IT WAS a comment at Frank Burke's funeral that alerted his family to the possibility that his death might not have been a completely natural one.

Nobody was surprised when Mr Burke died peacefully at the Aisling Nursing Home in Portlaoise in late August 1995. He was very ill with prostate cancer and heart disease, and he was also 86 years old. There was hardly any need for a post mortem.

But as the family gathered for the removal of the remains, they heard a suggestion that there was more to his death than met the eye.

After lawyers were consulted and a few phone calls made, the Garda became involved.

In the autopsy which followed, Mr Burke's body was found to contain a dangerous combination of drugs. Two of these were prescribed, although one - the sedative Sparine - was detected at more than twice the maximum level recommended. A third, pethidine, had not been prescribed and could be dangerous to a man in Mr Burke's condition.

It was acknowledged at the inquest that the high levels of Sparine could have been residues from therapeutic use in his body, as his metabolic rate had slowed considerably. The presence of the pethidine remains, in the words of the counsel for Philomena Gorman, the owner of the Aisling Nursing Home, "a huge mystery."

The assistant State pathologist, Dr Margaret Bolster, told the inquest that Mr Burke had been an extremely sick man "who could have died at any time." The combination of the three drugs in his system, however, explained "why he died at this particular time." The drugs had "pushed him over the edge," she said.

THE Aisling had been under health board scrutiny for some time before Frank Burke's death. Five days after he died the Midland Health Board stepped in to take over the running of the home.

In a damning letter to Mrs Gorman, the board said:

. The home was overcrowded. The permitted maximum of 13 residents had been exceeded "on numerous occasions." This overcrowding - and the fear of being caught by the board's inspectors - had led to the practice of frequently moving residents out. In some cases, they were taken to another home in Thurles but on others they were moved into an unoccupied house in Portlaoise. The elderly residents were temporarily isolated and their relatives were not notified of these movements.

. Nursing was not up to standard. There had been no nurse on duty at the time of several inspections in August 1995, including one period of at least six hours. General operatives and attendants had participated in the administration of medicines to patients.

. The home had not co operated with health board inquiries. On one occasion when they called at night, inspectors were refused entry for a period of 25 minutes.

. Record keeping was poor.

. Emergency practices such as fire drills had been neglected.

. Even the food came under criticism as "repetitive, deficient in nutritional value and variety and generally unsatisfactory."

Some of these criticisms were repeated, with added value, when Mr Burke's inquest finally got under way this week.

The setting was cosy - the coroner, legal teams, witnesses and jurors all sat around the same long table in the grand jury room of Portlaoise courthouse - but the atmosphere was not. When not giving testimony, Mrs Gorman sat by the wall with her husband a short distance away from her three main accusers and former employees, a nurse, nurse's aide and cook.

The nurse's aide, Alice Walsh, gave some of the most dramatic evidence. She told the court she had seen Mrs Gorman give Frank Burke 40ml of Sparine - the prescribed dose is 5ml - two days before his death. Troubled by this she had asked Mrs Gorman for an explanation and was told "Alice, I have to do it."

On the night Mr Burke died, Mrs Walsh said she had seen evidence of similar activity and claimed that, when she asked again, she was told "Mind your own business, what you don't know shouldn't worry you." She claimed Mrs Gorman had gone to bed at 3 a.m. after drinking half a bottle of brandy, leaving instructions that neither she nor the Burke family should be called if anything happened to Frank.

When Mrs Gorman was giving evidence, it was put to her that she wanted to get rid of Mr Burke because the home was overcrowded and he was "a handful." She said this, and all the other claims, were lies. On the allegations of her drinking, she said that if she'd had that much brandy she herself "would be dead, nearly."

SHE did concede that she had falsified the record of the time of death. She recorded "no change" in Mr Burke's condition at 7.30 a.m. on August 26th, when he had been dead for more than three hours, because she didn't want people in on top of her". She needed time to lay him out properly. She liked to have corpses looking as well dead as when they were alive, she said.

It emerged at the inquest that a nurse at the home, Kathleen Shiel, had reported Mrs Gorman to the health board earlier in August 1995. But Mrs Shiel herself came under scrutiny when counsel for Mrs Gorman Mr John Phelan, raised the subject of what he said was her previous conviction for embezzlement while working for the Midland Health Board.

Mrs Shield protested that this was not relevant to the inquest. But Mr Phelan insisted that her credibility was relevant and persisted with the line of inquiry as she broke down and complained she was being harassed.

Mr Phelan claimed that she, Alice Walsh and the former cook at the Aisling were in conspiracy with each other against Mrs Gorman, who had dismissed them in February 1996 when the home was being sold. Ms Shiel confirmed that she had once discussed a financial arrangement with Mrs Gorman for taking over the Aisling, because Mrs Gorman was having financial problems.

One of Mrs Gorman's last responses in the witness box was to pour - at the suggestion of the coroner - a bottle of the drug Sparine into a 20ml container, similar to one of two she was alleged to have used for Mr Burke. The exercise was to demonstrate the consistency of the liquid. She had referred in evidence to the difficulty of administering it to a comatose patient.

Mrs Gorman lingered over the action, explaining that a trained nurse always pours a bottle from the side opposite the label, to prevent the directions becoming obscured by stains. In keeping with her demeanour throughout the inquest, she poured the liquid with a steady hand and a calm gaze.

The jury was sent out with three, slightly varied suggested verdicts. All were in keeping with the pathologist's report that the drugs had combined with heart disease and cancer to kill Mr Burke. The verdict chosen - that Mr Burke's death was accelerated by drugs - carried, in the words of the coroner, "the implication that something unlawful happened. That somebody did something wrong.

Afterwards both the Burke family and Mrs Gorman welcomed the verdict. Asked if it did not reflect badly on her running of the nursing home, Mrs Gorman said: "Not at all." The Burke family called for further investigations and declined to comment on the possibility of civil action. Mrs Gorman said she would co operate with any further inquiries.

A new file would be sent to the DPP, gardai confirmed. This is normal procedure if new evidence emerges during an inquest. The gardai stressed that any decision on the case is up to the DPP.

The new owner of the former Aisling premises, Mrs Annie Walters, was a reluctant host to media visitors who called during the week to the long bungalow which fronts the home on Borris Road, Portlaoise. The building has been renovated and now trades as the Ballard Lodge Nursing Home.

Mrs Watters pointed out that she and her husband bought the place as a building, "not as a going concern. The location and some of the residents are the only remaining link with the Aisling, Mrs Watters said.