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Caitriona Lucas Inquest: Jury Returns Verdict of Misadventure and Issues Seven Recommendations

1st December 2023
Members of Caitriona Lucas's family after a verdict of misadventure was issued by a jury on the death of the Irish Coast Guard Doolin unit volunteer. From left to right, Tom Deely, Ms Lucas's father, brother Padraig Deely, solicitor Ronan Connolly, daughter Emma Lucas, legal representative Michael Kingston, son Ben Lucas and husband Bernard Lucas
Members of Caitriona Lucas's family after a verdict of misadventure was issued by a jury on the death of the Irish Coast Guard Doolin unit volunteer. From left to right, Tom Deely, Ms Lucas's father, brother Padraig Deely, solicitor Ronan Connolly, daughter Emma Lucas, legal representative Michael Kingston, son Ben Lucas and husband Bernard Lucas.

A jury has returned a unanimous verdict of misadventure at the inquest into the circumstances surrounding the death of Irish Coast Guard advanced coxswain Caitriona Lucas off the Clare coast in September 2016.

The verdict was issued by a jury of four men and three women before Limerick coroner John McNamara at Kilmallock Court on Thursday evening.

Seven recommendations were also made by the jury in relation to safety management, training and equipment used by the Irish Coast Guard.

Ms Lucas (41), an experienced member of the Doolin Coast Guard and mother of two, died after the Kilkee Coast Guard Delta rigid inflatable boat (RIB) she was crewing on capsized during a search for a missing man on September 12th, 2016.

She was the first Irish Coast Guard volunteer to lose her life during a tasking.

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 the jury on the facts of the case".

Attending the four-day full hearing, which had been preceded by two preliminary hearings in April and June, were Ms Lucas’s husband, Bernard, son Ben and daughter Emma, father Tom Deely, and siblings Padraig and Bríd, along with long time friend and former Doolin Coast Guard member Davy Spillane.

In a statement afterwards on behalf of the Lucas family, her son Ben said that “the Irish Coast Guard’s failure to have proper safety systems caused my mother’s death”, and “the minister in charge of the transport department in 2012 should be held to account”.

He said there were “critical lessons to be learned”, and the jury had made recommendations that should have been made seven years ago “to protect life”.

Ben Lucas said criticised the delay in holding the inquest, and said that “the preservation and production of evidence has been appalling”.

“Irish Coast Guard management, the Attorney General’s office and the Department of Transport did not act on a critical report in 2012 that instructed them to put in place a senior safety systems manager in the Irish Coast Guard that never happened, and my mother went to help others but was let down so terribly,” Mr Lucas said.

The hearing heard 28 depositions, including evidence that a recommendation for a safety systems manager at the Irish Coast Guard in 2012 was not implemented till 2018.

It heard that “interpersonal issues”, which had been reported to Irish Coast Guard management the previous March (2016), had led to a loss of experienced volunteers at the Kilkee unit – which meant “flanking stations”, including Doolin which Ms Lucas was a member of, were asked to help out.

It heard Ms Lucas was conscious in the water for 17 minutes after the Kilkee Delta RIB was hit by a wave and capsized in a shallow surf zone at Lookout Bay off Kilkee, and that 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, she had to requisition a privately owned vessel which rescued one of the three, Kilkee volunteer Jenny Carway.

Kilkee Delta RIB coxswain James Lucey, was rescued some hours later by the Shannon Coast Guard helicopter, which also airlifted Ms Lucas on board earlier and flew her to Limerick University Hospital, where she was pronounced dead.

The inquest heard that the cause of Ms Lucas’s death was due to drowning, but a head injury which could have caused temporary loss of consciousness was a contributory factor.

Two State investigations have already taken place into Ms Lucas’s death, and three years ago the Director of Public Prosecutions (DPP) directed that no criminal charges would be brought arising from an HSA inquiry.

A separate MCIB report was critical of the Irish Coast Guard’s safety management system and outlined a number of systems and equipment failures in relation to the Kilkee unit.

Summing up for the jury at the inquest in Kilmallock, Limerick coroner John McNamara said it appeared there was a “brain drain” in relation to the Kilkee unit and some “confusion” about the command structure of the unit.

He said that Ms Hassett had put it “quite succinctly” that this was not relevant when three people were available to launch a second RIB to effect a rescue.

He recalled that evidence had been heard about previous recommendations, including those in an appendix to the Marine Casualty Investigation Board (MCIB) inquiry into Ms Lucas’s death relating to a previous incident in a surf zone off Inch, Co Kerry, in 2014.

He said that the Kilkee unit was not aware of those Inch recommendations, and he noted evidence from HSA inspector Helen McCarthy that there was no site-specific risk assessment of the area where the capsize occurred and no map of hazardous areas at the Kilkee station.

Mr McNamara recalled evidence being heard that the radar system on the RIB was not operational, one of its seats was not in commission, and the radio was not working.

He noted that British marine safety expert Nick Bailey had confirmed the equipment was suitable for use in Irish coastal areas, but there was an issue for the Irish Coast Guard with helmets coming off on impact.

Earlier, Mr Bailey said in evidence that the loss of helmets by all three Coast Guard crew after the Kilkee Delta RIB capsized “should raise concerns” with the Coast Guard in relation to their design and whether they were being worn correctly.

Mr Bailey confirmed that Ms Lucas’s drysuit – which the inquest heard earlier in the week to have been taking water when she was recovered - was not available for his inspection.

Mr Bailey told the inquest that he had examined Coast Guard safety equipment, including lifejackets, helmets and drysuits, at the Health and Safety Authority (HSA) on June 12th, 2017, nine months after the incident in which Ms Lucas lost her life.

The inquest had already heard that the HSA was unable to start its investigation until then, when it could establish it had a legal right to do so, and was only given access to one piece of Ms Lucas’s safety gear – as in her drysuit, which it was allowed to photograph only, and which was then disposed of in a skip.

Mr Bailey said that in his assessment, the drysuit and thermal clothing used by the Irish Coast Guard was “appropriate” for the type of work it was doing in Irish waters.

He said that while the type of lifejacket he had examined was a “reasonable compromise” between support and free movement, it would not necessarily keep an unconscious person upturned with a clear airway.

The inquest heard that this Mullion design of lifejackets has since been withdrawn by the Irish Coast Guard..

In his summing up, Mr McNamara said that “it is clear that if Ms Lucas’s helmet had remained on, it may have avoided the head injury that she sustained”.

Mr McNamara said it was “unfortunate” that her drysuit, which had filled with water, was not available for inspection by the HSA or its experts.

The coroner said that “we don’t know what the outcome would have been” if the Kilkee D-class RIB had been launched, but Mr Kingston had established from drone footage that there was a window of 17 minutes.

“Ms Hassett, an experienced volunteer, felt they could have attempted a successful rescue,” he said, and he paid tribute to her presence of mind and that of Garda sergeant John Moloney in requisitioning a civilian vessel which rescued Ms Carway.

“This occurred within an emergency situation, with a lot of pressure on everyone involved,” he said. He also commended those who had recorded the drone footage.

The jury of four men and three women issued seven recommendations related to safety, equipment, training and implementation of previous reviews.

Condolences were expressed to the Lucas family by the coroner, Gardai, legal representatives of both sides and the HSA.

The seven recommendations made by the jury at the Caitriona Lucas inquest are:

  • Each Coast Guard station should take appropriate steps to ensure Irish Coast Guard volunteers are aware of relevant exclusions for Coast Guard vessels and where possible display same clearly at the base station;
  • an immediate ongoing review of training of Coast Guard volunteers/staff should provide up-to-date training for capsize incidents;
  • an ongoing review should take place of the suitability of all safety gear, including helmets, to ensure safety in operational conditions;
  • there should be “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;
  • there should be 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.
Published in Coastguard Team

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The Irish Coast Guard

The Irish Coast Guard is Ireland's fourth 'Blue Light' service (along with An Garda Síochána, the Ambulance Service and the Fire Service). It provides a nationwide maritime emergency organisation as well as a variety of services to shipping and other government agencies.

The purpose of the Irish Coast Guard is to promote safety and security standards, and by doing so, prevent as far as possible, the loss of life at sea, and on inland waters, mountains and caves, and to provide effective emergency response services and to safeguard the quality of the marine environment.

The Irish Coast Guard has responsibility for Ireland's system of marine communications, surveillance and emergency management in Ireland's Exclusive Economic Zone (EEZ) and certain inland waterways.

It is responsible for the response to, and co-ordination of, maritime accidents which require search and rescue and counter-pollution and ship casualty operations. It also has responsibility for vessel traffic monitoring.

Operations in respect of maritime security, illegal drug trafficking, illegal migration and fisheries enforcement are co-ordinated by other bodies within the Irish Government.

On average, each year, the Irish Coast Guard is expected to:

  • handle 3,000 marine emergencies
  • assist 4,500 people and save about 200 lives
  • task Coast Guard helicopters on missions

The Coast Guard has been around in some form in Ireland since 1908.

Coast Guard helicopters

The Irish Coast Guard has contracted five medium-lift Sikorsky Search and Rescue helicopters deployed at bases in Dublin, Waterford, Shannon and Sligo.

The helicopters are designated wheels up from initial notification in 15 minutes during daylight hours and 45 minutes at night. One aircraft is fitted and its crew trained for under slung cargo operations up to 3000kgs and is available on short notice based at Waterford.

These aircraft respond to emergencies at sea, inland waterways, offshore islands and mountains of Ireland (32 counties).

They can also be used for assistance in flooding, major inland emergencies, intra-hospital transfers, pollution, and aerial surveillance during daylight hours, lifting and passenger operations and other operations as authorised by the Coast Guard within appropriate regulations.

Irish Coastguard FAQs

The Irish Coast Guard provides nationwide maritime emergency response, while also promoting safety and security standards. It aims to prevent the loss of life at sea, on inland waters, on mountains and in caves; and to safeguard the quality of the marine environment.

The main role of the Irish Coast Guard is to rescue people from danger at sea or on land, to organise immediate medical transport and to assist boats and ships within the country's jurisdiction. It has three marine rescue centres in Dublin, Malin Head, Co Donegal, and Valentia Island, Co Kerry. The Dublin National Maritime Operations centre provides marine search and rescue responses and coordinates the response to marine casualty incidents with the Irish exclusive economic zone (EEZ).

Yes, effectively, it is the fourth "blue light" service. The Marine Rescue Sub-Centre (MRSC) Valentia is the contact point for the coastal area between Ballycotton, Co Cork and Clifden, Co Galway. At the same time, the MRSC Malin Head covers the area between Clifden and Lough Foyle. Marine Rescue Co-ordination Centre (MRCC) Dublin covers Carlingford Lough, Co Louth to Ballycotton, Co Cork. Each MRCC/MRSC also broadcasts maritime safety information on VHF and MF radio, including navigational and gale warnings, shipping forecasts, local inshore forecasts, strong wind warnings and small craft warnings.

The Irish Coast Guard handles about 3,000 marine emergencies annually, and assists 4,500 people - saving an estimated 200 lives, according to the Department of Transport. In 2016, Irish Coast Guard helicopters completed 1,000 missions in a single year for the first time.

Yes, Irish Coast Guard helicopters evacuate medical patients from offshore islands to hospital on average about 100 times a year. In September 2017, the Department of Health announced that search and rescue pilots who work 24-hour duties would not be expected to perform any inter-hospital patient transfers. The Air Corps flies the Emergency Aeromedical Service, established in 2012 and using an AW139 twin-engine helicopter. Known by its call sign "Air Corps 112", it airlifted its 3,000th patient in autumn 2020.

The Irish Coast Guard works closely with the British Maritime and Coastguard Agency, which is responsible for the Northern Irish coast.

The Irish Coast Guard is a State-funded service, with both paid management personnel and volunteers, and is under the auspices of the Department of Transport, Tourism and Sport. It is allocated approximately 74 million euro annually in funding, some 85 per cent of which pays for a helicopter contract that costs 60 million euro annually. The overall funding figure is "variable", an Oireachtas committee was told in 2019. Other significant expenditure items include volunteer training exercises, equipment, maintenance, renewal, and information technology.

The Irish Coast Guard has four search and rescue helicopter bases at Dublin, Waterford, Shannon and Sligo, run on a contract worth 50 million euro annually with an additional 10 million euro in costs by CHC Ireland. It provides five medium-lift Sikorsky S-92 helicopters and trained crew. The 44 Irish Coast Guard coastal units with 1,000 volunteers are classed as onshore search units, with 23 of the 44 units having rigid inflatable boats (RIBs) and 17 units having cliff rescue capability. The Irish Coast Guard has 60 buildings in total around the coast, and units have search vehicles fitted with blue lights, all-terrain vehicles or quads, first aid equipment, generators and area lighting, search equipment, marine radios, pyrotechnics and appropriate personal protective equipment (PPE). The Royal National Lifeboat Institution (RNLI) and Community Rescue Boats Ireland also provide lifeboats and crews to assist in search and rescue. The Irish Coast Guard works closely with the Garda Siochána, National Ambulance Service, Naval Service and Air Corps, Civil Defence, while fishing vessels, ships and other craft at sea offer assistance in search operations.

The helicopters are designated as airborne from initial notification in 15 minutes during daylight hours, and 45 minutes at night. The aircraft respond to emergencies at sea, on inland waterways, offshore islands and mountains and cover the 32 counties. They can also assist in flooding, major inland emergencies, intra-hospital transfers, pollution, and can transport offshore firefighters and ambulance teams. The Irish Coast Guard volunteers units are expected to achieve a 90 per cent response time of departing from the station house in ten minutes from notification during daylight and 20 minutes at night. They are also expected to achieve a 90 per cent response time to the scene of the incident in less than 60 minutes from notification by day and 75 minutes at night, subject to geographical limitations.

Units are managed by an officer-in-charge (three stripes on the uniform) and a deputy officer in charge (two stripes). Each team is trained in search skills, first aid, setting up helicopter landing sites and a range of maritime skills, while certain units are also trained in cliff rescue.

Volunteers receive an allowance for time spent on exercises and call-outs. What is the difference between the Irish Coast Guard and the RNLI? The RNLI is a registered charity which has been saving lives at sea since 1824, and runs a 24/7 volunteer lifeboat service around the British and Irish coasts. It is a declared asset of the British Maritime and Coast Guard Agency and the Irish Coast Guard. Community Rescue Boats Ireland is a community rescue network of volunteers under the auspices of Water Safety Ireland.

No, it does not charge for rescue and nor do the RNLI or Community Rescue Boats Ireland.

The marine rescue centres maintain 19 VHF voice and DSC radio sites around the Irish coastline and a digital paging system. There are two VHF repeater test sites, four MF radio sites and two NAVTEX transmitter sites. Does Ireland have a national search and rescue plan? The first national search and rescue plan was published in July, 2019. It establishes the national framework for the overall development, deployment and improvement of search and rescue services within the Irish Search and Rescue Region and to meet domestic and international commitments. The purpose of the national search and rescue plan is to promote a planned and nationally coordinated search and rescue response to persons in distress at sea, in the air or on land.

Yes, the Irish Coast Guard is responsible for responding to spills of oil and other hazardous substances with the Irish pollution responsibility zone, along with providing an effective response to marine casualties and monitoring or intervening in marine salvage operations. It provides and maintains a 24-hour marine pollution notification at the three marine rescue centres. It coordinates exercises and tests of national and local pollution response plans.

The first Irish Coast Guard volunteer to die on duty was Caitriona Lucas, a highly trained member of the Doolin Coast Guard unit, while assisting in a search for a missing man by the Kilkee unit in September 2016. Six months later, four Irish Coast Guard helicopter crew – Dara Fitzpatrick, Mark Duffy, Paul Ormsby and Ciarán Smith -died when their Sikorsky S-92 struck Blackrock island off the Mayo coast on March 14, 2017. The Dublin-based Rescue 116 crew were providing "top cover" or communications for a medical emergency off the west coast and had been approaching Blacksod to refuel. Up until the five fatalities, the Irish Coast Guard recorded that more than a million "man hours" had been spent on more than 30,000 rescue missions since 1991.

Several investigations were initiated into each incident. The Marine Casualty Investigation Board was critical of the Irish Coast Guard in its final report into the death of Caitriona Lucas, while a separate Health and Safety Authority investigation has been completed, but not published. The Air Accident Investigation Unit final report into the Rescue 116 helicopter crash has not yet been published.

The Irish Coast Guard in its present form dates back to 1991, when the Irish Marine Emergency Service was formed after a campaign initiated by Dr Joan McGinley to improve air/sea rescue services on the west Irish coast. Before Irish independence, the British Admiralty was responsible for a Coast Guard (formerly the Water Guard or Preventative Boat Service) dating back to 1809. The West Coast Search and Rescue Action Committee was initiated with a public meeting in Killybegs, Co Donegal, in 1988 and the group was so effective that a Government report was commissioned, which recommended setting up a new division of the Department of the Marine to run the Marine Rescue Co-Ordination Centre (MRCC), then based at Shannon, along with the existing coast radio service, and coast and cliff rescue. A medium-range helicopter base was established at Shannon within two years. Initially, the base was served by the Air Corps.

The first director of what was then IMES was Capt Liam Kirwan, who had spent 20 years at sea and latterly worked with the Marine Survey Office. Capt Kirwan transformed a poorly funded voluntary coast and cliff rescue service into a trained network of cliff and sea rescue units – largely voluntary, but with paid management. The MRCC was relocated from Shannon to an IMES headquarters at the then Department of the Marine (now Department of Transport) in Leeson Lane, Dublin. The coast radio stations at Valentia, Co Kerry, and Malin Head, Co Donegal, became marine rescue-sub-centres.

The current director is Chris Reynolds, who has been in place since August 2007 and was formerly with the Naval Service. He has been seconded to the head of mission with the EUCAP Somalia - which has a mandate to enhance Somalia's maritime civilian law enforcement capacity – since January 2019.

  • Achill, Co. Mayo
  • Ardmore, Co. Waterford
  • Arklow, Co. Wicklow
  • Ballybunion, Co. Kerry
  • Ballycotton, Co. Cork
  • Ballyglass, Co. Mayo
  • Bonmahon, Co. Waterford
  • Bunbeg, Co. Donegal
  • Carnsore, Co. Wexford
  • Castlefreake, Co. Cork
  • Castletownbere, Co. Cork
  • Cleggan, Co. Galway
  • Clogherhead, Co. Louth
  • Costelloe Bay, Co. Galway
  • Courtown, Co. Wexford
  • Crosshaven, Co. Cork
  • Curracloe, Co. Wexford
  • Dingle, Co. Kerry
  • Doolin, Co. Clare
  • Drogheda, Co. Louth
  • Dun Laoghaire, Co. Dublin
  • Dunmore East, Co. Waterford
  • Fethard, Co. Wexford
  • Glandore, Co. Cork
  • Glenderry, Co. Kerry
  • Goleen, Co. Cork
  • Greencastle, Co. Donegal
  • Greenore, Co. Louth
  • Greystones, Co. Wicklow
  • Guileen, Co. Cork
  • Howth, Co. Dublin
  • Kilkee, Co. Clare
  • Killala, Co. Mayo
  • Killybegs, Co. Donegal
  • Kilmore Quay, Co. Wexford
  • Knightstown, Co. Kerry
  • Mulroy, Co. Donegal
  • North Aran, Co. Galway
  • Old Head Of Kinsale, Co. Cork
  • Oysterhaven, Co. Cork
  • Rosslare, Co. Wexford
  • Seven Heads, Co. Cork
  • Skerries, Co. Dublin Summercove, Co. Cork
  • Toe Head, Co. Cork
  • Tory Island, Co. Donegal
  • Tramore, Co. Waterford
  • Waterville, Co. Kerry
  • Westport, Co. Mayo
  • Wicklow
  • Youghal, Co. Cork

Sources: Department of Transport © Afloat 2020