Coroners Act Response to the Coronial Findings in the matter of Ms Irene Magriplis dated 21 September 2017
Tabled paper 426
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2. My advice to him was that it would be inappropriate to press before the coroner the view that one or more of the nursing staff had failed to make a timely entry in the fluid chart, or that they had failed to ensure the chart was available for Dr Treacy to check when he attended Mrs Magriplis, or that they failed to draw his attention to something as important as the changing of the drain. 3. I pointed out that a coronia! inquest is not a civil claim, the coroner is not interested in allocating blame, and he is unimpressed when parties attempt to do so. 4 My advice was therefore that the significant fact for the coroner was that Dr Treacy believed there was only a small amount of bile in the drain, and that should be his evidence-inchief. If in cross-examination, the fi_uid chart became significant, then it would be appropriate to openly and comprehensively deal with the matters Dr Treacy had raised, but that would be preferable to doing so in chief as it would (or should) then not be seen as attempting to allocate bla1ne. S. Had Mr Treacy had his way, he would have raised the fluid chart in his evidence-in-chief with alacrity. It now appears that my advice had achieved exactly the opposite result to that which was intended, but Dr Treacy should not be blamed for that. I can absolutely assure you that Dr Treacy did not fail to speak of the fluid chart in his evidence-in-chief through a desire to conceal it and to avoid allegations that he may have erred. 6:. I also ask you to reflect upon Dr Treacy's answers in crossexamination. As soon as you mentioned the fluid chart he openly stated that it was a matter which had been causing him great concern. He did not hesitate to agree with His Honour's suggestion that this meant that either he or the nurses at DPH were at fault. He did not in any way downplay the significance of the entry and he did not attempt to enter into a debate about who was to blame, notwithstanding that his evidence was that he would have noticed it had it been available to him." 131. It is a most unusual course to provide such further evidence and submissions after the inquest, especially as Counsel for Mr Treacy was asked to deal with those very issues in the inquest. However given that my findings may have a significant impact on Mr Treacy I believed it appropriate to consider the letter and attached email.