Stardust inquests: Families call for State apology as jury returns unlawful killing verdicts in each of the 48 cases

Summary

The jury in the Stardust inquests has returned a verdict of unlawful killing in the cases of each of the 48 young people who died in the fire at the Artane nightclub 43 years ago.

Some of the victims’ families have now called for a State apology.

The 12-person jury reached majority verdicts in all cases, the foreman confirmed at the beginning of the hearing at the Pillar Room of the Rotunda Hospital, where the court has been sitting since April 2023.

They found, for the first time, that the fire that resulted in the deaths of 48 people, aged 16 to 27, started in a hot-press and was caused by an electrical fault.

They found it was first seen outside the building between 1.20am and 1.40am, and first seen inside the ballroom between 1.35am and 1.40am.

The time at which it was first seen inside the ballroom of the Stardust was approximately 1.35am to 1.40am.

The height of the ceiling, the polyurethane foam in the seats and the almost 3,000 carpet tiles used to line the internal walls all contributed to the spread of the fire, they found.

A lack of visibility because of black smoke, a lack of knowledge of the layout of the building, toxicity of the smoke and gases, the heat of the fire all contributed the speed of the spread of the fire, while failure of the emergency lighting and lack of staff preparedness contributed to the deaths.

The jury found that at the time of the fire, exits in the Stardust Ballroom were either locked, chained, or otherwise obstructed. For this reason, the deceased were impeded in their ability to access or exit through the emergency exits.

More than 90 days of evidence and testimony from 373 witnesses was heard at the inquiry into the deaths of 48 people, aged 16 to 27, in a fire in the north Dublin ballroom in the early hours of 14th February 1981.

Five verdicts were available — accidental, misadventure, unlawful killing, open verdict and narrative.

Key reads

• ‘Jesus Christ, the doors are locked’: The full story of the Stardust fire, by Kitty Holland
• Stardust families were better resourced and more involved in latest inquests, writes Legal Affairs Correspondent Mary Carolan
• Stardust manager Eamon Butterly made High Court application before jury began deliberations at inquests
• Visit the dedicated Irish Times Stardust page for pen portraits of all 48 victims

Speaking on RTÉ's Six One news, Stardust survivor Antoinette Keegan said that she spoke with Taoiseach Simon Harris over the phone following Thursday afternoon’s verdicts. The Taoiseach said that he would meet with Ms Keegan, she said.

Stardust manager Eamon Butterly made High Court application before jury began deliberations at inquests

Former Stardust manager Eamon Butterly made a High Court application shortly before the jury began its deliberations, it can now be reported.

Just before Easter weekend, Mr Butterly, who had been manager of the nightclub, sought permission to bring judicial review proceedings challenging decisions made by the coroner to allow the jury return a verdict of ‘unlawful killing’.

The case could only be reported following today’s verdict at the inquest into the deaths of 48 persons at the Stardust Nightclub on Valentine’s night in 1981.

The application came before Mr Justice Tony O’Connor who, in a judgement, refused Mr Butterly’s application for both leave to bring the challenge, and the inquest be put on hold pending the outcome of the challenge.

Read the full report here.

Former minister of state Finian McGrath, who campaigned for the Stardust families, has called on the Taoiseach to issue a formal State apology in the Dáil, reports Marie O’Halloran.

Mr McGrath, who got the issue onto the 2016-2020 programme for government said Simon Harris “should immediately meet all the families and find out exactly what they want now”.

The former Dublin Bay North TD said “the families are still traumatized, angry and hurt” and the Government should agree the wording of the apology with them in advance.

He added that a national review of fire services and fire safety at night clubs and other venues should be conducted to ensure that they are fully compliant with modern regulations.

Meanwhile, former independent TD Tommy Broughan, who also campaigned for the justice for the families, said he was “absolutely delighted” for Antoinette Keegan and her family, the Barrett and McDermott families in particular, “because they were constantly there” and kept the campaign for justice going for more than 40 years.

Mr Broughan, a former Dublin Bay North TD added that it was a “colossal day for all the families and a vindication of their deeply held belief that their deaths were unlawful”.

Martin: ‘A huge moment’ for families after over 40 years of fighting for the truth

Thursday’s verdict of unlawful killing in the Stardust inquests is “a huge moment” for families who have spent over 40 years campaigning for truth, Tánaiste Micheál Martin has said.

“This afternoon, Dublin Coroner’s Court has returned a verdict of unlawful killing,” Mr Martin said in a statement.

“This is a huge moment for the victims’ families, and an important day for the country as the Stardust tragedy is seared on the collective consciousness of the Irish people.

“The tenacity of those families and their success in securing this verdict at inquest has been a service to all.

“Nothing will take away the pain and loss that the families experience to this day, but I hope that this process and verdict will, in due course, be of help to them,” Mr Martin said.

He also thanked Dr Myra Cullinane and the jurors.

Darragh Mackin, a solicitor representing the bereaved families, said that at a time of “utter despair”, grieving family members “took up the reigns in their battle for truth and justice”, reports Jack White.

At the Garden of Remembrance, Mr Mackin said victims were inhumanely identified as numbers and were stripped of their integrity and dignity.

“Today the record has forever been corrected, today the record reflects what these families have known for four decades – that the 48 children and young people killed in Stardust were unlawfully killed,” he said.

He said although today is a day of great happiness, it is also a day of great sadness, due to the absence of some campaigners who have since passed away, including Eugene Kelly, Christine Keegan and Charlie Bird.

Green Party leader Eamon Ryan said that Stardust families were “denied justice for far, far too long”.

“Nothing can undo the long years of pain and suffering but I hope it is of some comfort that their tireless campaign on behalf of their loved ones has finally been vindicated,” he said in a statement.

“I commend the coroner and jurors for their determined work in allowing the full facts of one of the darkest nights in Irish history to finally emerge.”

Taoiseach asks Minister for Justice and Attorney General to consider inquest findings

Speaking in Brussels after the European summit, Mr Harris said he had asked the Minister for Justice and the Attorney General to consider the inquest findings and advise the government on their implications shortly, reports Political Editor Pat Leahy.

“My understanding is that the gardaí will of course consider the outcome of the inquest today, and that is a matter for the gardaí,” he said.

Asked if a new Garda investigation could result from the findings, Mr Harris said: “It’s not a matter for me to speak on behalf of An Garda Síochána who will consider these matters independently, but I am aware that the gardaí will of course consider the outcome of the inquest today and it will be a matter for the gardaí to consider what steps they believe they must now take.

“From Government’s point of view, we’ll consider it both through the Minister for Justice and the Attorney General the recommendations from the inquest and decide what further steps or actions that we can take.

“But I am conscious that for over four decades the families have campaigned for truth, for justice, for answers. Today, they got that. And I think it’s very important we now reflect on that.”

Asked why the families had to wait so long, Mr Harris said: “I think there’s very legitimate questions in relation to how these families were treated over many, many, many years. But today I don’t want to add to that conversation. I’m conscious it must be a day of incredible mixed emotions, a day of great pain, but also a day of vindication I’m sure for many. That their loved ones received answers and justice and accountability through the inquest process.

“I don’t want to over-comment on that today other than to pay tribute to the families for their campaign and to acknowledge the fact that this has been a campaign for truth and justice for over four decades, and to remember that the Stardust tragedy was one of the darkest days in Ireland, that it was one of those moments that stopped the country in its tracks and to thank and pay tribute to those who never allowed the 48 people who died to be forgotten and ensured that they would continue to work to get to this point today that answers have now been established.”

Several bereaved family members who spoke to The Irish Times following the Stardust inquests verdict said the “last step” is a public apology from the State, reports Jack White.

At the Garden of Remembrance, Maurice Frazer, who lost his sister Thelma in the fire, called for a “meaningful public apology from the State”, before the crowd of family members and friends erupted in applause and cheers.

He said families and friends have endured “unbearable pain” over the last four decades while their hearts and minds have been left “shattered”.

“The mental toll has been overwhelming and exhausting, persisting day after weary day,” he said.

“We tirelessly battled against the barriers and the closed doors of Ireland’s political and justice systems, clinging to hope even when it seemed futile. Finally, those doors have broken open,” he said.

Mr Frazer thanked firefighter and inquest witness Dermot Dowdall, who carried his sister Thelma out of the premises that night some 43 years ago, and all of the first responders “for their brave efforts on that dark night”.

The Irish Council for Civil Liberties (ICCL) has welcomed the Stardust verdicts.

ICCL Executive Director Liam Herrick said: “After more than 40 years, we in the Irish Council for Civil Liberties welcome the verdicts today of the jury of the Stardust inquiry.

“Today is a hugely significant day for the 48 people who lost their lives in the Stardust nightclub, and for their families and loved ones who have campaigned for truth and justice ever since. We hope that they finally feel that some justice has been delivered for their loved ones.

“We commend the coroner and jury for their careful consideration of this landmark inquest, which was unique in Ireland in terms of resources, legal aid and jury selection. It demonstrates the need for adequate funding and allocation of resources for legal aid and jury selection in the coroner service.

“In light of today’s verdict, we in ICCL redouble our call for comprehensive reform of the coroner service, in line with our research and the recent report of the Joint Oireachtas Committee on Justice. The lack of direct support for bereaved families is one of the fundamental deficiencies in the service and must be rectified,” Mr Herrick said.

‘A day of vindication and honour’: President Higgins highlights bittersweet emotions following Stardust verdicts

The verdict at the Stardust inquests will not bring loved ones back, but it is “of the deepest importance” for those whose lives were “so irreparably altered” by the events of February 14th, 1981, President Michael D Higgins has said.

“This afternoon’s verdict is a vindication of the fight of those relatives, a promised fulfilled, carried out over 43 long years, by the relatives, friends and community of the 48 young people, all aged between 16 and 27, who had their lives cut short on a night they had simply set out to spend and enjoy in the company of their friends,” President Higgins said in a statement.

“The inquests, which it must be remembered have only taken place due to endurance and tenacity in the insistence of their families never to give up and to have a conclusion as to fact, have provided for dignity and recognition, however late, being accorded to the lives of each of those 48 young people. Recognition as to the meaning of their lives, the significance of their relationships and friendships, and recognition of the devastating impact which their deaths had on the shared dreams and hopes of all those who cared for and loved them.

“Each of their lives has been so vividly remembered, recalled and honoured by their family members who presented such important portraits of their lives over the course of these inquests.

“Today’s findings have at last brought a conclusion as to the circumstances of their death: to the cause of the fire, to the factors which contributed to its spread, to the factors which impeded those who died in their ability to escape and to access and exit through emergency exits, by its ultimate verdict of unlawful killing.

“I am very conscious that today will be a day of the deepest emotions for the loved ones of those who died. A day of vindication and of honour, but also a day of the deepest sadness and regret. I think in particular of those whose passing means this conclusion comes too late for them.

“As President of Ireland, I congratulate each of the families for the outcome of their steadfastness in pursuit of justice in honouring the memory of those they cared most for on this most important of days,” he said.

‘Justice has been a long time coming... today it arrived’: McDonald responds to Stardust inquest

Sinn Féin president Mary Lou McDonald said justice for the Stardust families has been “a long time coming”, and today, it arrived. She said that the 48 young people who lost their lives would forever be remembered.

“My thoughts today are with the survivors and the families of those who lost their lives in the Stardust tragedy,” Ms McDonald said in a statement.

“The verdict of unlawful killing confirms what survivors, victims’ families and Dubliners have always known.

“The forty-eight young lives that were taken in the Stardust tragedy night will be forever missed by those that love them. Now each family has the comfort of knowing the truth of that night and why their loved one died.

“It has been a long and heartbreaking road for victims’ families and survivors.

“They have overcome countless, cruel obstacles and diversions, including those put up by the Irish State.

“They have overcome. We salute them,” she said.

People Before Profit TD Bríd Smith has welcomed the verdict.

Deputy Smith said: “Finally the families and loved ones of those killed and injured in the Stardust fire are getting justice.

“But it should not have taken 43 years to reach this unlawful killing verdict and I want to pay tribute to all those who campaigned for so long for justice. Our thoughts are with them at this time.”

McEntee: Government will consider the verdicts and recommendations of jury

Minister for Justice Helen McEntee said the she hoped the inquests would bring “answers and some comfort” to the friends and families of those who died at the Stardust, and added that the Government would “consider” the verdict and recommendations of the jury.

“All those affected have endured so much, and while I know the pain of such loss and suffering never fades, I hope they will feel they have today finally got to the truth of what happened,” she said in a statement

“The Stardust fire was a national tragedy that has left a particular legacy of pain for the country and most particularly for the people of north Dublin.

“I sympathise greatly with the families of the 48 young people tragically killed in the fire for the terrible loss they suffered. I also recognise the lasting impact on everyone who attended that night and their families. I know so many of you today will be thinking of your parents and other relatives who never got over their terrible loss.

“The conclusion of these inquests will not bring back those who died that night – but I hope that it will help their loved ones to achieve some small degree of closure and healing around this tragic event.”

She also paid tribute to the jurors and Dr Cullinane. “The Government will now consider the verdict and recommendations of the jury,” she said.

There has been plenty of political reaction to the verdicts this afternoon. Here’s a flavour.

“Justice at last,” says Social Democrats TD in Dublin Central, Gary Gannon.

People Before Profit-Solidarity TD Paul Murphy: “Finally the truth about Stardust.”

Labour TD Aodhán Ó Ríordán asks why the verdicts took over 40 years.

Families and relatives of the 48 bereaved have marched to the Garden of Remembrance, close to the Rotunda Hospital.

Dublin City Council has said that it hopes the verdicts of unlawful killing “will finally provide closure for the families who lost their loved ones”, and paid tribute to members of Dublin Fire Brigade who responded to the fire on February 14th, 1981.

“The Council thanks the jury for its long attendance at the inquests and its careful deliberations. The Council also thanks Dr Myra Cullinane, Dublin Senior Coroner, who presided over the inquests,” a spokesperson for the council said.

“The Council wishes to publicly commend Dublin Fire Brigade for its response to the fire on the night, for the members’ heroic efforts in effecting rescue and for conducting themselves to the highest standards of the Fire Brigade.

“Finally, our thoughts are with the 48 people who died on that awful night and their families.

“May they Rest In Peace.”

Mary Coleman, who lost two of her nieces in the fire has been waiting 43 years for today’s verdict, she said, reports Jack White.

Her nieces Mary and Martina were just 19 and 16 when they were killed, while their sister Antoinette Keegan survived.

Their cousin Ronan said Antoinette has been the “steadfast custodian” of the Stardust campaign, and expressed regret that her parents never got the chance to see today’s outcome.

“She did it for her daddy and her mammy as well,” said Mary adding that Antoinette’s parents would be “relieved” today. Their father died of cancer in 1986 while their mother died during the Covid-19 pandemic.

“It’s a great justice, a long-awaited one,” she said of today’s verdict. “It’s been a traumatic but rewarding time,” said Ronan.

Family members are giving their reaction to the verdicts outside the court.

‘You never gave up on justice for them’: Taoiseach pays tribute to Stardust families following verdicts

Taoiseach Simon Harris has released a statement following the verdicts.

“The Stardust tragedy was one of the darkest moments in our history, a heart-breaking tragedy because of the lives that were lost, the families that were changed forever, and the long, drawn-out struggle for justice that followed,” he said.

“Today we remember the 48 people who lost their lives, all those who were injured, and all those whose lives were marked forever by the tragedy.

“For over four decades, the families of the victims have carried the weight of this tragedy with unwavering strength and dignity. Their relentless pursuit of truth and accountability, their profound commitment to justice, even in the face of overwhelming challenges and setbacks, was not only a fight for their loved ones but a campaign to ensure that such a disaster never happens again.

“Their courageous campaign demands our respect and our support. They never stopped searching for answers, for justice, and for some form of peace. We best honour all those who died by ensuring that the voices of their loved ones are heard and acted upon.

“The Government will consider this verdict in full and the recommendations of the jury. I want to acknowledge and thank the coroner, and her team and the jurors.

“48 young people never came home that night, but as Taoiseach I want to say this to their families; You never gave up on justice for them, you never let Ireland forget about them. They were never alone, and our country owes you a great debt for that.”

Loud cheers in the courtroom as Stardust inquest jury return unlawful killing verdicts

Kitty Holland reports from the Pillar Room, in the Rotunda Hospital

Verdicts of unlawful killing have been returned in respect of all 48 young people who lost their lives in the Stardust nightclub in Artane in 1981.

There were loud cheers and a standing ovation by hundreds of family members who had gathered to hear the verdicts at Dublin District Coroner’s Court on Thursday, as families hugged each other and cried audibly.

The 12-person jury delivered the final overall verdict just after 2.50pm after eleven days deliberation of over 90 days of hearings and testimony from 373 witnesses.

A lack of visibility because of black smoke, a lack of knowledge of the layout of the building, toxicity of the smoke and gases, the heat of the fire all contributed the speed of the spread of the fire, while failure of the emergency lighting and lack of staff preparedness contributed to the deaths.

The five men and seven women jurors found at the time of the fire some or all of the exits were locked, chained or otherwise obstructed and these impeded the deceaseds’ ability to exit the Stardust.

All these contributed to their deaths, the jury found.

After some remarks from legal representatives present in court, Dr Cullinane formally closes the inquest.

Dr Cullinane saved her final words for the 48 young people who lost their lives “on that fateful night”. She said that theirs were the lives “we sought to vindicate” by holding the inquests over the last year.

Dr Cullinane also spoke to the bereaved families, acknowledging that the Stardust fire, and subsequent loss of their loved ones, was the root of the “defining loss of their lives”. She said she hoped that the families would take solace from the inquests.

Dr Myra Cullinane has delivered her concluding remarks.

She paid tribute to the services of the jury members, who stepped outside their normal lives to partake in the longest running inquest in the history of the State.

Unlawful killing verdict returned by jury in each of the 48 deaths in nightclub fire

The jury has returned a verdict of unlawful killing in each case of the 48 young people who died in the Stardust fire.

Forty-two people died in the Stardust premises, and six people died following removal from the premises, the jury finds.

The jury finds that at the time of the fire, exits in the Stardust Ballroom were either locked, chained, or otherwise obstructed. For this reason, the jury find that the deceased were impeded in their ability to access and/or exit through the emergency exits.

The lack of visibility because of the black smoke impeded some of the deceased in their ability to escape the building following the outbreak of the fire, the jury finds.

The lack of knowledge of the layout of the building impeded some of the deceased in their ability to escape the building following the outbreak of the fire, the jury finds.

The toxicity of the smoke and/or gases impeded some of the deceased in their ability to escape the building following the outbreak of the fire, the jury finds.

The fire was first seen outside the building between 1:20am and 1:40am, the jury finds.

The fire was first seen inside the ballroom of the Stardust between approximately 1:35am to 1:40am the jury finds.

The fire started in the hot press in the dispense bar of the nightclub.

The cause of the fire was an electrical fault in the hot press.

The jury was unable to determine the time that the fire started.

The jury will now deliver general findings relating to the fire on February 14th, 1981 at the Stardust.

We have now completed the individual statutory findings. The jury are satisified with the identification of each of the deceased.

In the majority of case, place of death has been recorded as the Stardust Nightclub, Artane. In some indiviudal cases, local hospitals are recorded as the place of death.

The cause of death was recorded variously as rapid incapacitation due to inhalation of fire fumes and heat; inhalation of fire fumes; complications of burns and the inhalation of fumes; complications of the inhalation of fire fumes.

We are now halfway through the delivery of the individual statutory findings. The jury are satisfied with the identification of each of the victims, with the cause of death for the majority of cases read out thus far being related to inhalation of fire fumes and heat.

In the majority of case, place of death has been recorded as the Stardust Nightclub. In some indiviudal cases, local hospitals are recorded as the place of death.

The jury is continuing to deliver individual finding, in the cases of Richard Bennett, Carol Bissett, James Buckley and Caroline Carey. The jury notes that the latter was pregnant at the time of her death. The jury was satisfied with the identification of each of the deceased.

The jury is now delivering statutory findings in the case of each of the deceased.

Michael Barrett (17) was identified on February 17th, 1981. The jury is satisfied as to the identification of the deceased. The medical cause for Mr Barrett’s death was inhalation of fire fumes. His date of death was February 14, 1981.

Michael, from Raheny, was the eldest of four children. His main hobbies were football and DJing, and had a wicked sense of humour, his mother Gertrude previously told the inquest.

Dr Myra Cullinane is now addressing the jury.

The jury foreman says that the jury has reached the same verdict in each of the 48 cases.

Kitty Holland has the latest from the courtroom.

The court is absolutely packed with hundreds of family members, with standing room only. A handful of survivors’ parents here, and legal teams have given up their seats for family members.

Family are arriving at the Pillar Room ahead of the 2pm verdicts.

Enda O’Dowd’s video report details the how the Stardust fire unfolded, and the subsequent decades of campaigning undertaken by bereaved families.

Marie O’Halloran has some early comments from the Dáil ahead of the verdict.

Tánaiste Micheál Martin has told the Dáil “my thoughts and all of our thoughts are with the families of those who died in the Stardust tragedy”.

He said the families had pursued justice for more than 40 years.

Mr Martin said that in a couple of hours there would be a verdict in the coroners’ court. “This will be a huge moment for the families and indeed for the entire country because it is seared in the collective consciousness of the Irish people.

He said “the tenacity of the families to secure this inquest has been a service to all”.

Sinn Féin finance spokesman Pearse Doherty also paid tribute to the families

Who faced “many, many obstacles including those put in their way by this State.

“And I hope that the families involved today will get the answers they have been waiting for. And I extend to them my solidarity and the solidarity of everyone in Sinn Féin on this momentous day.

People Before Profit TD Richard Boyd Barrett also extended his “solidarity and support to the families of the 48 who never came home”. He hoped that “they will finally get the truth and justice they deserve after a 40-year long struggle”.

Social Affairs Correspondent Kitty Holland is at the Pillar Room in the Rotunda Hospital, where the inquests have been taking place since last April.

Lots of families are gathering outside and inside the Pillar Room. Laura Millar, whose brother Jim died in the fire, has arrived from Belfast. Jim had moved to Dublin with Robert Hillick – who also died in the fire – to escape the Troubles.

Taoiseach Simon Harris has said that he is “ready to interact and engage” with the Stardust families once the verdict in the inquest is handed down later today, Pat Leahy reports.

Speaking in Brussels on the second day of the summit of EU leaders, Mr Harris said he is “extremely conscious of the fact that this must be extraordinary difficult and emotional day for all those involved”, describing them as “people who have sought justice answers and truth for such a long period of time”.

“As Taoiseach I certainly stand ready to interact and engage with those families once the verdict comes through today,” he said. “But let’s have that first.”

Stardust’s 48 victims - who were they?

The inquests into the deaths of the 48 young people who died in the Stardust fire in Artane, Dublin in 1981 feature pen portraits of each of the deceased by bereaved family members. Find all of the portraits and more coverage here.

Inquests heard Stardust exit doors locked or obstructed

The inquests heard evidence alleging, on the night of the fire, exit doors at the Artane, Dublin, nightclub were locked or obstructed; that staff had not been trained in responding to an emergency or how to use fire extinguishers; that windows in toilets had been sealed shut with metal plates and bars; that carpet tiles used to line most of the internal walls were flammable and central to the rapid spread of the blaze; that electrical wiring was faulty; and that the ceiling in the area where the fire was first observed inside the club was below permitted minimum height.

Evidence was also heard that the club was allegedly frequently overcrowded; that there were not enough doormen and some doormen were letting patrons in through side entrances for less than the cover charge at the main door.

Addressing the jury before their deliberations, Dublin coroner Dr Myra Cullinane said: “To sit on this jury brings with it great responsibility, You must approach your task in an objective manner, based on the law ... and the facts you have heard in evidence. These are the only considerations for you in reaching your findings.”

She said they must be “dispassionate” and “clinical” and “put emotions aside” adding they were “under no time pressure” to reach their conclusions.

Dr Cullinane, referencing sections 30 and 31 of the Coroner’s Act 1962, told the jury before their deliberations: “Neither the verdict nor any rider to the verdict at an inquest shall contain a censure or exoneration of any person”. A verdict of “unlawful killing” must not attribute criminality or civil liability to any person or organisation, she said.

“The verdicts and findings are about acts and omissions – they are neutral statements about where it happened and how it happened. But not who did or did not do those things,” she said.

There was “a very specific test” they must apply to arrive at an unlawful killing verdict, she continued.

“You must find there has been a failure by a person or people, to a very high degree, to observe such a course of action that experience shows to be necessary, if substantial injury to others is to be avoided ... and that such failure was a substantial cause of the death [or deaths].”

This verdict was available only where death occurs “in the most serious of circumstances,” she said and could be returned only where the jury was satisfied “beyond a reasonable doubt that each of the elements of the test ... are proven to that legal standard”.

“The facts are for you,” she told the jury. “If you are considering a verdict of unlawful killing the following matters should be borne in mind ... You should apply the standards of 1981 in deciding the extent of any failures that arose and not the standards of today.

“You should bear in mind the circumstances the people were facing at the time when they made decisions they made. You may conclude there were serious failures ... and each of those failings were of a high degree and that those failings were a substantial cause of the death.”

In considering other verdicts the standard of proof was “on balance of probabilities,” she said provided hypothetical examples of circumstance in which such verdicts could be reached.