A coroner's verdict into the death of a 25-year-old Galway man who fell to his death at the Cliffs of Moher has been stalled.
This follows Clare County Coroner, Isobel O’Dea stating at the inquest into the death of Jamie Costello that she would seek direction from the High Court as to whether she can take into account the contents of a HSE commissioned external report into the case before she delivers her verdict.
At the two-day inquest in Kilrush last week, lawyer for the Costello family, Damien Tansey SC stated that a “catastrophic system failure” occurred at a Galway mental health unit which allowed "high risk" Mr Costello to leave unaccompanied on two consecutive days "with devastating consequences for his family".
Mr Tansey said everyone at the unit treating Mr Costello knew he was there because he had attempted suicide on two occasions earlier in 2019 and knew he was high risk.
On October 1st, 2019, Mr Costello jumped off the Cliffs of Moher hours after leaving the Mental Health Unit at University Hospital Galway where he was a voluntary patient.
Ms O'Dea said that it is "accepted" that a catastrophic system failure took place.
In a deposition, an eyewitness at the Cliffs of Moher said they thought Mr Costello was taking part in a video before realising that he had jumped to his death.
On October 1st, 2019 Mr Costello left the unit at 12.30pm, however, it was only discovered that he was missing at 4.25pm that evening when his mother, Denise, called to take her son out for a number of hours on accompanied time away from the unit.
Jamie’s father, Galway GP, Dr Alan Costello of Ballinduff, Cornadulla contacted Gardaí, believing that his son was en route to the Cliffs of Moher.
Gardaí told Dr Costello a man was seen jumping off the Cliffs of Moher earlier at 3.45pm.
Haunted
Mr Tansey said Mr Costello's parents “are haunted and disturbed” that there appears to be "a plan to deny" by the nurses on duty who all deny, on both days, that they received a call from security at the unit to allow Mr Costello to leave unaccompanied.
Mr Tansey said: "All of the nurses on duty deny taking the call from security on September 30th and all of them deny taking the call from security on October 1st when this horrific tragedy takes place."
Mr Tansey continued: "On its face, when the same event takes place on two consecutive days, where you have exactly the same report and all nurses deny taking the call, it is haunting and disturbing to my clients and it looks like a plan to deny."
He added: "It looks like a design between people to deny - that is what it looks like."
However, counsel for the State Claims Agency (SCA) and HSE, Luán Ó Braonáin SC, said "the conclusion Mr Tansey has reached in his submission is one that cannot be reasonably inferred from the evidence".
In her response, Ms O'Dea stated: "It is beyond the realm of this forum to try to establish if indeed there ever was a design or plan. I have no reason to suspect there has been and I am not going there."
Ms O'Dea told Mr Tansey: "I am not holding with you on that - I am taking each nurse at what they say."
In the High Court last December, the HSE issued an apology to the Costello family for the standard of care provided to their son as part of a High Court approved settlement.
On behalf of his client, Mr Ó Braonáin repeated the contents of the apology to the Costellos at the first day of the inquest.
Ms O'Dea made the decision to adjourn the inquest to allow her to refer the issue of the HSE commissioned report's status to the High Court despite Mr Tansey contending that going to the High Court on the issue “is like taking a sledge-hammer to a nut”.
“It is unnecessary,” he said.
Amongst other items, the report, which is currently in its draft stages, examines how Mr Costello was able to leave the unit unaccompanied.
Mr Ó Braonáin said the external report is not evidence that is admissible as far as the inquest should be concerned.
"The evidence has been heard," he claimed.
