Relatives of Sally Maaz given garda escort after members of Burke family disrupt inquest

Sally Maaz (17) of Carrowreagh, Ballyhaunis, Co Mayo, died in Mayo University Hospital (MUH) on April 24, 2020, after contracting Covid-19.

For a third time, three members of the Burke family were removed by gardaí after heckling the coroner, the legal teams and the gardaí.

Martina Burke, her daughter Jemima and her son Josiah from Castlebar, Co Mayo, shouted accusatory statements about the integrity of the inquest after the Coroner for Mayo, Pat O'Connor, returned a verdict of death from natural causes.

Martina Burke also shouted at Sally Maaz's distressed father, Abdullah, as she was being removed from the hearing by gardaí.

Following two days of evidence and lengthy submissions by legal counsel for both the hospital and the Maaz family, Mr O'Connor came to a verdict of death from natural causes.

Mr O'Connor further recommended the Government establish an expert group to review the State's response to the Covid-19 pandemic in Ireland.

The coroner also set out a series of recommendations relating to protocols in MUH.

In his closing submission, Conor Bourke SC outlined Sally Maaz's complex medical history.

Sally was born with a congenital heart defect and underwent major life-saving surgery shortly after her birth.

Mr Bourke said Sally's condition had begun to deteriorate six months before her death and called for a verdict of death from natural causes.

"It is further respectfully submitted that there is no basis for a finding of death by misadventure," he said.

In his submission, on behalf of the Maaz family, solicitor Johann Verbruggen of Callan Tansey Solicitors said the appropriate verdict was medical misadventure.

Mr Verbruggen said a verdict of death from natural causes would "fail to account for the considerable and important evidence of the circumstances and the risks that arose in Sally's care, exposing her to the virus that killed her".

Mr Verbruggen was singled out for praise by the coroner for his "learned" and "erudite" submissions on behalf of the Maaz family.

Mr O'Connor described the volume and quality of work carried out by both legal teams as the most impressive he has encountered in his 33 years as a coroner.

Recording a verdict of death from natural causes, Mr O'Connor further outlined a series of recommendations.

These included that the Government establish an expert group to review the State's response to the pandemic "to learn lessons therefrom and ensure that the State is adequately and properly prepared for any further pandemic".

He called on the HSE, MUH and the Saolta Group to take "careful note and learn such lessons as are appropriate from the evidence adduced at this inquest".

The coroner further recommended MUH, Saolta and the HSE "put in place, if not already done, a clear line of responsibility for the care of patients by all clinical staff".

Finally, Mr O'Connor called for MUH to review and, if necessary, update its protocols for liaising and communicating with patients' families.

Addressing Sally's family, the coroner said he kept them at the forefront of his mind at all times when coming to his decision.

"In relation to Covid, it is regretfully still with us. It is the greatest single pandemic the world has ever seen. Around 6,500 people to date in this country (have died)."

Mr O'Connor said with the vaccines now available, two years on from the beginning of the pandemic, the impact of Covid is less severe.

"Regretfully Sally (fell ill) at the beginning" when science had not caught up with the disease.

He said most people who died from Covid were aged over 75, others like Sally with health conditions sadly succumbed to "that dreadful illness".

Mr O'Connor said Covid is a community-based illness.It was not possible to establish where and when Sally contracted the "insidious" virus, which is a "blight on society".

Following the verdict, Mr Verbruggen said Sally's family had found the inquest painful but helpful.

"This inquest allowed the family to ask questions that had kept them awake at night for two years. In that sense, it has helped with the grieving process and with getting closure.

"However, they heard evidence that was distressing, of a breakdown in communication, of unclear lines of responsibility and of protocols not being followed.

"It was upsetting for Abdullah and Roula to hear this, as it would be for any parent.

"These problems are not specific to Covid-19; they relate to patient health and safety generally at Mayo University Hospital.

"We are pleased that the Coroner has made recommendations to address these problems, and we ask that they are implemented."