That’s what comes out from a judicial inquiry into how the Garda Ombudsman handled its investigation into the case involving Sergeant Michael Galvin, who died by suicide, not knowing he had been cleared of any wrongdoing.
But one note of caution: only part of the report compiled by Mr Justice Frank Clarke has been published.
While the 27 pages published contain general observations and a summary of the findings, along with conclusions and recommendations, the detailed chapters are not available to the public.
But what has been made available paints a tragic picture surrounding the death of the 48-year-old married father of three, who was found dead at Ballyshannon Garda Station on May 28, 2015.
As Mr Justice Clarke reports, the circumstances of his inquiry “started and ended in tragedy”.
It started with the death of mum Sheena Stewart on the morning of New Year’s Day 2015. She died in a road traffic accident in Ballyshannon having earlier had “interaction” with passing gardaí, including Sgt Galvin.
Because of this contact, the matter was referred to GSOC under section 102 of the Garda Síochána Act.
The report said that within half an hour of learning of the events, the GSOC senior investigating officer Nick Harden recommended a criminal investigation be commenced, to GSOC director of investigations Ken Isaac, who agreed.
On this decision, the report said: “In summary the inquiry has concluded that it must have been the case that, at the relevant time, the circumstances then known did not appear to constitute a criminal offence.”
It said the decision was “mistaken”, although it said it was taken bona fide (in good faith).
The report said it was also “at least it part” due to the legal uncertainty regarding the commencement of a criminal investigation — and added that the law currently did not state evidence of criminal action needed to be present.
The report details a communication breakdown between GSOC investigators and gardaí at Ballyshannon, and between those gardaí and the members under investigation, about the GSOC investigation.
The report concluded that it was “wrong” that the members concerned did not know statements they were making internally were being submitted to GSOC, and it said this was an internal communications failure.
It said it was “extraordinary” that three gardaí didn’t know they were under criminal investigation until three months later.
The report said there was a “lack of clarity” among GSOC staff about keeping gardaí informed about the progress of an investigation in accordance with their “obligation” to inform.
The report also said there was a “lack of proper understanding” among gardaí as to the way GSOC “is required” to do its work.