845 entries for State Inspections

The TD who raised the matter in the Dáil took up the case as a solicitor and wrote making a claim. In correspondence, it was suggested that a payment could be made to the parents by way of settlement. The Christian Brothers at the time were willing to make a settlement in order to avoid proceedings, but they were advised that a payment would not prevent a claim being made when the boy reached his majority, and that payment should not be made to the parents. No agreement could be reached, and the matter apparently ended without any payment being made.

In conclusion: Young, inexperienced Brothers were left to cope with difficult children without adequate training, and without the support and supervision of a good management system. There was no ordered system of discipline: control was maintained by force. The gravity of inflicting serious injury on a boy was not apparent to the Brothers until an external complaint was made. It should have been routine for the parents and the Department to be notified of a serious injury to a child, however it was caused. Failure to disclose such a serious incident immediately suggests that there was a policy of concealing damaging information. Injuries inflicted by Brothers should have been fully investigated. The infirmary record was wrong, and was not subsequently amended as it should have been.

An Artane boy’s death in the early 1950s was recalled by complainants and respondents as a tragic and traumatic event that affected everyone in the School at the time and left a lasting impression for years after the event. Many former residents, including some complainants, alleged the boy fell because he was being chased and punished by a staff member. For this reason, the Investigation Committee investigated the incident in full.

At bed-time, around 8.30 pm, Stephen Cavanagh27 fell some 14 feet to the ground and suffered injuries including gum and lip lacerations. He was brought to the Mater Hospital, where he underwent an operation under general anaesthetic to repair the lacerations of his mouth. His condition deteriorated after the operation and he did not respond to treatment, and he died in the early hours of the next day. A post-mortem examination was carried out and an inquest was held in the hospital the next day, resulting in a verdict of accidental death.

A boy who was acting as monitor at the time of the incident told the inquest what he saw: the deceased went up the stairs to the dormitory with the other boys and then came back out onto the stairs and went to do a ‘circus trick’ in which he leaned his body on the handrail and slid down a short distance ‘when he seemed to overbalance and fall face downwards to the floor below’, which was a distance of over 14 feet. The injured boy had damaged his teeth and ‘put his hand to his left side as if he was hurt’. He was able to go into the dormitory to get his boots before he was taken to the hospital.

A Brother who was on duty on the first-floor landing described in evidence to the Committee how the injured boy was being partly carried by another boy and was brought to the infirmary before being removed to hospital. He said there was no question of the boy being pushed or being pursued at the time and that ‘he just accidentally fell over the staircase’.

The treating doctor at the Mater Hospital gave evidence to the inquest that the boy was admitted to the hospital at 9pm on the evening of the accident, with a history of having fallen about 14 feet and that, on examination, he was conscious and suffering from shock, with a laceration of the lower lip and lower gum, four upper front teeth missing and a bruise over the right lower jaw. The doctor decided to operate to repair the injury to the boy’s lip and gum, which he performed at around 12.30 am. He described the anaesthetic that was given and said that an endotracheal tube and pack were placed in position. He continued: ‘After the operation was completed, his breathing became embarrassed, for which he was immediately treated, but in spite of this he did not respond, and died’. The doctor expressed his agreement with the evidence given by the pathologist as to the cause of death.

The pathologist described the boy’s condition when he carried out the post mortem. Externally, there was a lacerated wound on the lower lip and the four central upper teeth were broken. There were superficial skin lacerations and bruises on the lower jaw near the chin. Internally, there were no fractures of the jaw or skull bones detected: ‘Both lungs were oedematous. The lower lobes, and the posterior half of the upper lobes of both lungs were congested with blood. The thymus gland was enlarged. The heart showed slight thickening and contraction of the cusps of the mitral valve. The veins on the surface of the brain were distended with blood, otherwise no abnormality was detected in the brain. All other organs examined appeared normal’. The pathologist then gave his opinion as to the cause of death which was embodied in the jury’s verdict: ‘Death in my opinion was due to cardiac and respiratory failure, secondary to acute congestion of the lungs following the injuries accelerated by general anaesthesia and probably predisposed to by the presence of an enlarged thymus gland’. The coroner added that he regarded the supervision of the Brothers as adequate.

A Sergeant from Raheny Garda Station visited the School on the day following the accident and inspected the scene, and spoke to the boy who was acting as monitor, and gave evidence to the inquest about the location of the fall.

The inquest concluded with a verdict of accidental death.

The Resident Manager reported the matter to the Department of Education in a letter that was received six days after the accident, in which he briefly described the incident and expressed his understanding that the boy died when he ‘reacted unfavourably to the anaesthetic’. Dr Anna McCabe visited Artane two days later to get details of the accident. She reported the following day in a short note, in which she recorded that the inquest found that the ‘cause of death was attributed to anaesthesia’. She went on to say: ‘No negligence was attributable to the School’.

— The evidence in this case does not support a conclusion that the Christian Brothers were at fault for the boy’s death. The precise reason why the boy died remains somewhat unclear because of the multiplicity of medical complications cited by the pathologist.

In the mid-1950s the father of a boy wrote to Br Gerrard, who was in charge of the boys’ kitchen, to complain about the treatment his son had received while working there. He wrote: Sir, It has come to my notice about my son’s hand which is sepiet; and also the method used in your kitchen. My son is no robber and I hope you will be able to answer for the character you have given him, have you got any authority to use a rod with iron through it. You have noticed I hope I have not giving you the title of brother, as I don’t think you are fit to be one. I will make regular inspection of his body either at home or in the school. I have already wrote to the authorities about the matter. I will expect a reply and explanation from you as soon as possible. If the child concerned has suffer any Punishment through this letter I hope you will be prepared to face a court of Inquiry as I will demand it from the Ministry of Education. I am not going over your head yet that’s why I am writing to you, hoping you will have a explanation of your conduct. You will want to look after that childs hand if you don’t Artane will be getting into trouble for neglect by outside factors. Trusting you will reply soon as I am fed up listening to the treatment dealt out at Artane by others who have complained.

The father received no response from Br Gerrard, and wrote to the Superior the following month: I have already sent a letter to Bro Gerrard concerning an Enquiry about my Son; which he did not reply to in fact it is nearly a week ago, as you Know silence is to admit of guilt. I wish you would remind him and ask him to reply so I am not going to be treated as dirt ... If I do not have a reply soon, I will be forced to lodge a Complaint to the Board Of Education as well as the Minister of Education as I would not stand by and see my Son Branded as a robber ... Hoping you will look into the matter as soon as possible ...

The Congregation commented in its Opening Statement that the main complaint of the second letter was that the boy’s character had been impugned. They further argued that, as there was no further document available on the matter, this was a case that they considered to have insufficient documentary evidence, and what was available provided evidence of opposing views and so left matters inconclusive. They did not refer to the first letter containing serious allegations of physical abuse.