deceased. However, the deceased's daughter expressed to the police officer concerns as to how the deceased had died.

9. The second witness called was Ms Kitching-O'Reilly the deceased's daughter. A statement made by her was read to the court by the police officer. That statement recited that the deceased had attended the hospital on the 18th January, 2000 for respite care. It went on to state that the witness arrived at the hospital at 4.00 am on the 25th February, 2000 and identified the body of the deceased to the police officer.

10. At that point the respondent asked the police officer whether there was a further statement made by the deceased's daughter. The police officer then commenced to read out the second statement which had been prepared by Ms Kitching-O'Reilly. This was a lengthy statement which for the most part recites the history of the deceased as known to the deponent from the time that she entered St Ita's Hospital on the 18th January, 2000. It concludes with an expression of deep dissatisfaction at the attitude and level of care by some of the staff at St Ita's Hospital concerning the deceased.

11. The applicant contends that until the second statement was mentioned in court neither it nor its legal advisers had been informed by the respondent of the existence of it or of its contents. This was so notwithstanding the fact that the statement was dated fourteen days prior to the inquest.

12. When the nature of the second statement became apparent it led to an exchange between counsel appearing for the applicant and the respondent. Counsel objected to the admission of the statement. He did so on the grounds that the purpose of the inquiry was to determine the proximate medical cause of death and that the matters rehearsed in the statement appeared to go beyond the scope of such an inquiry and into the realm of an investigation of civil liability. The respondent countered on the basis that it had been put to him that a lack of care may have caused the death of the deceased and that if so it was his duty to hear what had to be said with regard to the care that the deceased received. Apparently the statement had not been fully read at that stage, but in the light of the respondent's ruling the remainder of it was read and the deponent was questioned both by the respondent, counsel for the family of the deceased and by counsel for the applicant. In the course of this questioning it is said it became apparent that evidence would be required from a nurse employed by the hospital. Before the questioning was completed therefore, the coroner adjourned the proceedings until the 14th November, 2000.

13. The respondent gives a somewhat different version of events. He points out that the deceased died within one and a half hours of appearing to be ill. This, he says, was a very sudden death and one that caused great distress both to the deceased's daughter and the notice party together with other members of her family. Allegations had been made to him that there was a lack of care and he took the view that he was required to look at them. He has sworn to the fact that he was not inquiring into the standard of care at St Ita's Hospital, Portrane, but was merely seeking to establish the circumstances surrounding the death of the deceased. In order to do that, he said, it was necessary to have some picture of her last weeks in hospital.

14. The nurse, who did not appear on the day of the inquest, has been identified as Angela Roseingrove. She had furnished a statement to the respondent prior to the inquest. She was not mentioned in court by the respondent but simply as a nurse. It was counsel for the applicant who raised her name and indicated that she was not present although she had been directed to attend. It was as a result of the non-attendance of that nurse that the respondent considered it appropriate to adjourn the inquest to afford her an opportunity to attend. It is clear from the statement made by this nurse that she is dealing with matters which occurred two days prior to the death of the deceased. She was not on duty at the time of death nor did she deal with the matters which occurred within one and a half hours of the death taking place. She was however, a person against whom the deceased's daughter made complaint. The statement was taken from her by a police officer on the 12th October, 2000. The respondent says that the applicant cannot have been in any doubt as to the purpose of the inquest. This is to controvert an allegation made in the applicant's grounding affidavit indicating that the applicant had attended court with a view to assisting the coroner in determining the proximate medical cause of death and had not anticipated a wide-ranging inquiry into the system of care being provided at the hospital. The respondent says that he is not in any way involved in inquiring into the standard of care at the hospital, but in the light of the allegations made was anxious to obtain some picture of the deceased's last weeks in hospital. It follows, he argues, that as a statement was taken from one of the applicant's employees dealing with matters two days before the death of the deceased, they cannot have misunderstood that the inquest was only going to deal with the last hour and a half of the deceased's life.

15. The respondent said that at the inquest Mrs Kitching-O'Reilly was extremely distressed and was grieving deeply for her mother. As is his usual practise he allowed her to give her evidence and permitted her statement to be read without interruption. He says that the applicant is presumptive in assuming that simply because she made such allegations that he would have considered them to have been proven or have issued directions to the jury accordingly. What he was doing was merely affording the deceased's daughter the normal sensitivity that he would do to any grieving relative to express concerns about her deceased mother's treatment. He says that he issued no directives nor indicated by word or letter anything that could lead either the jury or the applicant to believe that he was investigating either criminal or civil liability within the meaning of section 30 of the Coroners Act, 1962. Indeed, he said that it had become apparent to him throughout the course of the inquest that if the applicant had cooperated the jury were most likely to return a verdict in accordance with the pathology reports.

16. The adjournment was not sought by the applicant because of any alleged prejudice or inability to deal with the evidence given by Ms Kitching-O'Reilly. Rather the adjournment came about with a view to ensuring the attendance of Nurse Roseingrove and clearly the applicant's counsel was aware of the fact that she had given a statement since it was he and not the respondent who mentioned Nurse Roseingrove by name during the course of the hearing.

17. In any event, with the inquest adjourned to the 14th November, 2000 and without any intimation being given to the respondent that an application would be made for judicial review, leave to commence these proceedings was sought on the 13th November, 2000. It was granted by O'Neill J.

18. Leave was sought to seek the following reliefs.

19. The grounds upon which these reliefs may be sought are six in number. However, it is clear that the first two supposed grounds are statements of fact more appropriate for an affidavit. The grounds are confined to the remaining four paragraphs. They read as follows:

20. Throughout the submissions which were made on behalf of the applicant, constant criticism was voiced in respect of the decision of the respondent to hold the inquest.

21. In my view it is not open to the applicant to do this for a number of reasons. First, the applicant has not sought in these proceedings to quash the decision of the respondent to hold the inquest. Secondly, the applicant attended at the inquest and participated fully in it being represented there by counsel who both conducted cross-examination and made submissions. Thirdly, it is to be noted that one of the reliefs which is sought by the applicant here, admittedly as an alternative, seeks to compel the respondent either to hold a new inquest or to direct the jury in the existing inquest in a particular way. These reliefs are inconsistent with the criticisms levelled at the respondent to the effect that he ought not to have held an inquest at all.

22. The principal basis upon which this criticism was levelled at the respondent was that he had no entitlement to hold an inquest in circumstances such as this for the purposes of allaying rumours or suspicions. Whilst it is true that that particular phrase does not occur in the provisions of the Coroners Act, 1962 nonetheless there is strong judicial authority in this jurisdiction supportive of the notion that the coroner may decide to hold an inquest in order to deal with such matters. The first of these cases is Farrell v Attorney General [1998] 1 IR 203. In that case Keane J. (as he then was) delivering the judgment of the Supreme Court said as follows at page 223:-

23. I cite that rather lengthy passage not merely to demonstrate the acceptance by the Supreme Court of the notion that a public interest may be served by a coroner's inquest convened to allay rumours or suspicions but also to cast light on some of the further submissions made by the applicant which I have to consider later in this judgment.

24. The views of the Broderick Committee were considered by the Supreme Court again in the case of Morris v Dublin City Coroner [2001] 1 ILRM 125. There Keane C.J. delivering the judgment of the court again pointed out that the holding by a coroner of an inquest is a purely fact-finding exercise which has no legal consequence other than the provisions as to the registration of the death under section 50(1) of the Act. He went on to say that it would appear that the coroner, in conducting the inquest is not exercising the judicial power of the State. Again he cited the recommendations of the Broderick Committee with approval.

25. It does not fall to me to decide whether or not the coroner was correct in his decision to hold the inquest in this case. However, any criticism of his so doing with a view to allaying rumours or suspicion appears to be in the teeth of judicial authority from the Supreme Court expressly recognising the entitlement to hold an inquest for just such a reason.

26. The applicant contends that the respondent has failed or refused to carry out the inquest in accordance with the provisions of section 30 of the Coroners Act, 1962. That section reads as follows:

27. It is said on behalf of the applicant that by permitting the deceased's daughter to give the evidence which she did the respondent went beyond what is permissible by reference to section 30.

28. Much reliance was placed on the judgment of Blayney J in Greene v. MacLoughlin (Supreme Court 26th January, 1995). That judge took the view that the Coroner in that case was in breach of section 30 by failing to confine the inquest to ascertaining the identity of the deceased and "how, when and where death occurred". He said

29. In the present case the applicant contends that the post-mortem here gave rise to a clear finding of death as a result of acute broncho-pneumonia. Such being the case and there being no dispute on that issue it is said that the respondent acted ultra vires in his conduct of the inquest by allowing Ms Kitching-O'Reilly to give the evidence which she did. The effect of the applicant's submission is that in any case in which there is a post-mortem which produces a clear cause of death there is really little scope for a Coroner's inquest since it will have been established that death occurred in the manner specified by the medical science brought to bear in the post-mortem. Apart from turning the respondent into something of a cypher such a submission seems to leave little scope for the express entitlement of a Coroner's jury to append a recommendation to any verdict with a view to preventing such a death from occurring again.

30. I do not think that Blayney J intended the statement which I have cited from his judgment which was particularly relied upon by the applicants to be construed as if it were the words of a statute and to have such a narrow and rather sterile application.

31. Rather I prefer the approach of Geoghegan J in Eastern Health Board v. Farrell [2000] 1 ILRM 446. In that case the Eastern Health Board sought judicial review in respect of an inquest being held concerning a deceased who suffered from a moderate form of mental retardation. There was no dispute but that the medical cause of his death was aspiration pneumonia. The Coroner directed an inquest because of a dispute between the notice parties and the consultant who treated the deceased as to the cause of the aspiration pneumonia. The consultant proposed completing the death certificate as demonstrating the cause of death as being "aspiration pneumonia due to cerebral palsy". The notice parties objected to that alleging that aspiration pneumonia which was the immediate cause of death, arose due to the deceased's mental handicap, which in turn was caused by the "three-in-one" vaccination which was administered to the deceased when he was an infant. The Coroner had assembled a number of expert medical witnesses to give evidence about the facts of the death and also about the possible connection to the "three-in-one" vaccine. The health board protested about the Coroner's actions and suggested that he was trespassing into the area of possible civil liability and that this was prohibited.

32. The health board was successful in obtaining judicial review.

33. In the course of his judgment having considered the passage from the judgment of Blayney J which I have just cited, Geoghegan J said this.

34. There is a world of difference between the facts in the Farrell case and those in the present one. Furthermore it is clear from the affidavit sworn by the respondent that he had not the slightest intention to investigate either civil or criminal liability. Furthermore he says that he was not conducting a wide-ranging inquiry in the state of affairs at St Ita's Hospital, Portrane. Had he been so doing he would not have directed that statements be taken from such a limited number of people. Statements were taken at his direction from only four persons. Two of these were doctors (one the consultant psychiatrist to the deceased) the other two were nurses. These witnesses were limited to those who had dealings with the deceased in the weeks prior to her death. That is a far cry from what happened in the Farrell case where the Coroner of his own volition directed the attendance of expert medical witnesses to inquire into matters other than the proximate medical cause of death.

35. I am of the view that the applicant's case here seems to place too narrow an interpretation on the role of the Coroner. He is not a rubber stamp for the views expressed by the pathologist following the post-mortem. He must have a certain amount of latitude and discretion depending upon the facts of each individual case so as to bring about an investigation into the real and actual cause of death. Like Geoghegan J. I think it is unwise to set down any hard and fast rules regarding the scope of a Coroner's investigations.

36. I do not think that on the facts of the present case it can be said that the Coroner here misapplied that discretion or acted in a manner which is ultra vires the provisions of section 30 of the Act. The case is very far removed on its facts from the Farrell case.

37. In my view the applicant's case to the effect that the respondent acted ultra vires the provisions of the Coroners' Act, 1962 is not made out. I do not accept that the Coroner was conducting a wide-ranging inquiry into St Ita's Portrane nor was he trespassing into the area of civil or criminal liability. He was in my view within the ambit of his discretion performing the function for which the Coroner's Office is designed.

38. The applicants contend that the respondent purported to extend his inquiry to the standard of care afforded to the deceased while in St Ita's Hospital. I have already dealt with that contention. However, they say that he did so in a manner which was unfair, unreasonable and in breach of natural justice. The reasons which are given for that are as follows:

39. The respondent points out that it is the practice of the Coroner's Court not to furnish statements of any of the witnesses to any party prior to the holding of the inquest. The police officer in charge of obtaining the statements obtains them and brings them to court on the day of the inquest to be read to the appropriate witness and duly signed. Each witness is entitled to add to the statement. He says that it has long been the practise of a Coroner's Court not to circulate statements prior to the holding of the inquest because persons may and indeed do change their statements or add to them at the inquest.

40. 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 upon the nature of such a hearing. I have already cited from the judgment of Keane J in Farrell v. Attorney General [1998] 1 IR 203 where he in turn expressed approval for the views of Lord Lane LCJ in R v. South London Coroner ex parte Thompson. The Lord Chief Justice said

41. 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 applicants convinced me that the behaviour of the respondent and indeed the general practise 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.

42. It is to be noted that once the initial objection to the admission of Ms Kitching-O'Reilly's statement had been rejected by the respondent she was questioned both by the respondent, counsel for the family and counsel for the applicant. There did not appear to be any inability on the part of such counsel to conduct the cross-examination of the witness. No application was made for an adjournment on the basis of any prejudice having been suffered by the applicant.

43. The inquest was in fact adjourned but not as a result of any application in that regard being made by the applicant's counsel. In fact no application at all was made by the applicant for an adjournment. It was decided upon by the respondent of his volition.

44. In circumstances where the applicant's counsel conducted a cross-examination of Miss Kitching-O'Reilly and where no application for an adjournment was apparently considered necessary in order to deal with her statement it is difficult to see how the applicant can contend now that they suffered any prejudice as a result of the alleged shortcomings of the procedure adopted by the respondent.

45. In these circumstances I am not satisfied that the applicant has made out any case for the intervention of this court in respect of all or any of the reliefs which are sought.

46. Consequently this application will be dismissed.