Butterly v Cullinane & Ors (Approved)

Factual and Procedural Background

On 14 February 1981, a fire occurred at a nightclub during a "St. Valentines night disco" event in The City, resulting in 48 deaths and 128 serious injuries. The victims were predominantly young adults from neighbouring areas. The Applicant, a retired businessman who was previously managing director of Company A (the venue including the nightclub), sought judicial review concerning the scope of inquests into the deaths. The inquests were conducted by the Coroner for the district, who had issued a ruling on the scope and possible verdicts for the inquests. The families of the deceased and several public bodies were involved as notice parties.

Following the tragedy, a Tribunal of Inquiry (the Keane Tribunal) was established to investigate the causes and circumstances of the fire, resulting in a detailed report with findings and recommendations on fire safety and building regulations. The Tribunal concluded the fire was probably started deliberately in a specific location within the building. Subsequent inquests recorded verdicts consistent with medical evidence. Later reviews questioned the original Tribunal's conclusion on the cause of the fire but did not find new evidence warranting a fresh inquiry.

In 2019, an application was made to the Attorney General to direct new inquests, which was granted, acknowledging insufficient inquiry into the cause of the fire at the original inquests. The Coroner conducted preliminary hearings to set the scope and procedural matters for the new inquests, involving the Applicant, families, and other parties. The Applicant sought a ruling to exclude the possibility of a verdict of unlawful killing, which the Coroner refused in a ruling dated 16 February 2022.

The Applicant then sought judicial review challenging the lawfulness of the Coroner's refusal to exclude a verdict of unlawful killing, arguing such a verdict is not permissible under the Coroners Acts. The Court granted leave for judicial review and this judgment addresses that issue.

Legal Issues Presented

1. Whether a verdict of unlawful killing is permissible under the Coroners Acts in the context of an inquest.
2. Whether the Coroner erred in refusing to exclude the possibility of a verdict of unlawful killing at the Stardust fire inquests.
3. Whether a verdict of unlawful killing necessarily involves consideration of civil or criminal liability contrary to statutory prohibitions.

Arguments of the Parties

Applicant's Arguments

• The Coroners Acts prohibit consideration of civil or criminal liability at inquests, and a verdict of unlawful killing would require such prohibited consideration.
• A verdict of unlawful killing amounts to a "censure" prohibited by section 31 of the Coroners Acts.
• Such a verdict is not permissible regardless of the evidence presented during the inquest.
• Past instances of unlawful killing verdicts do not establish their lawfulness, especially as no objections were raised then.
• The Coroner should rule out unlawful killing verdicts before the inquest commences.

Respondents' and Notice Parties' Arguments

• The Coroners Acts do permit a verdict of unlawful killing, provided no person is identified or identifiable.
• Unlawful killing verdicts have been returned in past inquests, including those related to the Dublin and Monaghan bombings.
• The application to exclude such a verdict is premature as no evidence had yet been heard.
• The Coroner can give appropriate directions to the jury regarding verdicts after hearing evidence and submissions.

Table of Precedents Cited

Precedent	Rule or Principle Cited For	Application by the Court
R. v. South London Coroner, ex parte Thompson [1982]	Inquests are inquisitorial fact-finding exercises, not trials; no parties or adjudication of guilt.	Confirmed the inquisitorial nature and limited scope of inquests, emphasizing fact-finding without apportioning guilt.
Eastern Health Board v. Farrell [2001] 4 I.R. 627	Prohibition on considering civil/criminal liability should not unduly inhibit inquiry; inquests may investigate surrounding circumstances.	Supported broad fact-finding scope of inquests while maintaining prohibition on liability adjudication; allowed findings relevant to liability without determining it.
Greene v. McLoughlin	Inquest verdicts are not limited strictly to medical cause of death; may include circumstances without adjudicating intent or liability.	Rejected narrow construction of Coroners Acts; allowed broader findings consistent with statutory purpose.
R -v- H. M. Coroner for North Humberside and Scunthorpe, Ex Parte Jamieson (1995) Q.B. 1	Coroner and jury may explore facts relevant to liability but verdict must be factual, neutral, and avoid naming persons or attributing liability.	Applied principles that verdicts must state facts without judgment or opinion, consistent with statutory prohibitions.
Ramseyer v. Mahon [2006] 1 I.R. 216	Inquests concern how, when, and where death occurred; fair procedures are required but within statutory confines; no verdict may censure or exonerate persons.	Reaffirmed wide coroner jurisdiction for fact-finding; distinguished inquiry from liability adjudication.
Lawlor v. Geraghty [2011] 4 I.R. 486	Coroner's jurisdiction to inquire into circumstances is wide; prohibition on liability does not restrict investigation scope except to prevent pronouncement on liability.	Confirmed broad investigatory powers of coroner; emphasized limits on findings blaming or exonerating individuals.
R. v. West London Coroner, Eng. Gray [1988] QB 467	Jury directions on unlawful killing verdict require attributing culpability to a single officer without naming; specific to English law.	Distinguished by the Court as incompatible with Irish Coroners Acts; not applicable to current case.

Court's Reasoning and Analysis

The Court began by affirming the inquisitorial and fact-finding nature of inquests, distinct from adversarial civil or criminal proceedings. It emphasized that sections 30 and 31 of the Coroners Acts prohibit consideration or investigation of civil or criminal liability and the inclusion of censure or exoneration in verdicts, but these restrictions do not unduly limit the inquest’s fact-finding function.

The Court examined statutory provisions, particularly section 18A, which allows a coroner to establish the circumstances of death, including how, when, and where it occurred. It noted that while a verdict of unlawful killing is not explicitly provided for in the Coroners Acts, it is permissible if it does not identify or imply identification of any person, thus avoiding prohibited considerations of liability or censure.

The Court considered relevant case law, including decisions from Irish and English jurisdictions, and concluded that unlawful killing verdicts are consistent with the statutory framework only when they are factual findings not attributing responsibility to any individual or entity.

The Court rejected the Applicant's submission that unlawful killing verdicts are entirely impermissible, finding instead that the key limitation is that no person may be identified or implicated. The Court distinguished English authority relied upon by the Applicant as incompatible with Irish law.

The Court also observed that the more detailed the evidence regarding the circumstances of the death and potential culpability, the more difficult it may be to sustain an unlawful killing verdict without identifying persons, but the determination of permissible verdicts lies within the Coroner's discretion after hearing evidence and submissions.

Accordingly, the Court found the Coroner’s refusal to exclude the unlawful killing verdict at this stage to be correct in law.

Holding and Implications

The Court REFUSED THE RELIEFS SOUGHT by the Applicant, upholding the Coroner's ruling that a verdict of unlawful killing is permissible under the Coroners Acts provided no person is identified or identifiable in the verdict.

This decision confirms the legal position that inquests may return a verdict of unlawful killing as a factual finding without attributing civil or criminal liability, preserving the inquisitorial nature of inquests and statutory restrictions on liability and censure. The ruling leaves the determination of permissible verdicts to the Coroner after evidence is heard, maintaining procedural fairness and statutory compliance. No new precedent was established beyond affirming existing statutory interpretation and case law.