A VERDICT OF misadventure has been returned at the inquest into the death of Irish Coast Guard advanced coxswain Caitriona Lucas in an incident off the Clare coast in September 2016.

The unanimous verdict was issued by a jury of four men and three women before Limerick coroner John McNamara at Kilmallock Court. The jury also issued seven recommendations in relation to safety management, training and equipment used by the Irish Coast Guard.

Ms Lucas (41), an experienced member of 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 hearing were Ms Lucas’s husband Bernard, son Ben and daughter Emma. Her father Tom Deely and siblings Padraig and Bríd were also in attendance, alongside Lucas’s 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 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, 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 on Thursday, 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”.

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.

Summing up for the jury, 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 Health and Safety Authority (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.

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, gardaí, legal representatives of both sides and the HSA.

The jury at the Caitriona Lucas inquest made seven recommendations. Firstly, that 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, as well as a review of suitability of all safety gear, including helmets, to ensure safety in operational conditions.

The jury recommended that there be “urgent” implementation and 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. Additionally, an appropriate and confidential centralised safety management portal should be established for identified risk issues.

The Irish Coast Guard should consider ongoing training for the officer-in-charge (OIC) and deputy OIC “as appropriate” at units, the jury recommended.

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.

A separate MCIB report, published two years after the incident, was critical of the Irish Coast Guard’s safety management system and  outlines a number of systems and equipment failures in relation to the Kilkee unit.