High Court: Parents fail in challenge to coroner verdict that newborn baby died from natural causes

High Court: Parents fail in challenge to coroner verdict that newborn baby died from natural causes

The High Court has dismissed a challenge by parents of a newborn baby who died shortly after his birth against a coroner’s verdict that the child died from natural causes. The parents identified a range of complaints, including that the decision was irrational, that insufficient time was provided to the jury for deliberation and that the coroner’s charge was in error.

Delivering judgment in the case, Ms Justice Marguerite Bolger held that there was ample evidence before the jury to reject the core proposition of the parents that there had been an inappropriate administration of oxytocin during the birth. Further, no evidence was put before the jury which supported the parents’ arguments.

The court also held that the parents provided an inconsistent account of the time afforded to the jury to reach a decision and that the coroner’s charge to the jury was adequate. Accordingly, the challenge was dismissed.


In July 2018, the applicants went to University Hospital Waterford for the birth of their baby. Unfortunately, complications arose during the birth and the baby was delivered by emergency caesarean section. He died four days later in Cork University Maternity Hospital. A jury inquest was held into the death which was heard by the coroner for Cork City in September 2020.

The parents were represented by solicitor and counsel at the inquest. The jury heard evidence from hospital staff and were cross-examined. The primary case put to each of the medical witnesses was that the hospital had administered oxytocin to the mother during labour and there was a failure to monitor hyperstimulation. The parents relied on cardiotocography (CGT) scans as evidence that oxytocin should have been discontinued after the frequency of contractions caused hyperstimulation and, ultimately, the death of the child.

Each of the witnesses rejected this proposition. The doctors gave evidence that a CGT printout was not sufficient to determine the appropriate course of action and that physical examination was required. A consultant obstetrician rejected that there had been improper monitoring of the uterine contractions.

It was also established in evidence that labour had fully commenced before oxytocin was administered, which was appropriate for the mother’s medical history. The doctors stated that hyperstimulation occurred where contraction happened more than five times every 15 minutes for a prolonged period. The use of oxytocin was an “inexact science” but the mother was on the minimum dosage.

After the evidence, counsel for the parents addressed the jury and the coroner gave the charge. In the charge, the coroner described the four verdicts available in the case, being 1) an open verdict, 2) a narrative verdict, 3) a determination of medical misadventure/accident and 4) a determination that the baby died from natural causes.

The jury returned a verdict on the same day at 4.35pm that the baby had died from natural causes. The parents were unhappy with this verdict and issued judicial review proceedings seeking to quash the decision.

The parents claimed that the evidence at the inquest did not support the verdict and the verdict was therefore irrational. It was also claimed that the coroner put pressure on the jury to reach a verdict that day because the courtroom was not available the next day. Finally, the parents claimed that the coroner’s charge to the jury was erroneous as it did not include directions that the parents’ claim was reasonably available and that a verdict by negligence, misconduct or malpractice was available.

High Court

Ms Justice Bolger began by considering the decision in Bingham v. Farrell [2010] IEHC 74 which stated that it was a high bar to overturn a decision on the grounds of irrationality. The court summarised the evidence from the medical practitioners and coroner (which had been placed on affidavit), noting that the parents’ solicitor claimed that his recollection of the charge and time afforded to the jury was materially different from that of the coroner.

In the issue of irrationality, the court held that the parents had put their proposition to the witnesses that oxytocin had been improperly administered. Each of the witnesses strongly disputed this proposition and no evidence was called by the parents in support of the proposition at the inquest. The applicants also did not seek to cross-examine the affidavit evidence placed before the court. The medical evidence was “consistently contrary to the propositions put forward by the applicants”, the court said.

As such, the court was satisfied that there was “ample evidence” before the jury to reject the parents’ proposition. Accordingly, there was also an evidential basis for returning a verdict of death by natural causes. In these circumstances, the applicants fell “well short” of the test for irrationality (State (Keegan & Lysaght) v. Stardust Victims Compensation Tribunal [1986] I.R. 642; O’Keeffe v. An Bord Pleanála [1993] 1 I.R. 39).

Dealing with the issue of insufficient time being allowed for the determination, the court noted that this issue was not grounded or supported in the parents’ affidavits. The coroner stated that he had never required the jury to deliver a verdict by any particular point and only mentioned that the building closed at 5pm. Further, it was arranged for the case to continue into the next day if necessary.

Subsequently, the father swore that he could not recall if it had been said in open court, but that either the coroner, registrar or attending garda told him that the inquest could not proceed the next day and would have to be adjourned if not completed on the day. The court held that this was an inconsistent and vague position adopted from the statement of grounds and the court preferred the evidence that no such statement had been made by the coroner.

The court noted that the allegation that the jury were pressured to return a verdict on the day was very serious and the evidence proffered by the applicants did not constitute the clear evidence required to ground the claim.

Finally, the court considered the coroner’s description of his charge to the jury and outlined that the applicants did not take any issue at the time with the summary of evidence. Further, no issue or challenge was made to the verdicts outlined by the coroner at the time. As such, the court was satisfied that an adequate direction had been given to the jury in the circumstances.


The court rejected each issue identified by the parents and, as such, the proceedings were dismissed. The court concluded by noting that a coroner was not automatically obliged to furnish their notes of an inquest and it was inappropriate for the applicants to suggest that the coroner had failed in their duty of candour by not furnishing them in the proceedings. Instead, the applicants should have sought the notes by way of discovery.

Cummins and Anor. v. The Coroner for Cork City [2022] IEHC 686

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