The inquest into the death of Noah Donohoe has found the Department of Infrastructure “erred” in its management of the culvert in which the teenager died.
14-year-old Noah’s body was discovered in north Belfast on June 27, 2020, six days after he went missing as he cycled to meet friends.
A post-mortem examination found that the likely cause of death was drowning.
Following an inquest spanning almost eight months, a jury of eight men and two women were asked to rule on a series of questions presented to them by the coroner.
After it was unable to come to a verdict on Monday, the jury resumed deliberations for a fifth day in total on Tuesday, taking a further three hours to reach its findings.
Calling in the seven men and two women shortly after 1pm, Mr Rooney asked the court clerk to formally ask the jury if they had reached unanimous findings.
The foreperson confirmed a verdict had been reached and the official Form 22 completed.
After considered the verdict, Mr Rooney asked the foreperson to read out the jury’s answers to the ten questions on the form.
They confirmed Noah’s name and date of birth and his medical cause of death as drowning and said he had been last seen at the top of Northwood Road, heading towards the waste ground in the direction of the Premier Drive Stream culvert inlet.
Asked if they were able to explain Noah’s behaviour after he left his home on June 21, 2020, jurors said: “No. The evidence is insufficient to enable us to reach a conclusion.”
They ruled Noah died between 7pm and midnight on that evening in the lower reaches of the Premier Drive Stream culvert between manholes 4 and 5.
Asked if it was probable the Department for Infrastructure (DfI)’s management of the culvert access more than minimally contributed to Noah’s death, the jury said: “No.”
They did however return findings concluding the Department had “erred” in its management of that access.
“DfI erred in not identifying the area around the culvert entrance as a location the public could possibly access the culvert,” they added.
“As a consequence, no warning signs were on the culvert. This fed into the decision for the 2017 work, including no formal screen assessment and a decision to install a debris screen.
“As a consequence, Noah was able to access the culvert via the debris screen.”
The jury did not find anything in the PSNI’s response more than minimally contributed to Noah’s death and did not identify any errors.
“No, based on the time of death,” they added.
Asked to provide any factors that may have impacted on the inquest’s ability to reach a conclusion, the jury identified thirteen.
They said a failure to secure 24 hours of CCTV from 65 Fitzroy Avenue resulted in lost investigative opportunities and also identified a failure to secure the relevant CCTV from 85 Northwood Road.
A failure to follow up on all investigative opportunities in relation to Noah’s coat was also identified as well as the failure to ensure body worn footage from the search of Daryl Paul’s flat.
Failures in the execution of the CCTV strategy were also identified, while the jury also found relevant statements had not been taken in a reasonable timeframe.
The jury said the quality of the police notebooks was insufficient and that there had been misinterpretation of the mobile phone location on a map.
A failure to identify the relevance of and to prioritise and communicate the photo of the hand found on Noah’s phone was also identified.
There were also gaps and uncertainty over the anonymous call evidence as well as a delay in identifying the culvert as a place to search, said the jury.
They also found failings in the speed of that search.
It comes after a second juror in the case was discharged on Monday morning.
The coroner reminded members to base their discussions solely on the evidence seen and heard in court.
“You must ignore anything you have heard, seen or been told outside of that,” he added.
“Do not do your own research. I have repeatedly reminded you to put out of your mind any theories you have heard.
“Your findings should be written in a factual manner and should not affix anyone with criminal or civil liability.
“There has been a significant delay to deliberations (but) it is important to emphasise that you are under absolutely no pressure of time. Take all the time you need.”
The jury spent three days in late June and early July in deliberations before the inquest was adjourned following a dramatic late-night sitting in the Royal Courts of Justice.
Mr Rooney described the scenes that evening as “unprecedented” as the court sat until the early hours of the morning.
“You have been in this inquest since the end of January, almost six months,” he said.
“This is totally unprecedented; we are in unchartered waters. I will not allow myself or you to be rushed into a decision.
“That would be totally wrong (to reach) a decision in such an important inquest because we were caught out for time.”
Asked if they were able to explain Noah’s behaviour after he left his home on June 21, 2020, jurors said: “No. The evidence is insufficient to enable us to reach a conclusion.”
They ruled Noah died between 7pm and midnight on that evening in the lower reaches of the Premier Drive Stream culvert between manholes 4 and 5.
Asked if it was probable the Department for Infrastructure (DfI)’s management of the culvert access more than minimally contributed to Noah’s death, the jury said: “No.”
They did however return findings concluding the Department had “erred” in its management of that access.
“DfI erred in not identifying the area around the culvert entrance as a location the public could possibly access the culvert,” they added.
“As a consequence, no warning signs were on the culvert. This fed into the decision for the 2017 work, including no formal screen assessment and a decision to install a debris screen.
“As a consequence, Noah was able to access the culvert via the debris screen.”
The jury did not find anything in the PSNI’s response more than minimally contributed to Noah’s death and did not identify any errors.
“No, based on the time of death,” they added.
Asked to provide any factors that may have impacted on the inquest’s ability to reach a conclusion, the jury identified thirteen.
They said a failure to secure 24 hours of CCTV from 65 Fitzroy Avenue resulted in lost investigative opportunities and also identified a failure to secure the relevant CCTV from 85 Northwood Road.
A failure to follow up on all investigative opportunities in relation to Noah’s coat was also identified as well as the failure to ensure body worn footage from the search of Daryl Paul’s flat.
Failures in the execution of the CCTV strategy were also identified, while the jury also found relevant statements had not been taken in a reasonable timeframe.
The jury said the quality of the police notebooks was insufficient and that there had been misinterpretation of the mobile phone location on a map.
A failure to identify the relevance of and to prioritise and communicate the photo of the hand found on Noah’s phone was also identified.
There were also gaps and uncertainty over the anonymous call evidence as well as a delay in identifying the culvert as a place to search, said the jury.
They also found failings in the speed of that search.
It comes after a second juror in the case was discharged on Monday morning.
The coroner reminded members to base their discussions solely on the evidence seen and heard in court.
“You must ignore anything you have heard, seen or been told outside of that,” he added.
“Do not do your own research. I have repeatedly reminded you to put out of your mind any theories you have heard.
“Your findings should be written in a factual manner and should not affix anyone with criminal or civil liability.
“There has been a significant delay to deliberations (but) it is important to emphasise that you are under absolutely no pressure of time. Take all the time you need.”
The jury spent three days in late June and early July in deliberations before the inquest was adjourned following a dramatic late-night sitting in the Royal Courts of Justice.
Mr Rooney described the scenes that evening as “unprecedented” as the court sat until the early hours of the morning.
“You have been in this inquest since the end of January, almost six months,” he said.
“This is totally unprecedented; we are in unchartered waters. I will not allow myself or you to be rushed into a decision.
“That would be totally wrong (to reach) a decision in such an important inquest because we were caught out for time.”