A verdict of death by misadventure has been returned at the Caitriona Lucas inquest in Kilmallock, Co Limerick.
The 41-year-old volunteer Coast Guard died when she was taking part in a search and rescue operation off the Clare coast in September 2016.
Evidence in relation to the tragedy was heard before Limerick Coroner, John McNamara, over the last four days.
Jurors heard how Doolin Coast Guard volunteer Ms Lucas had been called to assist colleagues from Kilkee on 12 September 2016.
During the course of a search, a freak wave capsized the rigid inflatable boat in which she had put to sea, with two other crew members.
The inquest heard about long-standing "interpersonal issues" at the Kilkee base, which left it short staffed at the time of the incident.
Evidence was also given by several volunteers that they had not been made aware by the Coast Guard of recommendations in relation to treacherous surf zones, such as the one in which the accident occurred.
This evening the jury of four men and three women returned a unanimous verdict, after deliberating for just under an hour.
Jurors also unanimously agreed on a number of recommendations, intended to ensure enhanced measures are implemented to safeguard Coast Guard volunteers.
These include improved training and awareness regarding surf zones; a review of training in relation to capsized vessels and an ongoing review of all safety gear used by the Coast Guard.
The jury also called on the Coast Guard to ensure full implementation of all recommendations made in relation to other incidents involving IRCG personnel and said all vessels used by the agency should have voyage data recorders.
Speaking after the conclusion of proceedings at Kilmallock Courthouse, Ms Lucas' son Ben said it was entirely unsatisfactory that it had taken so long for the inquest to take place.
He said this meant that the implementation of "critical lessons" for the safety of all Coast Guard volunteers had been delayed for more than seven years, until today.
He also said the Lucas family felt that the failure to act on a 2012 report, calling for a senior safety systems manager in the Irish Coast Guard, meant that his mother had been let down terribly by the Department of Transport and Coast Guard management.
He said the minister who was in charge of the department at the time, Leo Varadkar, should be held to account for that failing.
Earlier, in his closing submission, Michael Kingston who is representing the Lucas family, highlighted a 2012 recommendation that the Coast Guard appoint a Safety Systems Manager. He said this did not happen until after the death of Ms Lucas in 2016, and the subsequent loss of four Coast Guard personnel in the Rescue 116 helicopter crash, in 2017.
He contended that if Coast Guard management, the Department of Transport or the Attorney General's office had acted on the recommendations of the 2012 report by Fisher Associates, the chances of an accident such as the one that claimed the life of Ms Lucas would have been minimal, because there would have been appropriate safeguards in place.
'Hierarchal issues'
Mr Kingston also pointed to personnel shortages in the Kilkee Coast Guard station and ongoing "hierarchal issues", which had been discussed in detail with senior IRCG managers.
He suggested the jury should consider a verdict of unlawful killing.
Simon Mills SC, for the Department of Transport, suggested to jurors that either a narrative verdict, or death by misadventure or accident were the options that should be considered.
He said all crew members on board the rib that capsized were in satisfactory safety gear, but were blindsided by a wave. None of them meant to be in an area where they would be at risk from the conditions that unfolded.
Mr Mills said there was no dispute that a D Class rescue boat had not been launched at the earliest possible opportunity.
But he said jurors must consider even if it had been put to sea earlier, what would have happened? He said it could not have got into the area where Ms Lucas was located and would have had to stand off the surf zone, where the volunteer Coast Guard was in difficulty.
Charing the jury, Limerick Coroner John McNamara, told them that he had reviewed recommendations put forward by both sides, which they could factor into their overall deliberations.
He recapped on the evidence heard over the last four days before the jury of three women and four men retired to consider its verdict just after a 4.45pm.
Lifejackets would hamper ability to manoeuvre
In earlier evidence today, the inquest heard from a diving safety scientist, who carried out a detailed analysis of the type of personal protective equipment worn on the day of the drowning.
Nick Bailey inspected a number of items; including lifejackets, under suits, dry suits and helmets; similar to those worn by the crew members on board the rigid inflatable boat that capsized near cliffs, in September 2016.
The inquest has already heard how Ms Lucas' helmet, and that of one of her crew mates, James Lucey, came off when they entered the water.
The third person on board the rib, Jenny Caraway, gave evidence on Monday that her helmet was loose fitting and uncomfortable. It subsequently was "ripped off" by a wave when she was in the water.
Mr Bailey’s report notes that the lifejackets supplied to the crews would hamper the ability to manoeuvre in the water when manually inflated.
The Coroner’s Court has been told the lifejackets in question are no longer in use by the Coast Guard.
Today’s proceedings commenced with a statement being read into the record, as evidence from one of those on duty at the Kilkee Coast Guard station on the day of the tragedy.
The statement from Lorraine Lynch was read by Michael Kingston, who is representing the Lucas family.
In it, Ms Lynch said that she "was told by Martony Vaughan, as Officer in Charge, to come with him in the jeep to the cliff walk".
This happened after a mayday call had been made by Jenny Caraway to the Kilkee Coast Guard Station, alerting the base to the capsized boat.
