Clare Daly (Dublin Fingal, Independent) | Oireachtas source

I move amendment No. 8:

In page 12, to delete lines 19 to 25 and substitute the following:

“(3) At the request in writing of a family member of the woman concerned, a coroner may decide not to hold an inquest in relation to the death of a woman that is a maternal death or a late maternal death, if, having regard to the matters referred to in subsection (4), the coroner is satisfied that the death of the woman is a natural one and, therefore, an inquest in relation to the death is not necessary.”.

This is the substantive section of today's discussion in many ways and we will take some time on it because it is the meat in the sandwich. This relates to mandatory inquests for maternal deaths. The measure will have a triple effect when it is implemented. It will give families the fullest picture about the train of events that led to the death of a loved one. It will give clinicians and the HSE a crucial insight into where the system is failing women. Finally, it will give us, as policymakers and those holding the purse strings, the information to make our services safer.

This is critical, and the reason I was a little stressed in asking about the amendments on Report Stage was that I was mindful that several of the people in the Gallery today, including midwives and husbands who have lost their wives, were here three years ago looking for this legislation. Three years on, we know that a number of other women have lost their lives in our maternity services. This is beyond urgent. I say as much in recognition that this is where the tetchiness came from. I have no wish to see Report Stage delayed. Having said that, I want to be absolutely clear that we are in a completely different place now to where we were three years ago. We are on the verge of delivering this legislation - there is no question or doubt about that.

This is the amendment we are really pushing. I want to explain why because the reason gets to the heart of much of what we are talking about. The World Health Organization estimates that between 88% and 98% of all maternal deaths are preventable. That is shocking. It means they should not or did not need to happen. Obviously, every one of these cases is a tragedy.

We need as much information as possible delivered through inquests into maternal deaths to make our services safer. Let us consider the case of the death of Tania McCabe in March 2007. The inquest found that Tania and her son Zach had died as a result of septicaemia and returned a verdict of medical misadventure. As a result, the HSE created guidelines on the management of septicaemia, something that should have been implemented in all maternity units. Of course, we found out some years later at the inquest into the death of Savita Halappanavar that only five of the 19 maternity hospitals or units had implemented those guidelines. In other words, without the inquest into the original death or the latter case we would not have had the guidelines or found out about their non-implementation. The inquests were critical in developing the services.

I will set out some detail on this specific amendment to the Bill. What we are trying to do is make it absolutely and crystal clear that a decision by the coroner to not hold an inquest – we are talking about mandatory inquests into maternal deaths – will only be taken after a family member has asked for that decision and provided the coroner is satisfied, on the basis of the post mortem and other information available, that the death of the woman was natural.

This question arose three years ago on Second Stage. This was the major issue. The relevant Minister at the time, Deputy Harris, said that we did not want the unintended consequence of a bereaved family having to go through an inquest where the causes were obvious and the family did not need an inquest. The reasoning was that there may have been a pre-existing cancer or something like that and there may have been no dispute about it. The idea was that no one would want to re-traumatise people in cases of a tragic but natural death, as it were, or force the family to go through an inquest.

We have been trying to strike a balance between the needs of the family and the wider public interest. We have to be absolutely sure that we avoid a situation under this section whereby deaths that are avoidable do not get the inquest they should. We believe the way the Government has framed the legislation at the moment gives a little too much latitude to the coroner. It is a little too broad for us to be entirely comfortable with it at this stage. We would prefer a situation whereby it would only be possible for a coroner to decline to hold an inquest if specifically asked not to in writing by a family member as well as being satisfied, on the basis of the information available, including the post mortem, that the death was natural. The provision is not strong enough at the moment.

The issue for us is not that we believe the coroners will be declining inquests left, right and centre. We do not believe that to be the case – I am keen to put that on the record. I fully accept that these instances will only arise in exceptional cases. However, it is still important because the concern boils down to the fact that whether a maternal death is natural or otherwise is not always obvious. We need to be clear on that point.

Maternal healthcare is getting more complex. Our knowledge of what amounts to maternal death and natural death is changing. There has been a fall in direct maternal deaths, which is to be welcomed. It is probably as a result of improvements in our health service. However, the number of indirect maternal deaths has increased due to issues like obesity and diabetes, which are now major problems in Irish society and in many other European countries as well. Clinicians and coroners are faced with what one researcher called increasingly intricate associations between underlying medical and pregnancy-related pathology. Now more than ever it is likely that a death that looks natural and as if it has nothing to do with a pregnancy might actually be a maternal death. That is the issue we are trying to get to the heart of with this amendment. It is about changing and understanding the links between these complex medical factors. The coroner might not actually be up to speed about the nature of these changes. A coroner might think, entirely innocently, that a death is natural, for example, because of a heart attack. The coroner may believe it is clear that the woman died of a heart attack and so the death was natural and could have happened to anyone.

The reality is that an aneurysm that was made more likely by pregnancy could have been avoided and the right medical pregnancy treatment might have altered the situation. This is what we are trying to get at.

The window of discretion available to a coroner not to hold an inquest should be closed little further. This should only be an option if a family specifically requests it. We should put on the record, because in some ways this is where it started, that what we want to avoid is a worst-case scenario whereby it is less a case of intricate associations and is about more obvious ones. I will use the example of the death of Bimbo Onanuga who died in March 2010. On the basis of a perfectly written and perfectly correct post mortem report submitted to the coroner's office, the coroner first ruled there was no need for an inquest into her death as he deemed it was one of natural causes. Subsequent queries by international experts centred on what lay behind the rupturing of her uterus and what was the train of events that led to that moment. When the coroner was subsequently presented with the queries and granted an inquest he asked for 19 depositions and witnesses from the hospital concerned and, ultimately, there was a verdict of medical misadventure. The point here is that initially the coroner was satisfied it was natural causes on the basis of the post mortem but this subsequently turned out not to be the case. This is what we are trying to do here.

I recognise that once the Bill becomes law there will be a very strong positive obligation on a coroner to hold an inquest, which was not the case previously. I realise fully that for a coroner to take a step to decline an inquest when the Bill is law would be much more serious than before and there will not be a huge amount of wriggle room but the concern remains that if it is a coroner who starts the process of exercising discretion regarding to whether to hold an inquest the whole point of a discretionary element to make things better for bereaved families will be lost and an inquest that perhaps should take place will not. This is the impetus behind the amendment. We feel strongly about it. We do not think it is huge. All it does is tie the hands of coroners a little tighter so that matters are cut and dried and the families are respected but the health service gets the information it needs.