Lawlor -v- Geraghty High Court Judgment was delivered on May 20th, 2010, by Mr Justice Nicholas Kearns,
Judgment
An inquest on a man who died while undergoing cosmetic surgery in Colombia should have been adjourned to allow an attempt to obtain the medical records from the hospital in Colombia. Mr Justice Kearns quashed the decision to adjourn the inquest and directed that a further one be held.
Background
The applicants in the case were the parents of Pierre Christian Lawlor, who died at the age of 34 while undergoing elective cosmetic surgery at a hospital in Bogota, Colombia.
He had travelled to Colombia with his Venezuelan-born wife, Andrea Galeano, whom he had met over the internet, married in December 2006 and with whom he had a son. They visited her parents in Colombia in August 2007, where he arranged to have the cosmetic surgery on his eyes, cheeks, nose and neck, along with liposuction. He died on September 3rd.
According to his wife, he had been told not the drink before the operation or take the steroid drug he was using for a condition on his hands, but she claimed he had ingested both alcohol and cocaine on the weekend before the surgery on Monday.
Towards the end of lengthy surgery, he suffered a number of heart attacks and died. His body was repatriated to Ireland and a postmortem conducted by the State Pathologist, Prof Marie Cassidy.
The respondent is the coroner for Co Dublin who conducted the inquest on Mr Lawlor. It was convened and concluded on July 1st, 2008. Prof Cassidy offered her opinion that Mr Lawlor appeared to have died following extensive plastic surgery.
She made the point that liposuction could be associated with heart failure if excessive amounts of fat were withdrawn from the body. She said there was no way of knowing how much had been removed from Mr Lawlor’s body without the operation notes. She said the notes could reveal his condition prior to and during the surgery and possibly a cause of sudden deterioration and death.
In their absence, she could not give an opinion as to whether this was a natural death or a medical incident leading to death.
The applicants, through their solicitor, sought an adjournment in order to obtain these notes, as they considered not all attempts to do so, including consular assistance, had been exhausted. Their application for an adjournment was refused and the coroner recorded the cause of death as heart failure and an open verdict, citing the absence of information.
Following the inquest, the applicants successfully sought the hospital records through diplomatic channels. They then sought a judicial review of the coroner’s decision to refuse an adjournment and of his verdict, claiming his failure to give an adequate opportunity to obtain the medical records meant he failed in his duty to inquire into their son’s death.
This failure deprived them of an opportunity of testing the evidence offered by their late son’s wife concerning his conduct before the operation.
They also claimed that it was open to the coroner to make a finding of wrongdoing or unlawfulness in relation to the death, without this amounting to consideration of criminal or civil liability.
The coroner said a very full inquiry was made on his behalf seeking to obtain the medical records, in that he asked Det Insp Eamon O’Reilly to take whatever steps he could to obtain them.
Interpol informed Det Insp O’Reilly that it was necessary to make a rogatory request which could only be made where criminal prosecutions were being contemplated, which was not the case here.
He therefore considered it was not necessary to grant an adjournment. He also said that the notes later obtained by the applicants were not in English and the medical personnel involved were not available for questioning.
He said that even if he had the notes, none of the information would have led to a different conclusion being reached as to cause of death and the verdict.
Decision
Mr Justice Kearns said that while a coroner at an inquest was not concerned with civil or criminal liability, inquiring into the “how” of a death required an investigation into by what means and in what circumstances the death occurred. In relation to the decision not to adjourn, the coroner’s discretion was not unfettered and was subject to fair procedures and to review by the courts, he said.
The coroner must respect the legitimate interests of an interested party such as a next of kin to pursue legitimate lines of inquiry provided they did not extend beyond the scope of an inquest.
Given that the hospital notes in this case were clearly relevant, there was no doubt but that the coroner was required to consider granting an adjournment to see if they could be obtained. Had he tried, he could have obtained the notes. Instead, he chose to rely on the evidence of Det Insp O’Reilly and refused to consider that there may have been an alternative route open to him or the next of kin.
Mr Justice Kearns said he was of the view that the coroner should have adjourned the proceedings when requested to do so. The hospital notes, which became available through consular channels, were accessible without any great difficulty. They had since been evaluated by a number of medical experts on behalf of the applicants and these views had been placed before the court. The respondent, however, elected not to engage with the contents of these reports, he said.
The decision not to adjourn was inappropriate and disproportionate. There was no overwhelming need to conclude the inquest forthwith. The respondent was aware of an assertion made by the wife that Mr Lawlor had ingested cocaine and alcohol in the period before the operation, which had caused great distress to his family.
“It is difficult to imagine a more obvious case than this one where a family in the particular circumstances would require clarification about the circumstances surrounding the death of the deceased,” Mr Justice Kearns added.
“Given that I am satisfied that the applicants had raised and did have legitimate concerns, they were, in my view, deprived of the opportunity of a meaningful participation in the inquest because of the dearth of information.”
He made an order quashing the coroner’s decisions to refuse an adjournment and to record an open verdict.
Given that the respondent did not engage with the views of the experts presented on behalf of the applicants, a mere assertion that the outcome of the inquest would have been no different did not provide a sufficient basis to adopt a different course, he said.
The full judgment is on www.courts.ie
Eoghan Fitzsimons SC and Siobhán Phelan BL, instructed by James McGuill Co, for the applicants; Stephen Byrne BL, instructed by the Chief State Solicitor, for the respondent.