Coroner criticises Health Authority over dealings with inquest into man's death in ambulance blaze

Seán McCárthaigh

A coroner has sharply criticised the Health and Safety Authority over its dealings with an inquest into the death of an elderly Kildare man who sustained fatal injuries after an ambulance turned into a fireball outside Naas General Hospital almost a decade ago.

Kildare County Coroner, Loretta Nolan, told an inquest into the death of retired stud groom and farm labourer, Christopher Nolan, on Wednesday that she was not satisfied that the contents of a summary report provided by the HSA into the circumstances of the case were sufficient.

Dr Nolan said she was not shy about expressing her displeasure at what she described as “a very small report after a long investigation.”

She also expressed concern that she had to invoke her powers under the Coroners Act to get additional information from the HSA.

“I’m dissatisfied with the way the HSA has not sent information in a timely fashion. That is not appropriate,” said Dr Nolan.

Mr Byrne (79) a widower and father of five from Ard Brid, Suncroft, Co Kildare, died when an ambulance burst into flames shortly after it arrived outside the emergency department at Naas General Hospital on September 22nd, 2016.

Two paramedics who tried to assist the patient were also injured.

It is understood the fire arose after an oxygen cylinder in the vehicle ignited.

The inquest was originally opened and adjourned in March 2017 to allow for a file on the case to be forwarded to the DPP.

Dr Nolan recalled that her predecessor as coroner, Denis Cusack, had raised concerns at the time about the time waiting to receive reports on the case, particularly from the HSA.

The coroner also noted that the case had been outside her hands for seven years, as the DPP had only directed last February that no pr

She revealed that she had only been furnished with the HSA’s summary report in June 2025 and that she was not satisfied that its content was sufficient.

Dr Nolan said she had to use her statutory powers to direct the HSA to produce additional documents and exhibits, which she only received last week.

She observed that she should not have to resort to such a course of action to obtain relevant paperwork.

Counsel for the deceased’s family, John Kennedy SC, said it was “wholly unsatisfactory” that there had not been meaningful engagement by the HSA and expressed hope that an explanation would be forthcoming.

Mr Kennedy expressed concern that he would not be in a position to ask questions of an expert witness.

He claimed the evidence should not be heard on the basis of incomplete disclosure to ensure there were fair procedures.

Mr Kennedy said Mr Byrne’s family did not understand the position they found themselves in where there were difficulties in having documents made available nine years after his death.

Counsel for BOC Gases, which supplied an oxygen cylinder used in the ambulance, Ronan Kennedy SC, also said he was extremely concerned to discover at the hearing that other parties might have material which had not been available to his client.

Mr Kennedy claimed he was entitled to be provided with a list of witnesses and copies of their draft depositions as well as any other relevant material in advance of the inquest proceeding.

Counsel for the HSE and the National Ambulance Service, Damian Sheridan BL, said he had also identified three additional witnesses on top of 12 proposed witnesses due to be called by the coroner.

Dr Nolan acknowledged that all the parties should have all the relevant material, but stated that she “could not share what I did not have in my possession.”

The coroner ruled that she would proceed with hearing evidence from non-contentious witnesses.

However, she adjourned the hearing to a date to be determined after hearing submissions from various legal teams that a fresh jury should be empanelled to hear the case and to allow for all relevant documents to be circulated to the parties.