THE FAILURE TO adequately document the recovery of bodies in the wake of the Stardust fire means it is not possible to perform “any meaningful analysis” of the likely effects of the fire on those who perished in the blaze, an expert witness has told an inquest.
Dr Richard Shepherd also told the jury today that his review of photographs taken in the aftermath of the disaster during postmortem examinations confirmed that the mortuary facility was “overwhelmed” and for a time “completely inadequate”, with victims having been placed on the floor beneath some of the mortuary tables.
The witness, a retired consultant forensic pathologist with more than 35 years’ experience who was engaged by Coroner Dr Myra Cullinane to review all of the original postmortem reports and materials from 1981, also told the jury at Dublin District Coroner’s Court today that any exit doors which are “immovable” for any reason would present “a significant issue” for those trying to escape.
“That is partly because the exit doors are where people are likely, by definition, to congregate in an emergency,” he said.
“And if any of those doors are obstructed in any way it’s clearly going to cause a significant problem.”
The Stardust inquest has now moved into a new phase and has begun hearing evidence from expert pathological witnesses into the cause of death of the 48 young people who lost their lives in the nightclub fire at the Artane disco in the early hours of 14 February 1981.
Expert witnesses on behalf of families represented by Phoenix Law were also sworn in before the jury.
The court heard consultant forensic pathologists Dr Benjamin Swift and Dr Nat Carey, who both have decades of experience in a number of cases including the Grenfell tower fire investigation, will also give evidence to the inquest during this module.
Coroner Dr Myra Cullinane noted that the evidence which will be heard in this module is “very personal evidence” for each of those families who lost loved ones.
Dr Cullinane informed relatives that cases will be dealt with alphabetically.
She told the families that they can be reassured that, whether they observe the proceedings for this aspect of the hearings or whether they choose not to, this “very personal evidence will be dealt with in the most respectful manner that I can achieve”.
Addressing the jury, the coroner said this is “an important module” in relation to a number of findings that they will have to make at the conclusion of these inquests.
Dr Cullinane reminded the panel that their findings must be made separately at an inquest.
The coroner said the evidence heard to date applies to all of those persons who lost their lives in the same way and will inform the jury of their ultimate findings.
She reminded the jury that in any inquest, findings much be made in relation to the identity of the deceased, to the date and place of death and the cause of death in each case.
This is “scientific, clinical, medical, complex evidence”, she said, adding that notwithstanding this, “it’s up to you, members of the jury, to make the ultimate findings”.
In his review of the disaster victim identification procedures following the fire, Shepherd noted that the management of victims of mass fatality incidents has changed very significantly in the over 40 years since this fire, driven by changes in forensic science and forensic medicine, changes in societal approaches to these incidents and “very importantly” by pressure applied by the relatives of victims.
He said in 1981, the approach to mass fatalities appears to have focused solely on the speedy recovery of the victims and their examination so the bodies could be released to the families for “burial as quickly as possible”.
The doctor said it appeared that this simple approach to fatality management was designed to comply with the legal processes of identifying the victims and establishing a cause of death but had “little or no consideration” of the wider aspects of the investigation of the incident.
He noted that there was little formal documentation of the recovery of the bodies from within the club.
“Although a plan recording the positions of the bodies is available there was no attempt to correlate those positions with specific individuals,” he said.
The consultant pathologist said modern practice would mean that each fatality would be allocated a unique number at the time of recovery and that unique number would be attached and would be the identifier throughout the process of recovery examination and identification.
“The failure to adequately document the recovery process means that it is not possible to perform any meaningful analysis of the likely effects of either the fire itself or the fire fumes on individuals or groups of individuals,” he said.
The witness said such an analysis would undoubtedly have been very useful, as was noted by the then-State Pathologist Dr John Harbison in his report in April 1981.
In response to a question from the coroner, Shepherd said that if a “precise plan” had been available, it was “possible” but “not certain” that experts could have identified groups of changes such as groups of chemicals and groups of things linked to people in specific areas.
He said the site recovery of 42 bodies is recorded on the fire brigade plan, indicating that the site recovery of six individuals was not known, adding it was likely those not recorded were included in those taken to hospital.
He noted that a number of the bodies were recorded as being close to exits 5 and 2A respectively, and so were likely to have been recovered by the fire brigade as they entered the building.
In his review, Shepherd also noted that the facilities available for the pathological examinations of the victim of mass fatalities has always been a “significant problem” as indeed has the provision of suitable day-to-day public mortuary facilities by the authorities.
He said the facilities available in the aftermath of the Stardust fire were never designed to be adequate for managing a mass fatality, with only a small number of postmortem tables and limited refrigeration.
It was apparent from Harbison’s report in April 1981 that he considered the facilities to be very “significantly inadequate” for many reasons and the witness said his own review of the photographs taken during the postmortem examinations confirmed that the mortuary facility was “overwhelmed”.
“In addition to the general disorder seen in the background, the number of personnel in the room would have added to the difficulties,” he said.
Shepherd added that the presence of victims placed on the floor beneath some of the mortuary tables in some photographs indicated that body storage was, at least for some time, “completely inadequate”.
He said in his opinion, the quality of the pathological examinations of the victims was “very variable”.
Harbison performed “full and relevant examinations” and produced “detailed reports” containing much useful information, he said, but the reports from the other pathologists were “extremely variable” and few recorded anything more than the “very basic facts” and offered little or no interpretation.
The witness said despite Harbison’s position as State Pathologist and his established knowledge and skills, he did “not seem to have had control over how the examinations were performed or how the reports were prepared” and said these pathologists appeared to have worked as a “separate entity” rather than as a member of a team.
“The variability of approach and the quality of reports especially when combined with the absence of information … has resulted in an inability to analyse many of the forensic aspects of these deaths,” he added.
Shepherd also highlighted improvements in the use of DNA identification techniques and said a highly specialised variation of this technique was applied in 2007 to the five victims who were initially unidentified.
In his overview on survivability, Shepherd noted there were approximately 850 people in the building on the night of the fire and 48 deaths, representing about 5% of those present, with 128 – or 15% of those present – injured.
That the fire was survivable was demonstrated by the 80% who escaped uninjured, he said, while the fact that it was potentially lethal was demonstrated by the 20% who were injured or died.
He said some individuals would have collapsed and died very quickly, while others would have survived for longer periods before collapsing and dying while a third group comprised those who were injured but who were found quickly and taken to hospital.
Shepherd said variability in survival could be accounted for by a combination of individual characteristics and the fact that within the space of the building the patterns of heat and concentrations of the many noxious fire fumes would have been “variable” and “constantly and rapidly changing”.
The witness said in this context, survivability was dependent on three things; having the ability to move – in other words being conscious and not confused or injured -having the ability to identify a route to safety such as signage visibility and having free movement along that route to safety.
He said factors which could affect free movement would be congestion due to large groups of people, obstructions such as furniture and lastly exit doors.
He said an exit door that “isn’t openable” for whatever reason would present a “significant problem”.
Shepherd agreed with Des Fahy KC, representing a number of families, that if a person reached a locked door this would increase the risk and said it would also mean that they were “more likely to have to return to a more toxic environment”.
Shepherd agreed with Simon Mills SC, a members of the coroner’s legal team, that one factor not identified but which could have made a difference was the availability of trained staff who could have assisted in an emergency in pointing patrons towards the exits.
In an overview of a report on toxicology, Shepherd said increasing temperatures result in damage to the external body surfaces and to the airways and lungs that are exposed to heat.
He said the oxygen available in the atmosphere to support life is reduced while at the same time concentrations of many noxious chemicals in the fire increase rapidly.
The reduction in available oxygen can result in increasing confusion and a reduction in consciousness which may significantly affect decision making and reduce the ability of an individual to escape the fire, he added.
The inquest continues tomorrow.
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