Eastern Health Board v Farrell

• Jurisdiction: Ireland
• Judge: Keane C.J.,Mr. Justice Hardiman
• Judgment Date: 27 November 2001
• Neutral Citation: [2001] IESC 96
• Court: Supreme Court
• Docket Number: [S.C. No. 9 and No. 55 of
• Date: 27 November 2001

EASTERN HEALTH BOARD v. FARRELL (CORONER FOR CITY OF DUBLIN)

BETWEEN

THE EASTERN HEALTH BOARD

APPLICANT/RESPONDENT

AND

BRIAN FARRELL CORONER FOR THE CITY OFDUBLIN

RESPONDENT/APPELLANT

AND

BY ORDER VERA DUFFY AND KEVIN DUFFY

NOTICE PARTIES

[2001] IESC 96

Keane C.J.

Murphy J.

Murray J.

McGuinness J.

Hardiman J.

9 & 55/00

THE SUPREME COURT

Synopsis:

CORONERS

Inquest

Powers and duties of coroner - Power to call witnesses - Ascertaining cause of death - Death certificate - Pneumonia - Cerebral palsy - Vaccination - Delay - Whether coroner empowered to commission independent report - Whether coroner trespassing into the area of civil liability - Whether coroner acted ultra vires in commissioning independent report - Coroner's Act, 1962 section 30 (9 & 55/2000 - Supreme Court - 27/11/01)

Eastern Health Board v Farrell - [2001] 4 IR 627

Facts: The respondent, in the course of an inquest, sought to commission an independent report into a possible link between the death of a deceased and the pertussis (the three-in-one) vaccination. It was common case that the cause of the death of the deceased was aspirational pneumonia. The coroner originally proposed that this had been brought about by the deceased's cerebral palsy. However the family of the deceased claimed that the pertussis vaccination had in fact brought about this condition. The Eastern Health Board brought judicial review proceedings to prohibit the coroner from proceeding with an independent investigation of a possible link. In the High Court Mr. Justice Geoghegan granted the relief sought and held that the proposed course of action by the coroner was outside his official remit. The coroner appealed against the judgment.

Held by the Supreme Court (Keane C.J. and Hardiman J. delivering judgments; Murphy J., Murray J. and McGuinness J. agreeing with Keane C.J.) in dismissing the appeal. The Chief Justice held that it was clear that an inquest may properly investigate and consider the surrounding circumstances of a death, whether or not the facts explored might, in another forum, ultimately be relevant to issues of civil or criminal liability. The prohibition on any adjudication as to criminal or civil liability should not be construed in a manner which would unduly inhibit an inquiry. To suggest that the verdict of a coroner or a jury must be confined to the medical cause of death rested upon an unduly narrow construction of the 1962 Act and, in particular, s.30 thereof. Under the 1962 Act the coroner was not required to hold an inquest in this case unless the death occurred in an "unnatural manner". If a coroner's inquest were to extend its inquiries beyond the circumstances, including the proximate medical cause of the death, in which the death occurred, it would become an inquiry of a radically different nature and one which was not envisaged by the Oireachtas in enacting the 1962 Act. A coroner was obliged under law to conduct an expeditious and economical inquiry into four limited but significant issues: the identity of the deceased and where, when and how his death occurred. The appeal would be dismissed and the order of the High Court affirmed. In his judgment Mr. Justice Hardiman stated that a coroner in an inquest must establish the identity of the deceased and how, when and where the death occurred. A coroner could not consider any question of civil or criminal liability and could not censure any person. Coroners could make recommendations of a general character designed to prevent further fatalities. The issue of whether the death was caused wholly or in part by the administration of the pertussis vaccine was within the possible scope of the 1962 Act. However by virtue of section 26 of the 1962 Act there was no mandate to call more than two medical practitioners to give evidence, which number had already been exceeded. The coroner was therefore restricted from carrying out the proposed inquiry. Section 26 was a serious obstacle to the proper discharge of the statutory duty of a coroner in the more complex type of an inquest. The appeal would be dismissed.

Citations:

CORONERS ACT 1962 S30

EASTERN HEALTH BOARD V FARRELL 2000 1 ILRM 446

RSC O.84 r21(1)

GREENE V MCLOUGHLIN UNREP SUPREME 25.1.95 1995/2/798

CORONERS ACT 1962 S26

UK DEPARTMENTAL COMMITTEE REPORT ON CORONERS 1936 CMND 5070

R V NORTH HUMBERSIDE CORONER EX-PARTE JAMIESON 1995 QB 1

FARRELL V AG 1998 1 IR 203

CORONERS ACT 1962 S30(1)

R V SOUTH LONDON CORONER EX-PARTE THOMPSON 1982 126 SJ 625

CORONERS ACT 1962 S31

CORONERS ACT 1962 S31(2)

CORONERS ACT 1962 S39

CORONERS ACT 1962 S40(1)

CORONERS ACT 1962 S40(1)(E)

CORONERS ACT 1962 S17

CORONERS ACT 1962 S18

CORONERS ACT 1962 S18(1)

CORONERS ACT 1962 S26(2)

CORONERS ACT 1962 S25(2)

CORONERS ACT 1962 S57

CORONERS ACT 1962 S58

CORONERS ACT 1962 (FEES AND EXPENSES) REGS 1996 SI 151/1996

HALLSBURY 3ED VOL VIII

BLACKSTONE 6ED VOL I 347

BRODERICK COMMITTEE ON DEATH CERTIFICATES & CORONERS INQUESTS CMND 4810

CORONERS ACT 1962 S18(4)

CORONERS ACT 1962 S40

CORONERS ACT 1962 S26(1)

CORONERS (IRL) ACT 1829 S3

AN ACT TO PROVIDE FOR THE ATTENDANCE AND REMUNERATION OF MEDICAL WITNESSES AT CORONERS INQUESTS 6 & 7 WM IV CHAPTER LXXXIX (89) SII

1 27th day of November, 2001 by Keane C.J.

Keane C.J.

Introduction.

2 These proceedings arise out of an inquest held by the respondent/appellant (hereafter "the coroner") into the death of Alan Duffy on the 31st December 1995. The inquest was opened on the 4th December 1997 and was subsequently adjourned from time to time. On the last day on which itsat, the 29th March, 1999, it was adjourned until the 19th April 1999. On the 12th April 1999, however, the applicant/respondent (hereafter "the board") were given leave by the High Court (McCracken J) to apply for a number of reliefs including

3 2 "1. A declaration that the conduct of the inquest into the death of Alan Duffy (deceased 31/12/1995) by the respondent insofar as it purports to examine or determine the issue of whether his death was caused wholly or in part by the administering of the 3-in-1 pertussis vaccine in 1973 is ultra vires the Coroners Act 1962.

4 2. A declaration that it is ultra vires the said Act of 1962 to adjourn the said hearing for a period of sixteen months in order to conduct a medical investigation into the linkage between the pertussis vaccine and encephalopathy."

5 It was also ordered that the notice parties, who are the parents of Alan Duffy, should be joined in the proceedings.

6 A statement of opposition having been filed on behalf of the coroner, the substantive hearing came on before Geoghegan J. In a reserved judgment delivered on the 14th December 1999 (now reported at [2001] 1 ILRM 446), he held that the hearing of the inquest was conducted by the coroner ultra vires theprovisions of the Coroners Act 1962(hereafter "the 1962 Act") granted the first declaration sought. From that decision, the coroner has now appealed to thiscourt.

7 The evidence as to the circumstances giving rise to the inquest and the manner in which it was conducted by the coroner are described in affidavits sworn by the solicitor for the board and the coroner. While the account given by the solicitor is, in broad terms, accepted by the coroner, he takes issue with that account in some respects and, no further affidavits having been filed in the High Court, the appeal proceeded on the assumption that the coroners version of events, to the extent that it differed from that given by the solicitor, was not now indispute.

8 Alan Duffy (hereafter "the deceased") was born on the 11th May 1973 at Mount Carmel Hospital, Dublin: he was, accordingly, aged 22 when he died. It is not in dispute that he was given what is generally known as "the 3-in-1" vaccine which incorporates a vaccine against pertussis ("whooping cough") on the 17th October 1973, the 12th December 1973 and the 5th February 1974 and that, on being subsequently admitted to Our Lady's Hospital for Sick Children Crumlin, on the 17th July 1974, when he was aged 14 months, he wasdiagnosed by Professor Neil O'Donoghue, the paediatrician, as suffering from a degree of mental handicap.

9 The deceased was admitted to the Mater Hospital on the 21 st December 1995, where he was diagnosed to be suffering from pneumonia. He was then moved to intensive care and died ten days later. Dr. Padraig MacMathuna, a consultant physician and gastroenterologist at the hospital, was of the view that his death was caused by "aspiration pneumonia due to cerebral palsy" and proposed to complete the death certificate in those terms. The notice parties objected to his doing so, on the ground that the cause of death was aspiration pneumonia due to mental handicap caused by an encephalopathic reaction to the pertussis vaccination.

10 It was in those circumstances that the coroner proceeded to hold the inquest. Before doing so, however, he wrote to the board asking then to arrange for an official to attend the inquest and furnish it with evidence as to the immunisation/medical notes and records relating to the deceased.

11 When the inquest began, Dr. MacMathuna gave evidence that he was unwilling to attribute the death of the deceased to the immunisation that he had received as a baby and that "aspiration pneumonia" was the cause of death. Hesaid that, as the deceased was suffering from "severe mental handicap" he was at a much higher risk of aspirational pneumonia and other infections. He agreed with the coroner that the medical description of the deceased's cause of death was

"Bilateral staphylococcal pneumonia with associated septicaemia due to aspiration."

12 Dr. MacMathuna also said that the term "cerebral palsy" is an umbrella term used to describe mental retardation of the type suffered by the deceased and that this neurological condition would have been an exacerbating factor in his death.

13 The first named notice party, the mother of...