Widower Unhappy With Inquest Misadventure Verdict

A verdict of misadventure at the end of an inquest into the death of a North Clare Coast Guard volunteer has left her widower dissatisfied.
A jury of four men and three women also issued seven recommendations concerning safety management, training and equipment used by the Irish Coast Guard before Limerick coroner John McNamara at Kilmallock Court recently.
Experienced Doolin Coast Guard member, Caitríona Lucas was the first Coast Guard volunteer to lose her life following a search and rescue operation off Kilkee Bay on September 12, 2016.
Her husband, Bernard Lucas confirmed he is not happy with the official inquest verdict.
In his summing up for the jury, the coroner said unfortunately, I can’t give you the option of “unlawful killing”.
Mr Lucas believes the final verdict should have been “unlawful killing” and felt this option should have been available for the jury as submitted by his representative Mr Kingston.
Marine expert Michael Kingston, representing the Lucas family, had sought a verdict of unlawful killing.
However, Mr Simon Mills,senior counsel for the Department of Transport and Irish Coastguard, said the verdict of unlawful killing was not one open to a jury in a coroner’s court on the facts of this inquest.

It was argued that the point was not whether unlawful killing exists, but whether it was an appropriate verdict to return in the case of a boat overturned by a wave.
Ms Lucas (41), who worked as a librarian, died during a Coast Guard search mission near Kilkee in West Clare on September 12, 2016.
A native of Ballyvaughan in North Clare, the mother- of-two suffered fatal injuries during the mission and became the first Coast Guard volunteer to die while on active duty.
Ms Lucas was an advanced coxswain with the Doolin unit of the Coast Guard and had been with the service for a decade.
That day the Doolin team was assisting the Kilkee unit in the search for a young man who had gone missing in the area.

The inquest was told that the Kilkee unit was short of volunteers for sea operations that day and had asked assistance from the Doolin unit.
Ms Lucas – who had completed the Advanced Search and Rescue course – volunteered to help and went to sea with two other volunteers in a rigid inflatable boat (Rib) at 10.30am that day.
Around 1pm, the Rib carrying Coast Guard personnel Ms Lucas, James Lucey and Jenny Carway approached Lookout Bay near Kilkee.
The crew had not been made aware of the fact that Lookout Bay could witness “peculiar” waves – and that vessels should reverse into the inlet for safety reasons.
They were also unaware of any specific dangers posed by the waters involved, such as unexpected groundswell, with sea conditions much better than the previous day.
Ms Lucas was in a critical condition and she was airlifted to University Hospital Limerick (UHL) where she was later pronounced dead.
Mr Kingston raised several issues at the inquest, including that Kilkee boat logs were never provided to them; that the crew was not made aware of the unique wave threat posed in Lookout Bay; that Ms Lucas’ dry suit was filled with water; and that the safety helmets of both Mr Lucey, and Ms Lucas, and Ms Carway had ripped off during the incident.

Similarly, the inquest heard that one marine VHF radio was not working properly and that a seat on the Rib was not in commission.

Mr Kingston told the inquest he was “being gagged” when he was not allowed to raise a 2014 incident in Dingle involving a vessel capsizing, with coroner McNamara saying he had ruled that it was not relevant to the inquiry in hand.
As the week progressed, the importance of the Inch Report became abundantly apparent, as Mr Kingston persisted.

Following questioning from Mr Kingston of Mr Spephen Lynch who took drone footage with time stamps enabling a precise determination of when Mrs Lucas was rendered unconscious, in conjunction with Marine Rescue Sub Centre and Rescue 115 recording transcripts showing the initial mayday at 1311, the inquest heard Ms Lucas was conscious in the water for 17 minutes, until 13.28, after the Kilkee Delta RIB was hit by a wave and capsized in a shallow surf zone at Lookout Bay off Kilkee.
It emerged a second RIB owned by the Kilkee unit could have reached the area to effect a rescue of all three on board within 10 minutes.

However, after Kilkee deputy officer-in-charge Orla Hassett called for that D-class rib to be launched, two of her colleagues left the scene. She had to requisition a privately owned vessel which rescued one volunteer, Jenny Carway.

In a statement given to the inquest, Kilkee volunteer Lorraine Lynch, who had been at the station with Ms Hassett when a “Mayday” alert was relayed, said that she was “told” by Martony Vaughan as officer-in-charge (OIC) “to come with him in the jeep to the cliff walk”.
This rendered the available Coast Guard D-Class boat inoperable for any subsequent rescue.
In August 2014, a rib capsized in a very similar incident at Inch, County Kerry. One person almost lost their life but managed to survive and three was hopitalised.

The Irish Coast Guard conducted their own internal investigation, which recommended stringent training of identification of potential surf zones, and training in what to do in capsize in Surf, and the inquest established that they were never circulated to any volunteers.
No investigation was conducted by the Marine Casualty Investigation Board because this incident wasn’t officially reported, so these recommendations remained private within Irish Coastguard Managment.

“The Coast Guard never told volunteers there was an accident or a near miss in Kerry. It was a marine accident where one person nearly lost their life. All accidents by law have to be reported to the MCIB for investigation. This was either never done, which is illegal, or the Marine Casualty Investigation Board did not fulfil their mandate to investigate a serious casualty. In 2020 a European Court Judgment found that the MCIB was not operating independently from the State, and was house in the same office as the Department of Transport, and IRCG, totally at variance with independence and best practice in other countries.
” Critical Lessons would have been be learned from this incident that would have prevented the Kilkee tragedy,” said Bernard Lucas.

The Inquest established, that in 2012, a ‘Value for Money Fisher Report’ was completed and one of its recommendations was that a Safety Systems Manager at a very senior level should be established in the Coast Guard at senior level, which was again urged in the 2015 Inch Report, which didn’t happen until 2018. The 2012 Recommendation was directed to IRCG Management, the Transport Department and the Attorney General’s Office.
It emerged during the inquest the ICG identification logo was removed from Ms Luca’s drysuit by the IRCG before the drysuit and it was thrown in a skip.

It was also stated by HSA Inspector, Helen McCarthy that she was only allowed to take a photograph of this dry suit on a pallet and wasn’t allowed to take it into her possession to test it.
She also stated she had to delay her investigation by nine months while taking legal advice to confirm her jurisdiction that ICG volunteers are employees.
Responding to Clare Champion queries, a Department of Transport spokeswoman said Ms Lucas was a highly regarded and valued member of the Doolin Unit of the Irish Coast Guard who tragically lost her life in the course of duty.
The spokesperson extended their condolences to Ms Lucas’s family and friends on their enormous loss.

“Our priority at all times is the safety of our volunteers who save the lives of others. The Irish Coast Guard is committed to operating at the highest possible maritime safety standards so that we support and protect our volunteers as they work to serve communities all around Ireland.

“Following Ms Lucas’s death, both the HSA and the MCIB have conducted reviews into the incident and the Irish Coast Guard has worked to implement the recommendations stemming from both of these reports.
“The Irish Coast Guard fully accepts the findings and recommendations made by the coroner at last week’s inquest. Detailed consideration of how best to implement these recommendations is now underway,” she stated.